CHAZAQ's Torah Talks #209 Rabbi Naftali Katz & Rabbi Asher Millman - Life On The Line

The patient, your mother or one's father or one sibling, they live their entire life alpaka and there's no reason why their last few days in this world should also be any different. They should also be privileged to die ali and then they enter into the emis into the next world where whatever they accomplished here reaps them dividends in that world. And what we at can do is following a very careful Messiah tradition, a very careful recommendation, Jewish law to the letter of the law, make sure we give people the opportunity to maximize their time in this world. And the same way their entire life they were servants of Hashem, they served Hashem in all of their facets. We want to give them the opportunity to conclude their life as well. [Music] Welcome to to Kazak's Torah Talks program. Every single Tuesday night, we have amazing, tremendous speakers. And and and and today we have two amazing speakers, Rabbi Usher Milman and Rabbi Napali Katz. And before we get into tonight's topic, we want to we like to introduce Rabbi Katz or Milman if they could talk about about a little bit about themselves and the great work that they're involved with. So Rabbi Cats, I guess start us off. >> Okay, just to tell a little bit about myself, my name is Nafali Katz. I grew up in New York, currently live in Lakewood, New Jersey. I'm a local RV and I got involved in a little over a decade ago. Um actually with a personal story I had one of my children was not well and I was out of Lakewood for a while in the hospital. She's doing wonderful now. When I moved back to Lakewood they were just starting because I had spent close to a year in the hospital with my child. So I felt as this opened up this opportunity that I should get involved. And what's actually very fascinating is there's a medish in this week's para that is really what this idea pushed me to get involved. The medish asks why is it that Mosher Rabenu is so busy with arim mikl? Why is he so busy setting up the ar mikl where people who killed accidentally are able to go ahead and run away as a city of refuge. Moshe has a lot of other important things to do. Why is Moshe so involved in this? So the medish says, and I'll quote, somebody who eats food, he knows what it tastes like. And it says Moshe in his history had to run away from Egypt. And he was a refuge. He was somebody, he was a refugee. He was somebody that was running away. And he knew what it felt like to run away to be unsure of where you were. And there's a mitzvah to go ahead and make a city of refuge. So he said, Moshe said, I have a history of running away. I know what it feels like. So it's incumbent on me to get involved and to make an or so I felt after going through what I went through, I had the opportunity to get involved in helping other people out in hospitals and navigating different shas and different questions that it was a calling of mine. And I bar hashem have this an opportunity over the last decade to be involved with which is a 24-hour hotline which fields between 10 and 15,000 shilas and questions of medical issues which come all across the United States and actually even internationally coming in from all over the world. So it's a wonderful opportunity in to share with you some of the things that come across our hotline and explain to you how important it is to have a rabbi and rabbi who's trained in medical to be involved in any care. >> Amazing. Thank you. Thank you so much Rabbi Milman please. >> Hello everybody. I'm Asher Milman. I'm a uh also a local rev in pic New Jersey originally from Los Angeles California. I ore got involved in about a year and a half ago when a mpo of mine actually called me and I wasn't exactly sure what to do and I said of course the first thing that we do is we call it was actually Rabbi Katz who answered the phones I don't know if he remembers and I was enamored by the work and the knowledge and the breadth of experience that Rabbi Katz and all the other abanim on Rufim had and due many of my own medical challenges in the past as well as some significant medical training. I uh eagerly reached out to Karuin and thankfully I've been privileged to be with them on the past year and a half and have experienced some amazing amazing cases and it's really been privileged to be a part of this organization. I also have the opportunity to be the rabbitic adviser to the Hatsella of Pose Clifton and advise many others locally in PA Clifton on many medical matters. And it's been an excellent opportunity to be an Evan Hashem in this facet where it's a unique opportunity where people really are barereft of knowledge. They don't know where to go and who to turn to. And it's amazing to be on the hotline that amongst all the darkness there's this ray of light this hotline with the Rabunim and the discharge coordinator Mrs. Harowitz and we're there just to serve Cla Israel in all 50 states throughout the world and to give them the opportunity. It's a it's an amazing experience and I'm very privileged and to be part of the amazing work that we're doing. >> Both of you involved in such such holy amazing work for for for for the Jewish world at large. And so so we're jump we're going to jump right into it. Um so we know we know talking about end of life care. So, can you explain how the Torah's what what the Torah's viewpoint of it as well as how it how it might differ from the secular medical approach? >> You want to take this one? You want me to do this one? >> I'll I'll take this one first. In halaka as in all covers all aspects of the life that we live from the moment that we get up till the moment that we go to bed from what we eat from how we eat from how we interact with people and the are our guiding light for how we live as those who follow and when it comes to the medical challenges that people face the reality is that also dictates what we do what we don't do what what is recommended, what is supposed to be withheld. And one of the famous lines that we always tell people is that I'm sure the patient, your mother or one's father or one sibling, they live their entire life ala and there's no reason why their last few days in this world should also be any different. They should also be privileged to die ali. So the secular world has a perspective that the older you get, the larger a burden of society you are on, the more economic resources and social resources that you drain. If you're unable to perform your activities at a high level, perhaps it's your social interactions. Perhaps it's your recreational activities. You can't golf. You can't go swimming. You can't go on vacation. you're unable to do the things that are valuable from a secular perspective. So then life itself becomes devalued if you're unable to perform the actions in the way they see as ideal. But as mitzvah we value every mitzvah, we value every we value every shabas. We value every moment in this world because once one's time is over in this world the opportunity for for reward is over and then they enter into the into the next world where whatever they accomplished here reached them dividends in that world and what we can do is following a very careful Messiah tradition a very careful recommendation Jewish law to the letter of the law make sure we give people the opportunity to maximize their time in this world and the same way their entire life they were servants of Hashem they served Hashem in all of their facets we want to give them the opportunity to conclude their life as well and that's one of the major discrepancies that we face in terms of Jewish halaka versus the secular perspective in 21st century American medical systems do you want to add to that >> yes I like to add that I recently had a case that came up in Disseldorf, Germany. And it was the first time that the doctor there had ever spoken to a rabbi, forget a rabbi that um understands medicine. And they, you know, at first were quite apprehensive to speak to us. And I got on the phone and I said, "Obviously, I need an English- speakaking doctor. My German is not that uh haven't brushed up on it recently." And I got an English- speakaking doctor and he asked me, "Rabbi, what could I do for you?" And I asked him to explain to me exactly what was going on with the patient, what were their chances of survival, were they in pain? And I asked a lot of very pointed directed questions. I can tell you this that the doctor did not share the values that the family had or that I had. But one thing I realized is once the doctor understood that we were coming from our own system and this is a very important idea which I think people have to understand is that you know the secular world has a system. Medicine has a system and as rabbis we very much respect the medical system. We we respect their knowledge. I'm a rabbi. I'm not a doctor. However, we have to understand and be confident that the Torah gives us as Jews a map in every which part of our life it may be. And that includes dealing with people who are very sick and that includes with being able to deal with people who are even dying. And we want to do it in a Jewish way. And when I explained to him, you know, doctor, can we do X, Y, and Z? And he said, well, that I could do. And I said, well, if we do this, everybody's going to be happy. and he said 100%. If that's going to respect the family's wishes, it'll be my pleasure and honor to do that and the patient was able to unfortunately the patient was dying but the patient was able to as they lived and die as a Jew and as long as we explain to them clearly and confidently what we want and what we need. I find many times that it's not a us versus them. It's an education and we just have to educate them what we want. But the most important thing is that we have to be confident that we as Jews have a way that we deal with it. The facts are the medical facts, but then we have a way of interpreting it and interpretation is usually where we have to go ahead and have a discussion with the team in order to make sure that we're all on the same page. And on that note, what what would you say are the most common challenges like for Jewish laws? the challenges that that that that the Jewish families they face in the hospitals today. >> So I would I would tell you one issue is and this is an issue that's coming up again and again is regards to nutrition and hydration. What I mean by that is is that in the secular world it's been understood by many doctors that a patient that dies of dehydration that means they have they don't have enough fluid in them whether it's normally we drink water we drink different things which hydrate us when people are not well enough they would get an IV which is a simple IV and many in the medical establishment feel that somebody that dies of dehydration is considered to be a normal weigh it and they call it part of the dying process. But with Torah Judaism and the way we look at that is that giving basic necessities which include hydration, nutrition and antibiotics are things that we always have to provide to a patient even if they have to come in ways which are not natural in terms of not eating through the mouth. whether they have different types of feeding tubes that are able to give patient nutrition that we hold that it's a mitzvah and a commandment to give the patient the nutrition as long as the patients still able to get nourishment. There are cases where at the end of life where patients are not able to then what we call metabolize the food in which case we wouldn't necessarily have to give them food because they can't do anything with it. When we talk about dementia patients or patients who are declining, we have to be very vigilant when it comes to hydration and nutrition because this is something that could keep a patient alive for quite a while. I've had patients alive for a year or two years and the medical establishment very much so doesn't look at it in the same way we look at it and they'd be very comfortable with a patient passing away and that could often be within a day or two or three if they're not hydrated properly. Catsy, I think the nutrition and hydration is is a one of the main questions that we get in terms of end of life. Another very common question that we get which I deal with quite frequently is the question of pain medication and pain management in end of life. Unfortunately, many people especially at the end of their life if they're suffering from terminal cancer, they unfortunately are in a lot of pain. And the question is, you know, how does how does Jewish law dictate the approach to giving a patient pain medication? On the one hand, pain medication if given at too high a dose can hasten one's death and were never allowed to hasten the death of a person and that would be akin to murder in many cases. On the other hand, the Torah's ways are pleasant and there's a mitzvah to give people alleviation of pain. And one of the common questions we get from the medical team and the families is can we give or can we not give? And the answer always is like most things it's somewhere in the middle. Of course, you're obligated to give somebody pain medication to make them comfortable, but it cannot be at the risk or the likelihood that you're going to hasten their death. So, we never want to give somebody too much. We also don't want to give somebody too little. I'll give an example of a case that I had a few months ago from a relatively young lady who unfortunately was ill with cancer and the treatment had stopped, but she was told she has 3 to six months left to live. And I get a call from a family member somewhere far out of the uh far out of the northeast area just to keep the case a bit vague. And the mother had gone on hospice just a few days after stopping treatment. And she was told she has 3 to six months left to live. And the family tells me that my mother's not doing well. She's on hospice. They've been giving her a tremendous amount of pain medication. She's no longer responsive and and I think she's dying right now. So, the first thing I tell her is call the paramedics because we're over 3,000 miles away. It came out through the story that she had had some pain. She had some agitation and the hospice team was giving her a extremely high dose of medication every eight hours to the point where they gave her five times the normal dose for a regular person. And unfortunately, she passed away quite quickly after. And the unfortunate point of that case is that we could have given her the appropriate pain medication to made her comfortable and she could have lived three or six or even more months in this world and been with her family, been with her children and been with her grandchildren and enjoyed them during those last few months. And unfortunately that was not the case. And this is many of the cases that we try to point out to the family that there is a a balance that can be struck between making a patient comfortable but not hastening their death and pain medication especially something that we deal with quite frequently. >> If I may add just to Rab Milman that this is one of the major issues I think that the Torah Jew has is that at the same time there's something called quality of life and there's something called life. Now, which one is of prime importance and which one is secondary? So, although like Rabbi Milman said, as Torah Jews, we have a mitzvah to make sure people aren't in pain. I just literally on Friday got two calls regarding this where somebody was in a lot of pain and their family didn't want to give pain medication because they were concerned they would hasten death. But we worked out with the hospital that as long as we followed a certain protocol, we wouldn't be concerned about hastening their death. And thank God the person we were able to alleviate their pain. So we have to be very concerned about pain. But the difference between the secular world and ours is is quality of life the main concern or is life the main concern. As a Jew, our main concern is life and not to shorten it. At the same time, we're we want to go ahead and make sure that we alleviate pain and not leave somebody, god forbid, in pain. And we try our best to find a happy medium in working with the team. And when when we explain to them clearly what our goals are, our goals are for the patient not to be in pain, but not for you to go ahead and shorten their life. I find many times as long as the team is clear into what we want, we're able to work together and find a happy medium and make sure the patient's not in pain. But at the same time, not to, God forbid, shorten their life. And you know, I could tell you for people who sometimes didn't know this or didn't ask a question. You know, sometimes there's a lot of guilty feelings afterwards that maybe I shouldn't have done it, maybe I should have done it. And one thing is when you ask a shah a question, you ask the rabbi and therefore you could be guiltfree. you did what the Torah said to do and you're able to sleep much better at night knowing that you did the right thing and you treated your loved one because many times you're in a very vulnerable situation. You have a doctor you never met before or you've known them for a month or two and you're making major decisions for your loved one based on somebody's recommendation and many times that recommendation is not necessarily a medical recommendation. It's a personal opinion recommendation and therefore we have to make sure that we split between a medical opinion and a personal decision. And I believe that's one of the main issues that you always have to figure out is what the doctor or the team telling me is that a medical appropriate decision or is that a personal decision? And when it's a personal decision, as Jews, we're going to take the medical knowledge and then interpret it in a Jewish way and then decide what to do with the medical decision as opposed to have them tell us what their what they would personally do is very well-meaning, but it may not have relevance to us. >> Okay. And well from a legal perspective, what legal rights do do the families have um in in the US according to the US um the the legal system um in in in as it pertains to making medical decisions based on >> Okay. So that's a a wonderful question. There's one particular situation which unfortunately comes up which is when we discuss what's known as brain death. You know, there is a legal definition of brain death that has been accepted in the United States of America and other parts of the world. I'd rather not go into all the details, but however, in specifically New York and New Jersey, where I believe most of your listeners live, um, a person has to know that they have a lot of legal rights. And in the law, which I have right here, and I'll read for you what it says. It says when they're going to do something called a brain death test, which is where they need to prove that the person legally is what they call brain dead, there has to be reasonable accommodation of the individual's religious or moral objection to the test. And therefore in New York it's been interpreted as religious accommodations is that if a patient will say that because I don't religiously accept brain death as the definition of death which by and large most orthodox rabbis a high majority will not accept that. Therefore they're able to go ahead and say please don't do the test. And it's very important to know your rights because if you stop them from doing the test, then they won't won't have a legal definition of death and they'll continue treating. However, once they've done the test, at that point the person doesn't have legal rights as much to push them off because if they declare the person not to be alive, then the person doesn't have insurance. Only live people have insurance as as defined by secular law. And therefore, it's going to create a lot of problems. So in New York and New Jersey, you're very well protected in terms of asking the team not to perform any confirmatory brain depth tests. And once they do that, we're almost always able to work with the hospital if even if they don't want to care for this patient, we find facilities to transfer them to and the patients able to live out their life. I've also found in other states where you're not as protected, if we work with the medical team and show them that we want to go ahead and help transfer the patient to another facility, they're almost always accommodating and they'll work with us as long as they see that we're on top of things and we want to go ahead and work with them as opposed to against them. But it's very important for people to know their rights and we're very well legally protected in many ways across the United States. And I'll just jump off off of that. I want to give a case that Rabbi Cass kind of demonstrated. It was one of the first cases I was involved in. And there was a quite quite an ill lady at one of the top hospitals in the country in New York. And the head of the ICU called me in a in a panic because this lady in his opinion was probably brain dead. Of course, we directed them not through the brain death testing. And he was very frustrated and tells me, "Rabbi, what what is she doing here? I need the bed and we have to get her out and move her to somewhere else. And he was pressuring the family to do certain things. And after a very long and productive conversation, we developed a plan together to take care of some things in the hospital and then discharge her to a facility outside of the hospital. And at the end we spoke again and he was extremely comfortable and extremely happy that together we were able to work on a plan to make both the ICU team and the medical team happy and of course make sure that the adherence took to Jewish law was kept at the utmost as well. And I have found that many times family members discuss legal and and a lawyer. And unfortunately sometimes it is true that approach has to be taken. But I have found that in the vast majority of cases and I'm sure many of the have similar experiences is that when you convey to the team that we're here to help you, we're here to work together to do what's best for your patient. At the same time, we're here to make sure that the tradition of this family is kept to the utmost. Often there's a plan that's amendable to all parties involved. And sometimes it involves the hospital going a little bit out of their comfort zone, but they know that they're doing this with a plan in place and it makes their job much easier and therefore they're much more accommodating. So we always try to do is speak to the doctor, speak to the attendings, speak to the residents, speak to the fellows, speak to the nurses, anybody who is a material party to this patient. The more collegiality we have together with them, the more we're able to be effective. And many and a lot of what does is meetings with the rabbana cats and I have had many meetings together last was a memorable one with the major team at memorial ketering about a certain case and they're very listening and very open and very happy to hear what we have to say because often they realize that there's a plan there's an approach and there's a structure to what we're doing and they're very comfortable operating within our parameters even though it may be dissimilar than the parameter that they believe in. So, we do often have legal recourse, but we try very hard to avoid it and and instead we try to approach it as a team together that we're all working for the best of the patient and by keeping her ethics and her values or his or her values as with a primacy, they value that as well. And often we're able to accomplish what we need without having to take the, you know, legal or more technical approach. >> Thank you. This was so informative. We have we have a we we have a we have a tradition that we that we that we ask the guests to to leave us off with a final message. So I guess if you could both both give us a uh closing final take-home message for our listeners. >> In terms of the concluding remarks, first of all, I want to thank everybody for listening and taking their time to enjoin with us in this critical information. Shalom. God forbid nobody should ever need the services of but if anybody would ever need we have a hotline it's 24 hours a day it's 7 days a week it's days a year we all work together to make sure the is adhered to and you should never ever ever feel alone in a hospital feel lost you feel confused you don't know where to turn to you feel like perhaps there's more to be done you feel perhaps there's other things that should be done no one should ever hesitate to call us and We are here for Kai Israel. We will always be at the beck and call for the needs for all of Hashem's children. >> Just in in conclusion, I just had a very difficult phone call with somebody whose husband is not well and his level of consciousness is is waning. And I shared with her the following story which I found she found to be very powerful and she thanked me profusely for sharing it. So I want to share it with all your listeners. There was once a very big gudle who at the end of his life was declining and somebody went to the stipler goon in Benabra and asked him what's the point of this person's life they used to be a big roshiva they used to give lectures and help people and pray and now they can't do any of that they're sitting at home and doing nothing what's the point of them being alive so the stipler explained that you have to look at it from a Jewish perspective. He says the garra in kaducian on 48 says that a Jew that wants to do a mitzvah but it's beyond his control he's not able to do the mitzvah. So he or she gets reward as if they did the mitzvah. When it comes to doing an aa something which is improper if the person tries to do the a and didn't do it they don't get punishment. The stifler said, "What would this great rabbi have been doing if he wouldn't be sick? What would your loved one, I said, be doing if they wouldn't be sick?" She told me what he'd go pray. He'd go help people. He would give sodaka. He'd give charity. So I told her every moment that your loved one is alive, they're getting 100%ar reward for every good deed they would have done if they wouldn't have been sick without any aos without any blemishes. So although we wouldn't necessarily want to go ahead and pick that type of life for anybody but at the same time if those are the circumstances we have to understand that it's not that our hands are tied together. We're Jews we can't end their life. The loved one themselves is gaining a tremendous amount of reward for every moment that they're alive. every moment they're alive, they're getting eternal reward that they themselves are going to be eternally thankful to you for helping them. And at the same time, like we said before, a person shouldn't be in pain. And we therefore we have to treat that aggressively even though the person is gaining eternal reward. But don't think that that person is not gaining. That person is gaining a tremendous amount. And the stipler said just this person being around personally, he himself or she is gaining tremendously. After I got off the phone with this woman, she told me as I was getting off, she said, "Thank you. You've changed my perspective in caring for my loved one. Now I understand that I'm helping him every moment of the day when I go ahead and treat him, give him hydration, give him nutrition." And in fact, I've had people, we just had a case on the hotline where the doctor said, "We think she's too weak. We should let her go. She's not going to have a high quality of life. I had a phone call with her a couple of weeks ago where she said, "Rabbi, I want to thank you and for helping me because I just stepped outside and I got the beautiful sunshine. Thank you for not giving up on me and thank you for working with the doctors to save my life. Now, not only is she able to go ahead and act like a Jew, she's able to live a comfortable, relatively comfortable life in circumstances she wouldn't imagine. She said, "Thank you for not giving up. Thank you for giving me hydration and nutrition. It made me stronger and I was actually able to even get better." Thank you, my Milman, for this very informative um discussion. Um and and thank both both of you and and what you do for it's literally life-changing life-saving organization. If um you said that so many thousands of people call in on the on the hotline every single year. Um can you let us know what what the phone number is? People could call in if it if it comes up. >> Yeah, it's 718 Aruim 718-2782446. 718-278-2446. That number is available 24/7. >> Okay. Um we appreciate it. Thank you so much everyone for joining us. We thank Rabbi Katz, Rabbi Milman taking the time from the busy schedule to to join us. We want to thank everyone for for joining us of course every every single Tuesday night that 8:30 p.m. on Kazak. I want you to join us. Want to thank Tory Time of course one of the one of the streaming platforms. Torn time is a major um partner with Kazak and um we want to thank of course um our friends at Daily Giving who are um just an amazing life-changing organization. Um and everyone can sign up at daily giving.org. Thank you everyone. [Music]