Death and Dying

“A Time To Be Born and a Time To Die”

Yom Kippur 5778 Sermon
Rabbi Ruth Gelfarb

As a little girl, I used to marvel at the pageantry of Kol Nidre and Yom Kippur. Erev Yom Kippur, there was always an aroma of pre-fast chicken soup and an air of solemnity in our house. At synagogue, the Torahs would be adorned in white. Our rabbis and cantor would be dressed in white kittels or robes. And the bejeweled torahs would be taken out of the ark. The congregation would stand. We’d stare at the open, empty ark. My feet would grow tired. I would start to think about the coming hours without food or drink. I felt a sense of awe, wonder and a deep somberness –the meaning of which I, a young child, could not even begin to discern. The years passed, each Kol Nidre, I felt the same feelings.

It was not until, I went to rabbinical school that, thanks to my teacher, Rabbi Dr. Larry Hoffman, a world-renowned scholar of Jewish liturgy, that I began to understand the deep symbolism before me. Each year at Kol Nidre, we spiritually, emotionally, and physically prepare for our deaths. We are encouraged to dress in white, in linen. The same clothes that those who follow Jewish tradition will ultimately be buried in. We remove the torahs and we stand before an empty ark. The empty ark evokes an empty coffin. In fact, Hebrew the word for ark and coffin are the same – ARON. The call is clear, People get your life together. Our time on this earth is limited.

We do not know when our last day will be—tomorrow or in 50 years. We do not know if we will endure a long illness or be quickly taken by a fatal accident. And so, our brilliant tradition reminds us, urges us, pushes us, sets up the structure and time to get our lives in order. To put aside that which can be put aside so that we can heal that which is broken.

But tonight, unlike last year, I will not discuss with you- how to live a better life. Rather, I will discuss how to have a better death. Yes, I know it is a “morbid” topic. But it is one that is too important to ignore. In my roles as a rabbi and an ethics advisor to a local hospice, I knew this topic was important but I shunned discussing it in a sermon, particularly a High Holiday Sermon. However, my experience as a daughter and a sister over these past 24 months compels and propels me to speak on the topic. Not only as a rabbi but as a daughter, I have spent the past 24 months in hospital rooms, ERs, ICU, CCUs, Chemotherapy Sessions, wig buying expeditions, and home hospice. In the last 13 months, both my mother and father died.

I want to share my experience so that it might be help to you and your family if you find yourself in similar circumstances. At the same time, I am only sharing my personal familial experiences because I want to respect the confidentiality of the many, many families with whom I have journey thru dying, death, burial, mourning, and renewal.

I also acknowledge that there are others in our community who have recently lost loved ones. Members of our community have loved ones living with serious illness. And, there are others in our SOS community themselves who are living with serious illness. So, if this topic is not one that you are comfortable hearing tonight, I invite you to step outside for next 20 minutes.

In the Book of Ecclesiastes, part of the Hebrew Bible’s Wisdom Literature, we read “There is a Time to Be Born and A Time to Die. In the Jewish tradition, perhaps unlike in other faith traditions, when a person becomes a gosses (a rabbinic term for one who is close to death) we do not take action to hasten death yet removing or not continuing what stands in the way of the natural dying process is permitted.

There is a story in the midrash which is over 1500 years old that I want to share with you. It concerns the great scholar and beloved teacher Yehuda Ha’Nasi. Yehuda Ha’Nasi was very, very ill and suffering greatly. His talmidim, his students, gathered around him and prayed day and night for their teacher’s recovery. While he was not recovering, Yehuda seemed to be kept alive by their fervent and heartfelt prayers. Now Yehuda Ha’Nasi had a caregiver who lived with him for many years. She knew him very, very well. She saw that his suffering was great. She saw that the students prayers may have been standing in the way of a natural process. So, she took a vase from a shelf and went to the roof of the house. She dropped the vase. Startled, everyone stopping prayer for a split second. And during that moment, Yehuda Ha’Nasi’s soul left his body. The text views the caregiver’s actions with merit. When a cure and recovery are not possible, delaying death and increasing suffering, our wise tradition suggests, is not the preferred course of action.The prayers for Rabbi Yehuda ha’Nasi are not unlike the sophisticated medical technologies available to us today. They can keep us alive and prevent the natural processes of death from occurring.

My 90-year-old father, who was a physician, did not have a long-term health care plan in place. Throughout his life, he just didn’t want to discuss death. As a result, in the past several years, dad who living with advanced congestive heart failure and other ailments was rushed to hospital which carried out medical procedures and tests. Just last month, dad was rushed via ambulance from his rehab facility to the hospital. Without an alternative in place, the doctors intubated dad, gave him IV antibiotics, and kept him sedated. The team of excellent medical providers were providing thoughtful care and doing their best to cure dad of what ailed him.

After 7 days at the bequest of the hospital, we had a family meeting with the doctor. He told my brothers and me that dad’s antibiotics were not working as he would like and that their initial efforts at weaning dad from the respirator were not successful. Well, what does that mean? Well to my eldest brother it meant, let’s keep on trying more antibiotics. Let’s give it more time. Let’s try to wean him more. After all thanks to the sedatives, dad looked peaceful and relaxed, like he was sleeping. My eldest brother sharply inquired, “Why wouldn’t we keep on trying?”

At my request, we met with the palliative care team. They spoke to us in clearer terms. “Your dad’s body is not doing the work it needs to do to allow antibiotics to work. His body is too weak to make use of the antibiotics. He is not able to get the oxygen he needs without the respirator. When we try to wean your dad from the respirator, his heart races and he panics. Due to his congestive heart failure, there is too much strain on his heart. I am sorry, but your father is not going to get better.

What are options? Gallit, the palliative care LPN, shared, “Your options are to put your dad on a respirator and feeding tube and move him to a special long-term facility where he would live like he is now. Or, you can take him off the respirator. She explained our options in clear, lay persons terms and the implications of those choices.

Miracles happen but it was more helpful to be told that my Dad would not be Getting better. Why? For the same reason that in a Jewish funeral the mourners put dirt on the coffin of their loved ones. In a time when we cling to magical thinking, it is important to help make ones’ thinking real so that we can live in reality before us so that we can make informed, compassionate decisions.

Thankfully, my dad had a living will. It said that if recovery was not possible, dad did NOT want to be kept alive in an unconscious state through the use of feeding tubes and respirators. We would follow dad’s wishes.

Thankfully, we had a living will, without one there could very well have been great conflict in my family between my brothers and me about what to do.

Thankfully, we were able to FIND that living will and health care proxies. At first, no one knew where they were kept.

Thankfully, there were palliative care professionals whose job it was not to try and CURE the INCURABLE but rather to relieve dad’s suffering and provide comfort. Thankfully, these same palliative care professionals provided us, the family, with clear information and escorted us on this journey every step of the way.

Thankfully, there is an organization called the Conversation Project, which I bring to your attention tonight. The Conversation Project is dedicated to helping people talk about their wishes for end-of-life care. The conversation has something called a Starter Kit, a useful tool to help people have conversations with their family members or other loved ones about their wishes regarding end-of-life care and wishes. I wish I could tell you that my parents (a doctor and a teacher) had this conversation with us. They did not. However, Tom’s family and I have had used the Conversation Project’s materials. And we are glad we did.

I wish my dad would have been willing and able to talk to his family, or rabbi, or doctor about his long-term health care plans, at some point, especially before his health and faculties deteriorated so dramatically. In contrast my mom, who was diagnosed with Stage 4 metastasized pancreatic cancer in December 2015 did. Mom was really, really angry about being sick. She was angry the whole time. Yet, she willing to talk about what she wanted to do with the time she had. She wanted to be treated aggressively, although the treatments were always palliative. Without complaint over 7 months, she went thru 3 rounds of chemotherapy at Memorial Sloan Kettering Hospital (MSK). Yet, mom also made sure to honor that which she held sacred and that which gave her life meaning. Mom told her doctors that she wanted to take a trip to Boulder and visit her daughter’s new home. Mom wanted to go to her granddaughter’s college graduation. Mom wanted to go on an overdue trip to celebrate her 80th birthday. Mom got to do those things. Her oncologists and palliative care team made that possible.

During our visits and time together, I thanked mom for all she had taught me. I thanked her for all she had done for me. We reminisced- we laughed and we cried. I apologized for the numerous ways I had let her done and hurt her. She apologized to me too. Although I would miss her more than she could ever imagine, I let her know that I would go on living a good life. I told her over and over again: I love You. She always replied: I love you more. (I think she did!)As the months progressed, mom began to eat less and less. She grew thinner and thinner. She grew weaker and weaker. She slept more and more. One day, during her 3rd round of treatment, Mom turned to her sister, My Aunt Sue, and asked, “is there a time when you would stop receiving chemo and stop these treatments?” Lovingly my aunt who had been at mom’s side all along and had encouraged an aggressive approach from the start, replied, “Yes, Lois, there is a time I would stop. When it just isn’t helping anymore.” My mother replied, “I’m surprised to hear you say that, Sue.” In her own way, my aunt was giving mom permission to stop the exhausting, debilitating treatments. My aunt was telling her sister, There is a Time to Live and A Time to Die. Like many people close to death, mom needed to know that her loved ones would be ok. She told my aunt, “Ruthie needs a mom.” Aunt Sue replied, “I will be there for her always. I promise.”

Shortly thereafter, it was clear to anyone who looked at mom that her treatments were no longer working to slow the growth of her tumors. She was sleeping more, and more. Her doctor told her, “Lois the treatments are no longer working. They are going to do more harm than good. Mom knew what that meant. It was devastating. She was so angry. Yet, the disease was taking over. Mom shared that she wanted to be at her home (where she had lived for 49 years) and not in a hospital for her final weeks and days of her life.

We were able to arrange that for her.

In Preparing for tonight’s sermon, I had a long talk with Gallit, the Pallitve care LPN, at my dad’s hospital. I asked her what she wished her patients and their families knew and acted upon long before they ever reach the Hospital’s ICUs and ERs.

This is what she said,

  1. I wish people were not in denial about death. There is nothing unnatural about death. Death is a part of the process of life.
  2. Knowing that we will all die sooner or later, I wish people would plan ahead. Sooner rather than later. I wish people would have conversations with family, doctors, clergy, lawyers, and make their end of life treatment and long term care wishes known. They should do the necessary paperwork and let people know where it is.
  3. By not doing planning ahead, Gallit elaborated, typically more medical procedures will be done for longer periods of time, even if the patient is unconscious and there is no help for a meaningful return to life.
  4. Finally Gallit shared that The ER, ICU and CCU are very inopportune places to make life and death decisions. “I can’t tell you the number of fights I have been privy too,” Gallit painfully shared, “in which well -intentioned family members, with differing ideas and views, debate what to do. The hurt feelings sometimes last a long, long time. It would be better for all if they were following the expressed, articulated wishes of the patient.” Not planning ahead also leads to unnecessary strife between loved ones.

I have prepared an email for you which you will receive after Yom Kippur. The email has a reading list of novels, biographies, autobiographies, medical non-fiction that deal with the topic of death and dying. It includes the NY Times Best Seller: Being Mortal by Atul Gawande. I hope there is something for everyone. The email also has information on the Conversation Project and a link to their starter kit. I encourage you to check it out. I invite your during my visit in October and December (or anytime for that matter) to arrange a coffee date with me to talk thru any of this, if you would like.

If you or your family members just are not able to have these kinds of conversations, then please do your best to love them, treat them with utmost respect, compassion and lovingkindness. We are all doing the best we can!

Friends, in the beginning of my remarks I said I was going to speak not about how to live a better life but how to have a better death. That wasn’t totally true. I hope you now realize that in our tradition death is in fact a part of experience of living. May we all be blessed with a good life.