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| | Email this article • Print this article | The final passage
More Jews directing end-of-life care
by Richard Greenberg, Associate Editor
It was 15 years ago, and Jo-Anne Tucker-Zemlak's 42-year-old husband, Barry, was dying of terminal cancer. A hospice social worker asked if he had a "living will," a legal document designed to give patients control over their end-of-life care. He did not.
After consulting with her rabbi, Zemlak arranged to have one written for her husband, and it specified, she recalled, that he be allowed to "die peacefully and with dignity," unencumbered by extraordinary life-saving measures that would only seek to delay the inevitable.
His final days followed the script faithfully, said Zemlak, 52, who had a living will written for herself shortly afterward, and it echoes many of her husband's wishes.
"I don't want to be hooked up to machinery without the full capacity of living; that's not living to me," said Zemlak, assistant executive director of the Rockville-based United Synagogue of Conservative Judaism Seaboard Region.
The living will written by Neal Meiselman's elderly mother, Bessie, was based on a boilerplate document drawn from Maryland state statutes. But it was modified extensively so that her last-stage caregivers would know in simple, rubber-meets-the-road terms precisely what level of medical intervention she would desire and under what conditions.
"She was able to tie her quality of life circumstances to a variety of end-of-life options," said Meiselman, 54, a Silver Spring resident and member of Conservative Ohr Kodesh Congregation in Chevy Chase.
Noting that his mother (as was his late father) was deeply involved with the Jewish Funeral Practices Committee of Greater Washington, Meiselman said the living will reflected her appreciation "for the way Jewish tradition treats dying and death as a part of life and not apart from life."
Bessie Meiselman died at age 82 in February 2006 with several of her family members at her side, the road map for her final journey contained in a legal document she had authored. "It doesn't make you feel any less sad or any less of a loss," Meiselman said of the circumstances under which his mother died, "but it does relieve you of a burden that no one wants to undertake. We were relieved of the pain of choosing, not of the pain of implementing."
Increasingly, that option has become a viable alternative for Washington-area Jews of all denominations, according to rabbis, attorneys and others with experience in this area.
The trend, they said, is driven largely by high-profile, end-of-life cases that have illustrated wrenching problems that can result when a patient has failed to clearly communicate - in legally binding fashion - his or her final-stage care wishes.
The most prominent of these cases involved Terri Schiavo, a severely brain-damaged Florida woman who did not have a living will. Her parents and husband waged a protracted legal battle that attracted international attention over whether to remove or retain her feeding tube. Schiavo died in March 2005 at the age of 41 shortly after the tube had been removed via a court order.
"Cases like these have sensitized families as to the need for a way to initiate certain actions when patients are not capable of making the decision themselves," said Rabbi Yitzchok Breitowitz of Orthodox Woodside Synagogue-Ahavas Torah, who is also a professor of law at the University of Maryland.
Patients often seek to control their end-stage medical treatment in order to avoid burdening their family members financially or saddling them with excruciatingly difficult life-or-death decisions, sources said.
Sometimes, the will-writer's motivation stems from having watched a loved one die after suffering through a prolonged illness while tethered to machines, according to Gary Fink, rabbi emeritus of Reconstructionist Oseh Shalom in Laurel and a chaplain for Montgomery Hospice.
"This enables people to understand that sometimes death is no longer the enemy to be feared, but instead becomes a welcome friend," said Fink, who is also a private counselor for the bereaved and those suffering from life-limiting illnesses. "It's counterintuitive, because as Jews, we so often affirm life." But at some point, he added, that pro-life imperative is matched by a duty "to minimize suffering."
Living will is a generic term that usually applies to a pair of related documents. In one such document (sometimes referred to as a "health care directive"), the principal typically outlines the desired course of his or her final-stage medical treatment, often discussing such matters as nutrition, hydration, medication and surgical procedures.
In the accompanying document (often known as a "proxy directive" or a "durable power of attorney for health care"), the principal designates another individual to make end-of-life health care decisions on his or her behalf in the event of incapacitation. Ideally, those decisions reflect the patient's wishes as outlined in the health care directive.
Several denominations have model online living wills that are tailored to conform to statutory requirements in different states.
Although the Schiavo case spurred many Jews to sign such documents, it also exposed differences among the various movements on permissible options when death is imminent - and these discrepancies are often reflected in the respective living wills.
In general, living wills sanctioned by non-Orthodox denominations grant greater latitude to patients seeking to reject life-sustaining measures, including hydration and nutrition. The Conservative movement, however, is split on the issue of withholding or withdrawing food from the patient, and that division - among others - is incorporated in the movement's model living will.
While Orthodoxy stresses "that it is a mitzvah to keep people alive," most Orthodox decisors of Halacha, Jewish law, "believe that there is a point beyond which life does not have to be aggressively prolonged," especially if those actions exacerbate suffering, according to Breitowitz, a recognized authority on halachic decision-making in medical matters. However, he added, withholding food and water is considered "a major controversial area, and the burden of justification is much higher in the Orthodox world."
Fink said he typically presents clients with a "range of views along the Jewish spectrum so that each individual can find a place that resonates with them spiritually and emotionally."
Once his clients learn that Jewish tradition permits withholding or even withdrawing life support in certain circumstances, he added, they generally opt for a less aggressive end-of-life treatment scenario. (Fink emphasized, however, that none of the movements allows euthanasia, which he defined as any action that "actively hastens death for the sole purpose of hastening death.")
Reston-based attorney Wayne Zell, who is a member of the Reform Northern Virginia Hebrew Congregation in Reston, has written living wills for many clients. A majority of them reject the use of the full arsenal of life-preserving medical interventions, he said, but a "significant minority" take the opposite view.
Philosophically, the latter group includes Rachel Silver, 60, an Orthodox Jew from Montgomery County, who asked that her real name not be used to protect her privacy. She said that to her dismay, today's hospital culture promotes the idea of "letting people die in ways that are not in line with Halacha." She added: "These people don't mean ill, but as patients, it makes us feel very vulnerable."
As a result, Silver recently signed a living will developed by the fervently Orthodox organization Agudath Israel of America. It specifies that all health care decisions be made "pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition." It also requires the proxy agent to consult with an Orthodox rabbi designated in the document, and it asks the agent to follow the rabbi's advice.
Although living wills can contribute to peace of mind by helping alleviate confusion and guesswork in a patient's final days, they are not foolproof.
Despite their existence, conflict can flare when survivors are of different religious sensibilities. But when everyone is on the same page, a living will "can remove some guilt from family members," Breitowitz noted. "They're just doing what they've been instructed to do by their relative. It relieves some of the burden of having to grapple with" a momentous decision.
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