Reflections on Hospice in the Jewish Tradition
I will never forget Jay.
Jay Gold was a high-powered, successful forty-six-year-old Wall Street lawyer with a very warm heart. Though he had an extremely hectic schedule, Jay always found time to help those in need: he did pro bono work for numerous charities and volunteered to represent the indigent through legal aid societies. Four months before Jay was admitted for hospice care to the nursing home where I am the director of pastoral care, he was diagnosed with advanced colon cancer with a terminal prognosis of less than six months. Fortunately, our staff kept Jay quite comfortable and he was able to work from his laptop and keep in touch with family and friends by phone. But within a month after Jay’s arrival, our social worker and psychologist observed that he had become increasingly agitated, and they suggested to Jay that I meet with him.
When I stopped by to visit, Jay was engrossed in working on his laptop. He looked up and managed a wane smile.
“Hi, Rabbi. I’m so glad you came by.” He looked troubled.
“A penny for your thoughts, Jay. It seems like you’ve got a lot on your mind. Perhaps I can be of help.”
“Rabbi—it’s about my mother. Maybe you can speak to her. You see, I’m an only child. My dad died when I was fifteen years old. Overnight, Mama, who had always been a homemaker, was forced to become the breadwinner. She became more than a mother to me—she was a friend, supporter, advocate and cheerleader—you name it! I became her whole life. Mama tried to make sure that I had everything I needed, that I wasn’t deprived. Above all, she took pride in my education. Her happiest days were my high school graduation, when I delivered the valedictorian address, and my law school graduation, when I graduated near the top of my class. I never got married….I was sort of married to my career. It became my life.”
Jay paused. “Now comes the hard part: Mama must know the truth. I’m sure she knows I’m dying. The doctors told her everything. But whenever she’s around me, she acts as if everything will be OK. She tells me I’m going to get better, that I’m coming home and she’ll be there to take care of me, just as she always has. I try to tell her gently that I’m not going to make it, that my days are numbered. She gives me an incredulous look, and says, ‘No, Jay, you’re going to make it! I just know it. You’re coming home again. Where there’s life, there’s hope!’
“Rabbi, I know Mama will be devastated when I die. I’ve been her whole life. That’s what she’s always told me. But now that I’m dying, Mama won’t let go. Incredible as it may seem, I feel guilty about dying because I’m leaving Mama alone in the world. But what can I do? It’s not up to me….Please, Rabbi, I beg you: Speak to Mama and tell her it’s OK to let me go. Please, please!”
It’s hard to let go. It’s hard to believe that the people we loved and those special moments we shared with them will never be again. For the dying, death means leaving loved ones behind and departing alone on a final journey. For the survivors, loss of a loved one means a profound void in their lives, and the end of a one-of-a-kind relationship.
In her classic 1969 book On Death and Dying, psychiatrist Elisabeth Kubler-Ross identifies five stages in the dying process:
• Denial (This can’t be happening to me!)
• Anger (Why is this happening to me?)
• Bargaining (I promise I’ll be a better person if…)
• Depression (I don’t care anymore. I can’t go on this way.)
• Acceptance (I’m ready for whatever comes. It’ll be OK.)
These stages, when they occur, don’t always follow this order—certainly not for both patients and their families. When Jay asked me to tell his mother to let him go, he was clearly in the final stage of accepting the reality of his condition, while she was still in denial. Jay desperately needed his mother to accept his new reality and to be fully supportive during his last days.
Anger and rage are very powerful emotions and are difficult to address. Sometimes, a dying patient may direct his anger at God, while at other times he may transfer his rage towards a caregiver or family member. His fury is sparked by the gross injustice of life in general, and of his life in particular. He laments the eternal question of human existence: Why do the innocent suffer and the wicked go unpunished? “Why me?” he fumes.
When we hear one’s “why me” questions, we cannot respond or try to formulate answers. A dying patient doesn’t expect a reply; when he asks “Why me?” he knows that no human has the answers; his questions are clearly rhetorical. His cries about life’s injustices give expression to his overwhelming anger, which cannot be placated by reason or by theological discussions about the meaning of life. As a chaplain, I can simply listen to his woes and validate his feelings. Most importantly, I can assure him that being angry at God, under these circumstances, is an understandable and normal reaction. His rage is not blasphemous!
Anger and Rage
Sam Gordon was a truly devout eighty-six-year-old, who rarely missed a religious service and who performed mitzvot with enthusiasm, despite his poor health. Sam was a long-term resident in our nursing home, who suffered from serious cardiac and respiratory illnesses. Yet, against often insurmountable odds, his strong faith prevailed, and he observed mitzvot without fail. Not long after Sam’s eighty-seventh birthday, there was a dramatic decline in his respiratory condition. It became clear that he would have to spend the rest of his life on a mechanical ventilator. For Sam, whose faith was his raison d’être, this devastating development meant that he would be tethered to a machine on the vent unit, and would never again be able to regularly attend religious services.
When I visited Sam, he was downcast and meditative—a far cry from the ebullient and outgoing senior that we had all come to know.
“Rabbi, I’m so glad you stopped by. I really wanted to speak with you. Did you hear the bad news?” Sam asked. (I had already heard that Sam was being placed on a ventilator, but it was important for me to know how Sam had taken it. I wanted to have him tell me the news in his own words.)
“No, Sam, what bad news?”
“Rabbi, my breathing is worse, and my pulmonologist told me that the only way I can continue to live is if I’m attached to a ventilator, which will help my lungs work. Without it, I’m dead! But with it, I might as well be dead! I’m going to be stuck in my room on this unit forever. I won’t be able to attend daily services and your holiday programs. I’ll never be able to take leave and join my family for an occasional yom tov!” Sam raised his voice. “Is that right, Rabbi? Is this yashar [just]?”
“You sound angry. Are you angry, Sam?”
“At whom?”
I paused briefly. “At God.”
“God….How can I be angry at God? I’m a religious man. God must know what He’s doing, that’s what I believe. So how can I be angry with Him?”
“I’m asking you again, Sam—are you angry?”
Sam didn’t answer because he knew that I knew what he must have been thinking. The expression on his face and the tone of his voice said it all.
“Sam, you’re angry. You’re angry with God for doing this to you, but you’re afraid to admit it.” I waited for him to respond. He was stone-faced.
“Sam, you’re a religious man. Let me ask you a question: Do you believe that God knows what’s on your mind and what you’re feeling?” He nodded in the affirmative.
“In that case, God knows you’re angry with Him even if you don’t say a word. Right? But that’s OK, Sam, because God knows why you’re angry with Him and He understands.” Sam nodded again, listening closely to my words, but still unwilling to admit to his anger.
“Sam, it’s OK to tell God in your prayers that you’re upset with Him. Remember, you’re not telling Him something that He doesn’t know anyway! But just keep speaking to Him. Keep the lines of communication open. Don’t worry about God becoming angry with you when He hears your complaints. He can take it. …He’s got big shoulders!”
I shared a thought with Sam that I had heard many years ago from one of my mentors, the late Rabbi Jacob Goldberg, a pioneer in Jewish bereavement counseling. The Torah tells us that Aaron, Moses’ brother and the first high priest of Israel, suffered a most grievous loss on what should have been one of the happiest days of his life—the dedication of the new Tabernacle in the desert. But his two sons, Nadav and Avihu, brought an incense offering with a “strange fire that God did not authorize them to bring.” As a result, they were consumed in a Divine fire. What was Aaron’s reaction to this tremendous tragedy? “And Aaron was silent” (Leviticus 10:1-3).
How was it possible for Aaron to sustain his crushing loss in stoic silence? The great Chassidic master Rabbi Menachem Mendel of Kotzk, better known as the Kotzker Rebbe (1787-1859), offers an astonishing insight. In reality, Aaron did not accept his loss in total equanimity. The Hebrew expression for “he was silent,” “vayidom,” derives from the word for “blood,” “dahm.” On the outside, the Kotzker Rebbe observed, Aaron accepted his fate in silence, but on the inside, his blood boiled with rage at his overwhelming tragedy!
Spiritual Transformation
I have witnessed even religious patients and their families experience a spiritual crisis during a life-threatening illness. After all, since we believe, as Rabbi Akiva said, that “all that the Merciful One does is for the best,” it follows that even illness must be preordained for one’s ultimate spiritual good. If we accept this premise, why would we pray to change a decree that is for the good? And, ultimately, do we truly believe our prayers will reverse God’s decision? Does God change His mind?
Some of the greatest of the classic Jewish thinkers pondered these most challenging questions. Rabbi Joseph Albo, the fifteenth-century Spanish author of Sefer Haikarim (The Book of Jewish Principles), and Rabbi Judah Low of Prague, the sixteenth-century preeminent sage known as the Maharal, address these very issues. They conclude that since God acts in our best interests, and we accept His judgment, our prayers are not intended to “change His mind”—even if that were possible! In a most revolutionary insight, Rabbi Albo explains that prayer doesn’t directly change God’s decisions. Prayer changes the patient, and elevates him to a higher spiritual level, where he may become worthy of God’s blessings and miracles. Moreover, I believe that a patient’s brush with death—more than any other experience in his life—brings him to the realization of his own fragile mortality, leading to life review, and, quite often, to spiritual renewal and genuine repentance.
Maimonides describes the ba’al teshuvah, the genuine penitent who undergoes spiritual renewal and transformation, as one who “constantly cries and supplicates before God, giving as much charity as he is able and distancing himself from the sin he has committed, and changes his name, as if to say, ‘I am a different person.’” Through sickness and suffering, intercessory prayer, and, most importantly, genuine repentance, a patient may undergo a spiritual transformation and become a different person. Indeed, God did not change His mind: His harsh decree was made against the patient’s former self and not against whom he has become—a renewed and truly transformed individual.
This profound insight might help explain a somewhat mysterious Jewish custom. When a patient is seriously ill, many give him a new Hebrew name connoting life, such as Chaim (or, in the case of a woman, Chaya), with the hope that God’s harsh decree was directed at a person with a different name. But the obvious question is, Whom are we trying to fool with this name change? Doesn’t God know that this is the very same person with a new name? In truth, we add a new name with the hope that it will reflect the new person the patient has become through the tribulations of illness and by his offering sincere prayer and genuine repentance.
The Big Picture
I often hear patients ask, “Rabbi, why me? What did I do to deserve this? Why now, when I have so much left to do?” At this most difficult time, I can only assure patients and families that while we don’t have the answers, we believe that God does. Sometimes our lives seem out of control and nothing makes sense, and clearly, from where we’re sitting, there seems to be no rhyme or reason for what’s happening to us. But from God’s perspective, in a spiritual dimension, there is an explanation for everything that happens. And, one day, when our souls return to the spiritual world from whence they came, everything will become clear.
Imagine, I tell the questioner, that you’re a young child once again. It’s a rainy summer day, and, to pass the time, you start working on a beautiful 500-piece jigsaw puzzle. After you throw all the pieces on the floor, someone grabs the box cover, which displays the puzzle’s picture, and walks out of the room, leaving you to fend for yourself. You try to put the pieces together in some logical order. Sometimes, luckily, you discover a pattern, but overall, you’re extremely frustrated. You’re getting nowhere. Then the person who took the cover returns and shows you the big picture on the box. Now it all makes sense! So too we are born into a world where life doesn’t always make sense, no matter how hard we try to rationalize events and put them in order. What’s happening to us seems arbitrary, unpredictable, and, sometimes, downright unfair! Then, after we leave this world, God shows us the big picture on the box, and the puzzle of our lives makes sense for the first time. Similarly, some of my colleagues have compared our lives to a needlepoint: We can only view the back of the needlepoint and, from our perspective, it looks like a bunch of stray colorful threads. God, however, sees the front of the needlepoint, as if He were looking down from Heaven, viewing the intricate designs that are the patterns of our lives.
The Final Encounter
What precipitates an individual’s final acceptance of his fate, his acquiescence to death? I believe that this decision originates deep within the recesses of his soul, when he receives a subconscious signal from his spiritual core: It is ready to return home to its source. In fact, the Zohar and other kabbalistic works observe that this process begins as early as a month before death (which might help explain the clairvoyant behavior of some who are near death). And so, with a sense of homecoming, the saintly tzaddikim looked forward to their reunion of Soul with Source. Shortly before his death, the great Rabbi Nachman of Breslav said, “I very much want to divest myself of this garment that is my body.” On a higher plane, the holy may exclaim, “My soul thirsts for the Lord, the Living God. When shall I come and see the Lord’s countenance?” (Psalms 42:3).
I talk about the Jewish belief in an afterlife—“Olam Haba” —with sick elderly residents because I believe that it offers them the opportunity to accept death with a serene sense of hope, rather than with dread and doom. Incredibly, I find that many of our elderly are totally unaware of this most basis Jewish tenet. “Rabbi,” one of them recently exclaimed. “You mean there really is an afterlife? Do you really believe it?” In my talks with our residents, I explain the underlying rationales for our belief in the afterlife. Philosophically, it is absurd to assume that man, a being with intelligence and emotional depth far superior to any other creature, should simply decompose as all lower animals do without a trace of his unique spiritual personality. Why, indeed, would God endow man with such extraordinary spiritual gifts for only a fleeting moment in eternity?
Theologically, the afterlife is perceived as the World of Truth, where God’s justice is ultimately revealed. In this world of ours, we can’t explain why bad things happen to good people or why good things happen to bad people. We can’t comprehend why an innocent girl is senselessly slain or why her assailant escapes prosecution. We can’t explain why little children were murdered in the Holocaust and why their Nazi butchers found refuge in Argentina. In the World of Truth, God holds man accountable for his actions. The good and innocent, who were deprived of their just reward during their lifetimes, will, at last, receive their due. And the wicked, too, will not escape Divine justice; they will be punished, measure-for-measure, for all the pain and suffering they inflicted upon others. All that doesn’t make sense to us now in this topsy-turvy world will then be understood. The secrets of life and of living will be revealed in the World of Truth.
Finally, to the skeptics and cynics in the crowd, who reject any phenomenon that cannot be empirically demonstrated, I suggest studying the phenomenon known as near-death experiences (NDE). Recently, I lectured on “life after life” to the residents at my nursing home and shared with them some of the many studies on this fascinating topic. Researchers describe the NDE phenomenon in detail and cite supporting evidence. NDE, also known as out-of-body experiences, occurs in survivors of near-fatal incidents, such as those who go into cardiac arrest on the operating table or who are severely injured in a car crash. These survivors experience a sensation of leaving their own bodies, floating above the scene, as it were, accompanied by a sense of having a “spiritual body.” They often see a light of dazzling brightness and reunite with departed friends and ancestors. During this experience they witness, almost as incredulous spectators, how medical personnel down below work frantically on their bodies in an effort to save them.
Amazingly, I discovered that these descriptions of out-of-body experiences are reflected in the age-old teachings of kabbalah. Contrary to common belief, kabbalah teaches that the soul doesn’t depart to meet its Maker immediately after death. For a brief period of time, it hovers above its earthly home, the body, and, in some supernatural manner, perceives what is happening below. This would, of course, explain the great reverence Jewish law demands of the living while in the presence of the dead, particularly before the burial. Later, according to kabbalah, the soul gradually ascends to its ultimate destination, where it is judged and receives its spiritual due.
This vision of the afterlife is the ultimate hope for those facing their final encounter. As a caring human being, all I can offer the dying is hope for tomorrow. For, in a deeper sense, if there is no tomorrow, there is no today. When the dying still have a reason to live because they are looking ahead for tomorrow—a celebration, reunion or some unfinished task—I plan with them. When they are hoping against hope for a miracle, I pray with them. And, then, finally when they have made that most difficult decision of all—to accept their fate—I assure them that their lives had meaning: The World of Truth awaits them.
No words can better capture the essence of man’s hope in the face of death than those etched on the wall of a concentration camp bunker by a young victim of the Holocaust:
I believe in the sun—even when it does not shine,
I believe in love—even when it is not shown,
I believe in God—even when He does not speak.
Rabbi Schostak is the director of pastoral care at the Gurwin Jewish Nursing and Rehabilitation Center in Commack, Long Island. He is the founder and chair of Gurwin’s Ethics Panel and is affiliated with the Center for Medical Humanities, Compassionate Care, and Bioethics at the State University of New York at Stony Brook, where he lectures on bioethics in the medical school. Rabbi Schostak speaks and writes extensively on end-of-life bioethics and on issues of aging in halachah.