June 21, 2011 What I’ve learned in 30 years as a rabbi RABBI MORLEY T. FEINSTEIN http://www.jewishjournal.com/ opinion/article/opinion_what_ive_learned_in_30_years_as_a_rabbi_20110621/

“The results of a computerized survey indicate the perfect rabbi preaches exactly 15 minutes. He condemns sins but never upsets anyone. He works from 8 a.m. until midnight and is also a janitor. He makes $50 a week, wears good clothes, buys good books, drives a good car and gives about $50 weekly to the poor. He is 28 years old and has preached 30 years. He has a burning desire to work with teenagers and spends all of his time with senior citizens. The perfect rabbi smiles all the time with a straight face because he has a sense of humor that keeps him seriously dedicated to his work. He makes 15 calls daily on congregation families, shut-ins and the hospitalized, and is always in his office when needed.       “If your rabbi does not measure up, simply send this letter to six other synagogues that are tired of their rabbi, too. Then bundle up your rabbi and send him to the synagogue on the top of the list. In one week, you will receive 1,643 rabbis and one of them will be perfect. Have faith in this procedure: One congregation broke the chain and got back the rabbi they fired 25 years ago.”            I am certainly glad I never read that bit of humor before I was ordained 30 years ago this week. Yet there is an element of truth in the joke. People expect that we rabbis in congregations are Jewish experts at everything; every question can be answered because we have an infinite amount of time to handle every event, meeting, committee, class, service and program; use phone calls, e-mail, letters and postcards; and deal perfectly with every baby, toddler, child, teenager, college student, the single, the married, the young and the old. We actually are the harshest critics of what we do when we fall short of our own expectations. Through my 30 years of rabbinical experiences, I have learned to have the highest expectations of myself, because I can never know exactly what generates how a congregant may view his or her rabbi.        Along the way, I have learned that my actions speak far louder than the words of my sermons. When I spoke about homelessness in Indiana, and then urged my congregation to help with the founding of the South Bend Center for the Homeless, there was a connection between word and deed. And when my sons became bar mitzvah, and each wanted to plant a tree as a mitzvah project, they were witnesses to our concern for the environment. We are living role models of Judaism, and that is most important for our children. I can’t speak about workers’ rights without caring for every waiter, busboy, parking lot attendant, carwash jockey or store clerk I meet. I can’t talk about the holiness of our Sabbaths, festivals and sacred times if I don’t observe them. I can’t profess concern for Israel without visiting there, learning about the land and the state, and teaching about the importance of Israel to us as Jews. Rabbis cannot be hypocritical.       Our sources from the ancient past continue to speak to me about life in the present. I have learned to extract from our tradition and from my teaching the way to make our texts speak to modern life. This world may be filled with a little device that holds more technological power than the first spaceship, but the stories of our biblical heroes and heroines, prophets and judges, the questions raised by the talmudic rabbis about ethics and morality, of what is right and what is wrong, about how people are to deal with one another, maintain extraordinary relevance today. This past week, as we discussed matters of lifnim mishurat hadin — going beyond the letter of the law — my adult students raised profound links to the ancient texts ranging from the daily news to sophisticated philosophical questions. Even more so, our younger students approaching bar or bat mitzvah and their tichon high school years must learn how our ancient sources can speak to us each and every day.        And that requires that we rabbis continue to put the fuel of knowledge in our spiritual tanks. Early on, I learned the value of continued study and rabbinic camaraderie. Meeting colleagues over the ancient texts of our tradition, learning from them and with them, has given me the energy I try to bring back to the congregation. It authenticates us as rabbis. It reminds us of why we became Jewish role models and teachers. Study connects us to Hebrew and to the essence of our faith. It brings us close to the only people who truly understand what we do — other rabbis. From rabbinic gatherings, to my work in local regional and national associations as member and officer, to my fellowship at the Shalom Hartman Institute in Jerusalem, I live by “oh hevruta oh mituta” — comradeship or the death of the spirit (Ta’anit 23b) “for the Torah is not learned alone but in pairs” (Brachot 63b). Martin Buber was right: Relationships matter. Rabbis uniquely enter the incredibly holy and personal space of individual lives and family processes. So much of what we do is never seen at all by the congregation — it happens in private, in the office, at a home or hospital or nursing home, without the whole congregation or its leadership watching. It is in the inner personal relationship that we live our Torah. Every child has to feel that his bar mitzvah is the most important. Every bride has to feel that her wedding is going to be amazingly special. And every funeral is unique because family dynamics are unique. There are no cookie-cutter recipes for such moments. A wise president of my temple once said every bar mitzvah is the same, and there’s none like any other. We rabbis have to be fresh and inspiring and personal and warm to the limit of our abilities. And our presence at such moments can, in the eyes of the family, represent the totality of Jewish faith and tradition. Not every moment, however, is easy, sweet, meaningful and enjoyable. When tough moments do come, rabbis may receive criticism because we are in the public eye. Whether fair or not, listening carefully, dealing with the critic kindly and understanding the comment are essential. We must remember that perception is reality. And we cannot shrink from facing that perception even when it may hurt. Apologizing maintains a balance in the relationship even when it is strained. I have visited people in their homes to apologize, even if I felt wronged, and being direct and honest about such moments has helped bring healing. Two final and essential lessons: We rabbis are privileged to teach God’s Torah. We have to be God wrestlers ourselves, Yisrael, a people deeply bound to and engaged in a hearty and constructive dynamic with God. Some may think us odd to be believers when they themselves are not. Most have given up on their fourth-grade concept of God but not refreshed themselves from the springs of our heritage with a new idea, a radically different concept. That’s why I challenge every bar or bat mitzvah and confirmand to struggle with a personal and individual God concept. We rabbis must be God-enthused, God-intoxicated, God-enveloped,  because if we are not, how can we possibly expect others to relate? And when we are personally challenged — by the death of the young, the innocent, the suffering that has neither logic nor reason —that is when we must draw deep from the wells of our faith. Most important, we have to place our family on our pedestal, always in front of our eyes, always before us, always before the consuming, demanding, energizing, crazy and sometimes ridiculous pressures we face. Family gives us our strength, our hope, our nourishment, our love. Many synagogues have the words inscribed near the Holy Ark, “I have set the Eternal always before me.” Rabbis need to have the words inscribed on the walls of our offices, “I have set my family always before my rabbinate.” When we take care of those nearest and dearest to us, we can be genuine. If we don’t, we can rightfully be called phonies. A congregation that cares for its rabbi and his or her family welfare ensures that the rabbi will be able to continue to give as much as possible back to the community. It’s a relationship based on our covenant. In Torah portion Beha’alotcha, Miriam and Aaron challenge Moses’ leadership and criticize his wife. Yet the Torah responds, “[T]he man Moses was more humble than anyone on earth” (Numbers 12:3). Nachmanides interprets this to say that Moses never quarreled, never expected anyone to hold him in esteem and did not boast about his merits. Moses recognized his own faults, personal flaws and limitations, even though he was chosen by God for his holy task. We rabbis must follow the example of Moses as we remember our history, work each day in the midst of the community with its heartaches and joys, and always keep our eyes on our goal of reaching the Promised Land. Amen. Morley T. Feinstein is the senior rabbi of University Synagogue in Los Angeles.

© Copyright 2011 Tribe Media Corp. All rights reserved. JewishJournal.com is hosted by Nexcess.net. Homepage design by Koret Communications. Widgets by Mijits. Site construction by Hop Studios.

Advance Health Care Directive:  A Jewish (and Human) Necessity

Rabbi David Novak

Delivered on Rosh HaShanah morning, September 9, 2010/1 Tishri 5771.  Expanded from what was delivered.

None of expect to be incapacitated in such a way that we are unable to express the direction of our health care.

Yet it happens, more often than any of us would want.

Even though our High Holy Day liturgy has famous lines like “Who shall live and who shall die” ascribing the sum total of all of our fates to God’s hand, the fact remains that we human beings have the ability and the responsibility to articulate preferences by our own hand for those times when we are unable to express them.

This is done by creating an Advance Health Directive.

Last January I was in need of such a directive.  January 1, 2010 in the morning, fine.  By the middle of Friday night worship, not so good.  Saturday is lost to me, as is Sunday.

Apparently I was alert to make decisions on Monday and Tuesday but the entire week is lost to me.  

I was not aware of what happened to me, or of my surroundings, until late Saturday night.  By Sunday I was competent to express what I desired.

But what about the entire week?  I don’t remember anything.  

Fortunately I had a health care advance directive that I created during my time in California that left my partner with knowledge of what to do and the legal power to make decisions on my behalf.  This allowed my mother to defer to what he wanted.

This leads me to tonight’s sermon:  why it is a religious responsibility for every Jewish person to have an Advance Care Directive for health care.  

Why a religious responsibility?  Because we Jews are lovers of life.  

We respect and embrace medical care to preserve and extend life.  

We affirm p’kuach nefesh, the preservation of life as one of the highest Jewish values.  

Jewish people are required to take whatever steps are necessary to preserve life, even if it means violating other laws, such as those of Shabbat.   

And we affirm that while the liturgical trope of the Yamim Noraim, Rosh HaShanah and Yom Kippur, is that God writes us in the “book of life for good,” there is much that we can do to articulate our own wishes.One way that each of us can assert p’kuach nefesh for our selves is by creating an Advance Directive. 

If we could look under the skin in our bodies we would experience an architecture both marvelous and artful.  It all works together.  Heart, brain, lungs, liver, glands, blood, oxygen, air, food, joints, our senses.  The human body is miraculous.  When it works well we are really unaware--or unconscious--of our underlying health.  After all, when you feel well, why even think about it?  

And then there are those times when our health becomes an ever-present issue.   Rabbi David Hartman once said, “You never really appreciate the prayer for health until one of those passageways is blocked!”

Rabbi Hartman is, of course, referring to the prayer that is said each morning:  

Blessed are you, THE ARCHITECT, our God, the sovereign of all worlds, who shaped the human being with wisdom, making for us all the openings and vessels of the body.  It is revealed and known before your Throne of Glory that if one of these passage-ways be open when it should be closed, or blocked up which it should be free, one could not stay alive or stand before you.  Blessed are you, MIRACULOUS, the wondrous healer of all flesh. 

Complementing that prayer is what we pray in Kol ha Neshamah that does not ask God for divine intervention in the illness, but rather that those in the medical establishment use all of their skill and knowledge to bring about healing to grant us a length of days.  There is no promise to God that our individual merit will be recognized in response to our request.  

This reflects, to my mind, a theology of creation that believes that all was created at the time of creation, to be discovered in its own time.  This is why the advanced medical technology that we benefit from today makes me glad to live in 2010 instead of 1910.  Human knowledge coupled with technology has advanced medicine dramatically in the last hundred years.  Can you imagine what it will be like one hundred years from now?

Yet with all of the advances come new profound challenges, especially around end of life care.  There are now machines that can keep us alive, often indefinitely, often without brain waves, often without our choice. 

Few of us will make the journey from birth to death without encountering the medical system in a serious way.  Which leads to this most important question:  if we don’t think about what we would like to happen when we cannot advocate for our selves, what would happen?

What would happen is that doctors would be do whatever they could to preserve life.   This is the oath they have sworn to uphold.  Lacking a health care directive means you lack your voice in times when your voice cannot speak.  The lack of voice translates, perhaps, into decisions you would have never made for yourself. 

As a lover of life, as a Jew, as a human being, you cannot afford to lose your voice.  If you cannot speak for yourself, you absolutely must have an agent appointed, as well as a deputy agent, who can speak for you in times like this.  

Our desires must be respected because as Rabbi Elliot Dorff writes in “Matters of Life and Death” “the fact that we can medically do something does not necessarily mean that we should.”

Rabbi Dorff, a renowned medical ethicist, continues:  “Whether we should something depends, in part, on good medical information, but it depends at least as crucially on our own value system.” 

What needs to be done, he writes “requires us to relate this specific question to our broader concepts and values. Ultimately it is the patient who has the legal right and must take the moral responsibility to make the decision according to his or her own values.”

As a forceful advocate of the Advance Health Directive your silence does not become complicit in your care.   Your voice will be heard even when you cannot articulate what you want.  

Second, you will prevent your family from making difficult decisions, for example whether to maintain life support.  

As Rabbi Dorff sagely concludes:  “By filling out an advanced health care directive, a person saves near and dear ones from the moral responsibility of making such decision and from the arguments that may otherwise occur.”

In other words, no matter how emotionally taxing these moments are, your voice is allowing your family the comfort in knowing that they are doing exactly what you wanted.  

We are blessed with many things in Vermont, including support for creating Advance Directives for health care.  The Vermont Ethics Network publishes a booklet, “Advance Directives Vermont:  Taking Steps:  Planning for Critical Health Care Decisions.”  

What is so magnificent about this little booklet is how encompassing it is in guiding our decision-making in the health-care setting.  Let me assure you that I was gratified to have the strength to navigate many of these issues myself over the past several months--but if I had been unable, a directive such as this would have been akin to my own speaking, through my agent.

Thinking about these issues when you are in good or relatively good health gives you and your loved ones an opportunity to prepare for the sort of medical crisis that can happen to anyone at any time.  If your health is already compromised, it is important that you create your Advance Directive right away:  the people who love you need to know what you want, and it needs to be in writing.

No matter how young or old you are, how healthy or sick, you need an Advance Health Directive.  At any time you could have an accident or unexpected illness and suddenly be unable to speak for yourself.  

First:  choose an agent and if possible, an alternate agent, people whom you trust to make potentially difficult decisions for you, who understands your beliefs and values, who is likely to be available, and who is wiling and able to speak up clearly and firmly in a crisis.  Your personal physician cannot be your agent.   It can be a family member, but make sure that the alternate is someone who is outside of your immediate nucleus. 

Second:  Talk to your agent.  Make sure he/she understands you and is willing to support your views.  If you have someone who does not agree with your views, you should choose someone else.  What is important is that your agent faithfully represents what you want, irrespective of their own personal opinion. 

Third:  talk w/others; ask your doctor for any medical information you need and find out if he/she supports the instructions you plan to give your agent.  Your doctor may be able to recommend more effective ways to state your instructions.  Consult with your rabbi if you have religious questions, especially with respect to organ donation.

Fourth:  Write your Advance Directive.

The key step in writing your Advance Directive is to name your agent.  Once you have done that and filled out the form properly the law requires that decisions about your care cannot be made without considering your wishes.

Fifth:  Sign and distribute the document.

Sixth:  Review your Advance Directive.

Remember that for many people revisiting the Advance Directive is an ongoing process. Changes in your health may change your views about your Advance Directive.  You should talk to your agent as well as your doctor about these things.

______________

That’s the nuts and bolts of creating the directive.  Behind it is the process of distinguishing what you do and do not want to have happen for you.

These are not easy questions, and they should not be easy, for you are considering situations that few of us want to ever consciously consider.  

What do you value most about your life?

Do you hold any religious or moral views about medicine or particular medical treatments?  

Jews who think of  themselves as “traditional” believe that God as the giver of life is the only one who can take it and thus write directives that instruct the medical team to do everything within their power to preserve life.

Liberal Jews assert more authority over their own bodies and health and are willing to consider decisions that may allow the end to come sooner.  No matter what your religious beliefs, you need to consider them in concert with your other concerns.   This is why some people find it a good idea to talk with their rabbi during this process. 

Most people have heard of difficult end-of-life situations involving family members or neighbors or people in the news.  Have you had any reactions to these situations?  

Should financial considerations influence decisions about your medical care?

What other beliefs or values to you hold that should be considered by those making medical care decisions for you if you become unable to speak for yourself?

You can see just from this recitation that there are many, many factors that go in to shaping an Advance Health Directive.  

Medical Situations and Treatment

Next consider possible treatment plans:

A. I would want all possible efforts to preserve life as long as possible.

B. I would want comfort care only and would not want medical treatment, including tube feeding, to prolong my life.

C. I would want comfort care and tube feeding, but would not want other types of medical treatment to prolong my life.

D. My agent should consider the possible benefits and burdens of disease-fighting treatments and consent only to treatment that he or she believes is in my best interests, as we have discussed them.  My agent may refuse any active treatment and then stop treatment if it is not beneficial. 

------------

Then review possible medical situations:

Suppose you are dying.  You are unconscious and death is expected soon, with or without treatment.  What treatment plan would you want?

Suppose you are permanently unconscious from an accident or severe illness. There is no reasonable hope of recovering awareness, but life support could keep your body alive for years.  (persistent vegetative state).  What treatment plan would you want?

Suppose you are in advanced loss of mental capability.  You cannot recognize or communicate with those close to you and can do almost nothing for yourself.  You could survive in this state for some time with medical treatment.  What treatment plan would you want?

Suppose you are frail, chronically ill, and uncomfortable, with a limited range of activities available to you. Then you become unconscious, at least, temporarily due to an acute illness. The illness is likely to be fatal unless vigorously treated in a hospital, but even intensive care offers only a small chance of recovery to your former condition.  It’s much more likely that you will end up worse off than before.  What treatment plan would you want?

Suppose you suffer a serious injury or illness.  You have less than a 5 percent chance of good recovery and if you will survive you will ever serious brain damage.  What treatment plan would you want?

____

Trust me that the above was not designed to depress you.  Nor was it reviewed to make you feel out of control of your own life.  What it is is planning for contingencies in life, the contingencies that we all face at one time or another.  

If you love someone please make sure that there is an Advance Health Directive.  To help you in creating one I’ve acquired for us the little booklet from the Vermont Ethics Network.  Much of what I’ve spoken of is in this booklet.  While its suggestions may shape your thinking, you are ultimately in control of expressing your preferences and then choosing an agent that will uphold them for you, especially in a time of crisis that could involve decisions of life and death.

Our liturgy this time of year asks that we be written in the Book of Life for good.  While are prayers are directed to God above, the work of our hands and our heads can be directed to creating our Advance Health Directive.  

Who shall live and who shall die is not just a matter of our liturgy, it is a matter of our agency.  We should all enjoy good health in the new year along with the peace of mind that our health care directives are completed, making our voices heard even when we cannot speak. 

All clear.


MRI shows no progression of the GBM that used to reside in my head.  Best result we could hope for!  Thank you for all of your good wishes and prayers and words and thoughts and. . .


Onward, together.


Love,


David

Good Friday morning.


It's MRI-Friday. So we're off to Bennington at 9:30, hospital by 10:30, MRI @ 11.  Then Shabbos.  Then Ida comes to retrieve her lovely dogs.  The MRI Results Show is scheduled for August 11th in the afternoon here in Manchester.  And next week:  New Hampshire!  Shabbat Shalom!

Good Monday morning.


Went to the internist this morning for rashy developments following week of chemo.  Nice guy.  


Now home.  Day off.  Going to rest today and try to get a few things done.


We saw Avenue Q in Weston yesterday.  If you're in Vermont, do yourself a favor and see it before it closes on the 31st.  


Enjoy the cooler weather--I know that I am.

Good evening.  This round of chemo is more grueling in the past in that it makes me feel more tired.  I spend almost all of the day at home, resting.  Fortunately there are only two more nights of this and then I can begin to recover.  I wish I didn't have to take this chemo (or the radiation, or the surgery), but I am grateful to be alive.  I wish that this could all progress more quickly, but it has an agenda of its own. 


The next MRI is scheduled for the last Friday in July.  I won't know anything until the second week of August.  That's okay.  I just want to take the MRI and feel better from this *$*%(*Y# chemo.  Suffice to say it is a drug designed to kill cancer cells.  While your body is under attack from the drug, the other cells are doing what they must to stay alive.  


In Hebrew it is "Gam zeh yavo"--this too shall pass.  I'm looking forward to it. 

Good Monday morning.


After a vibrant family day here at the homestead it was back on to the chemo meds last night.  Ugh.  I slept well, though.  Perhaps it is going to be a challenging week.  I don't know if I feel the way I do this morning because of the amount of expended activity yesterday or because of the drugs or probably both.  Whatever the case I'm taking it easy until tonight.