Learn more: PMC Disclaimer | PMC Copyright Notice
Spiritual Care For Jewish Patients Facing A Life Threatening Illness
Rabbi Olga F. Bluman, MAHL, MAJE, Linda Klein, JD, Jay Thomas, MD, PhD, and Betty Ferrell, PhD, MA, FAAN, FPCNAbstract
Providing biopsychosocial/spiritual care for patients facing a life threatening illness can be complex, and this complexity can be amplified when a patient identifies as Jewish. A common but incorrect assumption is that a person who identifies him or herself as Jewish abides by the tenets of the Jewish religion. However, many Jews consider themselves Jewish in an ethnic or cultural sense rather than connected to a religion or belief in God. This case report presents an ethnic/cultural Jew with a life threatening illness of advanced lung cancer. Despite evidence of spiritual/existential suffering, this patient declined spiritual care. From an analysis of this case and clinical experience, we suggest exploratory questions that clinicians can use in response to common questions or statements made by such patients. This exploration may lead to a chaplain referral and we highlight interventions that chaplains and clinicians may find helpful as they come alongside Jewish patients.
Introduction
Caring for a Jewish patient with lung cancer can be complex in that providing holistic care encompasses meeting physical, psychological, social, and spiritual needs as they arise. How patients approach a life threatening illness may or may not be founded in or influenced by, their religion or belief system. Often, clinicians assume that because a person identifies him or herself as Jewish, he/she adheres to the Jewish religion. It is not uncommon for people to think of Judaism as a monotheistic world religion like Christianity and Islam, which define themselves primarily by adherence to a certain creed or set of beliefs. Judaism on the other hand, begins with an ethnic identity as most Jews are Jewish by virtue of being born into a Jewish family. Judaism as a religion is comprised of a set of beliefs and rituals and a person converting to Judaism does need to make a commitment to a set of beliefs. However, it is not uncommon for Jews by birth to identify as Jewish in an ethnic or cultural sense, as their Jewishness is not connected to religion or a belief in God.1 Some Jews are atheists and consider themselves to be good Jews, and others are secular Jews who choose not to live in accordance with the sacred texts.2 Yet, the patient case discussed in this article will demonstrate that even though Jewish patients may self identify as only ethnically or culturally Jewish, their identity and behavior has been influenced and shaped by the Jewish religious tradition and there are ways that Jewish teachings and values can provide comfort to them during their cancer journey.
Case Description
Mrs. K is a 65 year old Jewish woman who never smoked and is being treated for late stage lung cancer. She has no prior personal or family history of cancer. Mrs. K has received several lines of chemotherapy and each time had to stop treatment due to disease progression. However, this present chemotherapy has been working for over a year and her Karnofsky Performance Scale is 90% with minimal side effects. Mrs. K has been happily married for 43 years with three grown children and four grandchildren. She has great support from family and friends and is always accompanied by her husband or one of her daughters to clinic appointments. She and her husband love to travel and when not travelling, she enjoys getting together with friends as well as volunteering at the local library. Mrs. K’s parents were Holocaust survivors and immigrated to New York where she was born and lived until she married. Mrs. K’s two older brothers died very young in the Holocaust, and her two younger sisters are both alive and living in New York. As she grew up, Mrs. K was deeply affected negatively, by the horrific events her parents experienced.
When Mrs. K was asked if her Jewish religion or spiritual beliefs provided comfort or strength in dealing with her lung cancer and treatments, she stated that it did not. She stated that Judaism is what she was born into, it wasn’t a choice. For her, thinking about religion made her depressed. Her illness had not changed her belief in God. She maintained that “God is too busy to care about one person.” She does not believe “being Jewish” has any bearing on her illness or the way she copes. For her, the element of long term hope is gone because she knows she is going to die from the cancer. The uncertainty of not knowing how long the chemotherapy will continue to work and when the cancer will progress is depressing to her. She feels sad about what she will be leaving behind because she has enjoyed her adult life very much as compared to her childhood. Her parents taught her to live a good life and to help others, because of their belief that in helping one person you help the whole world. She feels good when she can help others and it gives her a sense of purpose. When asked if she would be interested in talking with the chaplain about any of her concerns, she declined. For her, God is silent.
Discussion
This composite case study illustrates the challenges to healthcare professionals providing care to Jewish patients. Traditional spiritual language may not always apply in the clinical encounter. When a patient is admitted to the hospital or seen in the outpatient clinic, they are routinely asked for their religious affiliation. When the patient endorses, “Jewish”, he or she may refer to their religious and/or ethnic and/or cultural identity.3 In order to understand what the patient means by “Jewish”, more information needs to be gathered by the clinical team.
Data from the 2001 National Jewish Population Study shows that nearly three-fourths of American Jews, including many who are not synagogue members, identify as Jews through a framework of a particular Jewish denomination.4 However, “while denominational identification is often highly predictive of attitudes and behavior, it is important to keep in mind that respondents do not necessarily adhere to official doctrines or practices as articulated by denominational leaders” (p. 4). Therefore a Jewish patient who states that he or she is Reform/Conservative/Orthodox may be referring to the type of synagogue he or she is affiliated with, or the type of synagogue he or she grew up in, but not necessarily to their belief system or religious outlook. Even though most Jews identify with a particular denomination, increasing numbers of Jews do not identify with any denomination but rather refer to themselves as “just Jewish” or some secular alternative.4 There are a growing number of patients who state that they are Jewish, but their Jewish identity is an expression of their ethnicity and/or culture. As clinicians, it is important for us to adapt the spiritual/religious language we use with Jewish patients (as well as patients from other religions), to be able to better screen and assess their spiritual needs and provide spiritual support as appropriate.
Many Jews assume that Judaism is a monolithic religion which views religious topics and God in only one way. Consequently, many Jews have left their religious communities because they believe that Judaism no longer speaks to them as it seems to contradict their own values and/or life experiences. Similarly, many Jews assume that a chaplain (who may be a clergy member) has an agenda and will judge them based on their level of observance of Jewish traditions. As a result many Jewish patients decline the offer to speak with a chaplain in the hospital for fear that the visit will result in feelings of guilt rather than comfort. In the United States many Jewish chaplains are rabbis, however a significant number are also cantors and professionally trained lay personnel.5 The term “chaplain” in this article refers to any individual who provides spiritual care to the patient, whether it is a professionally trained chaplain (Jewish or of another faith) or a Jewish clergy member.
In the case of Mrs. K, it is interesting that she does not believe being Jewish affects her illness or the way she copes, since some of her statements reflect Jewish religious values and ideas. For example, Mrs. K seems to reject the notion of a personal God, a God who cares about each individual and can be affected by the behavior of individuals. She is not alone. According to the Pew Forum on Religion & Public Life/U.S. Religious Landscape Survey (2008), one in four people, including approximately half of Jews, view God as an impersonal force.6 However, in Judaism a personal God is not the only God idea that can be found. Mrs. K might find comfort in speaking about her religious/spiritual beliefs with a Jewish chaplain and learning that many Jewish scholars and rabbis who came before her, also shared her beliefs. Knowing that she is not alone in her beliefs about God may help her feel less isolated and more connected to members of the Jewish community, who continue to struggle with understanding God’s nature.
Another factor that may influence Mrs. K’s view of God is the direct effects of the Holocaust on her family and ultimately her. For contemporary Judaism, the Holocaust is a significant event that affects Jewish theology and many areas of life. According to Katz7 the presumed absence of God during the death of six million Jews caused many Jews to reconsider their beliefs, specifically, God’s role in their personal daily lives. So harrowing was this event that many no longer believed in the existence of God, as exemplified by this statement from a Holocaust survivor, “[I] cannot find any explanation to excuse the inaction of traditional Judaism’s assertedly benevolent, omnipotent, historically active God during the Shoah (Holocaust).”p274
For other Jews, God not intervening in the midst of suffering was attributed to evil perpetrated by other human beings. Because God had given human beings free will to make decisions, God was obligated to respect those decisions, thereby turning God’s face away from their suffering.3 Katz quotes Rabbi Eliezer Berkovits who describes this as “the ultimate tragedy of existence: God’s very mercy and forbearance, His very love for man, necessitates the abandonment of some men to a fate that they may well experience as divine indifference to justice and human suffering.”7p470 Would it not be logical then for Mrs. K to conclude that if God did not intervene in the vast suffering of six million Jews in the Holocaust, including her parents, then God would remain silent and not intervene in one individual’s life who has cancer? A clinician’s inquiry into Mrs. K’s beliefs could pave the way for the chaplain to engage her in a discussion about her beliefs about God. This may help Mrs. K to express her feelings about what happened to her parents and siblings during the Holocaust. It may be possible for Mrs. K to feel God’s presence in her cancer journey, even if she does not believe that God will intervene and take away her illness.
Mrs. K states that long term hope is gone because she knows she is going to die from her cancer. There is looming uncertainty about how long the chemotherapy will continue to work. Even though Mrs. K very much enjoys her life, the uncertainty of her quantity of life is like an endless void that encircles her world, casting shadows on her joys and hopes. Judaism views illness and death as a natural part of life as eloquently stated in Ecclesiastes “For everything there is a season, and a time to every purpose under heaven…A time for being born and a time for dying…A time for weeping and a time for laughing…A time for mourning and a time for dancing”8(vss 1,2,4) On the other hand, much of Jewish traditions focus on living life and enjoying life. Human life is so important, that the saving of human life takes precedence over most other commandments in Judaism.9
It is natural for Mrs. K to feel sad, as she realizes that her time on earth is limited. Perhaps an invitation from the clinician to reflect on the life that she has lived as well as the life she feels she will leave behind when she dies would be valuable to her. The chaplain’s intervention for Mrs. K might include helping her to reflect on the biblical character, Moses, who also was distressed about his impending death. Sharing this narrative may give her comfort as she thinks about her own death. When Moses is told by God that he will die on Mt. Nebo and will not be able to lead the Israelites into the Promised Land, he does not accept God’s plan. Instead, he repeatedly pleads with God to let him live longer. Resistance to death is a natural response for a human being. But there comes a time when one may have to accept their impending death, whenever it comes, just as Moses did. At the end of the Book of Deuteronomy, Moses climbs Mt. Nebo, as God commands him, looks at the Promised Land and dies. Perhaps after Mrs. K. takes a look at her “promised land”, she like Moses, will be able to accept what life holds for her.
The knowledge that she will leave behind her family was what distressed Mrs. K the most. Her family was the source of her joy and gave her meaning and purpose in life. These feelings are normal for Jewish patients to have when the end of their life may be approaching. Many of the Jewish religious and cultural practices take place in the home. Today many Jews attend the Passover Seder so that they can relive their childhood or spend time with their family and not necessarily for religious reasons. It may be helpful for Mrs. K to think about how her legacy could live on, even if she is no longer physically present on this earth. A wonderful custom originating in the Bible with the patriarch Jacob and his children is the writing of an ethical will. In Genesis 49, Jacob, on his deathbed assembles his children to bless them. Since the time period of the Bible, ethical wills have developed into documents in which parents or loved ones can write their reflections on what they have learned in life and can express what they want most for and from their children and loved ones. Ethical wills stemmed from the belief that the wisdom parents had acquired was just as much a part of the legacy they wanted to leave their children as were all the material possessions.10
Mrs. K also stated that her parents taught her to help others, as, by “helping one person you help the whole world.” This statement sounds very familiar to a teaching in the Mishnah, a compilation of Rabbinic teachings codified approximately in the 2nd century, “Whoever saves a life, it is considered as if s/he saved an entire world.”11 Mrs. K said that Jewish religious or spiritual beliefs do not provide her comfort as she deals with her cancer treatment. Yet, Mrs. K seems to find meaning and purpose in life in following the ethical teachings of the Jewish religious tradition which teach the value of helping individuals and the whole world. It is interesting that Mrs. K does not identify these values as Jewish religious values and does not want to speak to a chaplain. Perhaps, this is due to her assumptions about the teachings of Judaism and about the role of a chaplain.
In Judaism, pastoral care is provided through an egalitarian relationship between the patient and the provider. In Hebrew, pastoral care is referred to as, “livui ruchani”, spiritual accompaniment. The root of the Hebrew term refers to someone who “walks with” another.12 It is the role of the chaplain as well as the clinician to be present with the patient and to let the patient guide the visit. The chaplain and clinician can provide comfort to the patient by being present with the patient, actively listen to the patient speak about whatever is on their mind, and appropriately responding to the patient’s concerns. Even if the subject of the conversation is not a traditionally religious topic, it may provide a huge sense of relief for a patient to be able to direct the visit and share whatever is on their mind, in a non-judgmental space.
Conclusions
This case illustrates the challenges faced by clinicians and chaplains when caring for the Jewish patient. Also illustrated are the broad differences in beliefs among Jews and that clinicians/chaplains cannot make assumptions based upon the patient’s identification as “Jewish.” It is important for the clinician to be willing to engage in spiritual conversations in order that timely referrals can be made to the chaplain. Table 1 provides examples of Jewish patient comments along with clinician probes for further screening, and possible chaplain interventions.
Table 1
Common Jewish Patient Comments and Clinician/Chaplain Interventions
| Patient Comment(s) | Clinician Probes To Screen For Chaplaincy Referral | Chaplain Interventions |
|---|---|---|
| Acknowledge the patient’s feelings and ask any of the following probes:
|
|
|
| Ask the patient:
|
|
|
|
|
|
|
|
|
|
|
|
|
Acknowledgments
This work is supported by a grant from the National Cancer Institute (PO1 CA 136396 – Palliative Care for Quality of Life and Symptom Concerns in Lung Cancer; B. Ferrell, PI)
Contributor Information
Tami Borneman, City of Hope, Division of Nursing Research and Education, 1500 E. Duarte Road, Duarte, California, USA 91010.
Rabbi Olga F. Bluman, Spiritual Care Services, City of Hope, Duarte, California, USA.
Linda Klein, Patient and Family Resource Center, City of Hope, Duarte, California, USA.
Jay Thomas, Palliative Medicine, City of Hope, Duarte, California, USA.
Betty Ferrell, Nursing Research and Education, City of Hope, Duarte, California, USA.