Dana Lustbader, MD, FCCP

Can I prevail upon the Jewish members of the "gossip" line for some advice. I have a man in his 70s with renal, respiratory and cardiovascular failure secondary to sepsis. I and my colleagues feel he is not going to get better .....10 days of progressively increasing inotrope requirement....now on neat adrenaline and noradrenaline. The family are adament that withdrawal of treatment is not possible. God ends life not me. To my eyes they are very orthodox, the patient wouldn't sign his consent form on the Sabbath, his aged wife walked about 3 miles because it was the Sabbath and she couldn't ride. The women wear wigs and the men the black hats (sorry don't know the name for the hats perhaps I need some education).

My question is ....is the reluctance to pull out a religious stricture as they say (I am not doubting their sincerity) or influenced as much by the fact that their son died in similar circumstances after a liver transplant and they persuaded dad to have the procedure. I am aware we have discussed similar things in the past but perhaps as they lacked relevance at the time I didn't take so much notice.

I have a pretty good rapport with this family and they accept reluctantly my daily bulletins of gloom and despondency and I have told them I (this is a group I not just me) think we should stop but that I will only do that with their consent. In the meantime I will try and convince them that is the right thing to do they accept my point of view as I rather reluctantly accept theirs.

Dana Lustbader:

Orthodox patients will not discontinue therapy that has already been implemented and is essentially sustaining life. If you were to withdraw mechanical ventilation or vasoactive drugs, the patient would die as a result. Therefore it is not allowed. You are not obligated however to institute NEW therapies. You are also not obligated to do CPR should the patient have a cardiac arrest. In the situation that you describe with your patient, you may want to discuss with the family a DNR as it pertains to cardiac arrest. If the patient is actively dying as in the case of cardiac arrest, and given his comorbidities, he would not likely survive CPR. Therefore you wouldn't want to interfere with his dying process with painful therapies such as chest compressions and DC cardioversion. Since he is already on the ventilator, respiratory failure is not relavent here, and withdrawal of mechanical ventilation is out of the question.

Gill Hood:

I cannot comment on the religious aspect of this although I will ask the opinion of a couple of my colleagues who are Jewish ñ one albeit very un-orthodox! However hereís my 2 p worth regarding this sort of situation in any patient regardless of ethnicity.

This sort of situation always seems somewhat anachronous to me in that you already appear to have been interfering with Godís will by what you have done. If it was left to God, the patient would not be in intensive care anyway (IMHO).

Be that as it may, I do not believe that you are legally bound to continue with medical therapy that you and a reasonable body of your peers would regard as futile just because the patientís family want you to do so. It is best to attempt to reach consensus with the family but sometimes it is just not possible. In this case you must take control. Either set limitations to therapy (eg maximum inotropic dose; no more dialysis; etc) and do not move the limits, keep the patient comfortable and wait for nature to take its course or set a date by which you will withdraw if the patient has not died, tell the family, and stick to the proposed date.

Document your opinion. Get other specialists to write their opinion regarding the hopelessness in the case-notes. Steel yourself. Rely on the support of colleagues and friends. Do the deed.

Ask yourself what it is that will happen if you in the end have to withdraw against their wishes. You are not in the USA. Feel safe to practice sensible medicine.

David Rier:

While I am not a rabbi, I am a practicing Orthodox Jew. While I am not qualified to render an opinion in Jewish law, I am pretty sure that the family is correct, according to Jewish law. The Talmud and the Shulchan Oruch [Code of Jewish Law] both forbid doing anything to hasten death (the classic example involves turning the patient's head in such a way that this will hasten death). Leading rabbinical opinion has (and continues to do so) affirmed this view. This is obviously a sensitive, delicate area for all concerned. Because disregard of these laws can amount to murder in Jewish law, Jews have taken them very seriously throughout history.

I will quote (with my own comments in brackets) from "The Comprehensive Guide to Medical Halacha [Jewish Law], 2nd edition", by Abraham S. Abraham, MD, FRCP (NY/Jerusalem: Feldheim, 1996), who is a unit chief at Shaare Zedek Hospital here in Jerusalem [this book bears the approbation of Lord I. Jakobovits, former Chief Rabbi of Great Britian]. On the subject of dying patients, he writes: "Nothing may be done to a dying person that might hasten death [here, his footnotes cite Shulchan Oruch, section Yoreah Deah, Chapter 339, sect. 1, and the commentary of the Sha''ch, Chapt. 100, 1]....

Since there are rare cases in which critically ill patients, for whom all hope has been abandoned, do nevertheless recover, it is the duty of the physician to continue to treat a dying patient until the very end. One should set aside the Sabbath laws for such a patient....This is equally valid if treatment may prolong life for only a short time, but not if the treatment would *add* suffering to a patient who has reached the natural end of the disease....(p. 190)

Within this quote, he refers us to his next chapter, on euthanasia. Given the life-and-death nature of these issues, I quote at some length, because he spells out clear parameters: Under the heading "active euthanasia", he writes: "One may not hasten death, even that of a patient who is suffering greatly and for whom there is no hope of a cure [here, he cites the Shulchan Oruch, sect. Yora Deah, Chapter 339, sect. 1], even if the patient asks that this be done [more cites].

To shorten the life of a person, even a life of agony and suffering, is forbidden. If one does so, albeit for reasons of compassion and even at the request of the patient, it is equivalent to murder and is punishable accordingly [here, he cites Igros Moshe--section Yora Deah, sub-sect. 2, opinion #174--the rabbinic responsa of Rabbi Moshe Feinstein (died 1986), leading authority in Jewish law of the post-war world]. Under no circumstances does Jewish law permit escape from suffering at the price of one's life, for, as the Psalmist says [Psalm 118, verse 18]: "G-d has caused me suffering at not permitted me to die." The value of a life is infinite and therefore the value of every part of it, however brief, is similarly infinite.

Thus seventy years of life have exactly the same value as thirty years, one year, an hour or even a second....The moment one is willing to shorten, by however little, the life of a dying patient, on the grounds that it is of no further value, one destroys the infinite value of all human life [cite]. Thus, even if death is near and absolutely certain, the life of a patient is still of infinite and estimable value, and shortening it is in no way different from killing an absolutely healthy individual [more cites]. A patient in pain should be treated with such pain-relieving medication, including morphine, as is necessary.

However, in no circumstances may morphine be injected in order to *shorten* life...." (pps. 193-94) Under the section "Passive Euthanasia", he writes in part: "It is the duty of the physician to treat the patient even if only to prolong life for a short time. It is therefore forbidden, for instance, to withhold food, fluids, or drugs such as insulin or antibiotics, even if such measures result in prolongation of suffering [cite to "Tzitz Eliezer", responsa of R. Eliezer Waldenberg, sect. 13, chapter 89]. All procedures needed to nourish or sustain the patient must be carried out, even if they can be performed only by artificial means. Thus the patient must be given food and fluids by nasogastric tube, feeding gastrostomy or intravenously, as necessary [cite to R. Shlomo Zalman Auerbach (d. 1995), who was probably the leading figure in Jewish law after the death of R. Moshe Feinstein, cited above]...." (pps. 194-95)

I am well aware that these views do not necessarily match those of many of the members of this List. However, they are grounded in the Bible, millenia of rabbinic rulings, and are applied daily by rabbis to this day. These are the principles I, myself, have been taught. Because such unfortunate situations as described by Dr. Batchelor occur frequently, and because the issues involved are life-and-death, I have taken the liberty of an extended post. To this, I would only add that in such critical situations, a Jewish family is advised to consult a leading Orthodox rabbinic authority, to see if any specific extenuating circumstances apply.

Avi Roy Shapira:

You are facing an ultra orthodox family, and they would not let you pull the tube out. However, there is a solution. They consider actively pulling the tube sacriligious, and the patient probably does too. However you can stop monitoring, suctioning, adjusting the ventilator, or the ionotropic drugs. In short, you stop making any necessary changes, don't change the fluid orders, don't push fluids, and do not do CPR.

There is a religious ruling (PSAK HALACHA in hebrew) signed by three of the most respected rulers in ultra orthodox circles (the ruling was written by someone called Shlomo Zalman Auerbach and cosigned by Rabbi Elyashiv and another famous rabbi whose name escapes me. I give you the names so you can get the family to accept this. They will have heard of them.) The psak says that in a hopeless patient, ventilation, food water and comforting measures cannot be denied, but that any changes to the current ventilator setting, or the current medications, including ionotropic support, or even changing antibiotics is actually forbidden, as it amounts to interference with the process of dying.

In our experience once you stop adjusting, the patients die within 24h.

You may think this is silly, and I agree, in a way. However it is their way of getting around the inevitable problems you encounter when you try live by laws written a few millenia ago in todays world.

Anna Batchelor

Thanks for all the helpful comments We discussed your comments with the family and agreed to continue but not escalate treatment. The family were delighted with our care and pleased we had taken the trouble to find out about their beliefs. Now the problem in my mind is..... I did this because it was very important to them.....but say a family who didn't want to give up because "where there is life there is hope" and I was convinced there was no hope ......what do I say...... is a none specific feeling any less important than a religious conviction ?