June 20, 2019

Knowing when it’s time

The patient, a Jewish man in his 70s, lay in the intensive care unit (ICU) with a machine pumping and oxygenating his blood. He had received emergency heart surgery, but it had failed. The doctors called the family and said, “Let’s meet in the patient waiting room tomorrow and talk about this.”

As a hospital chaplain, I was asked to support the patient’s family at this meeting. The doctors explained that the patient would not likely be able to function on his own again, although they were open to letting him stay on the heart-lung machine for a couple of more days — “just to see.” 

What a terrible decision for a family to have to make. What should they base it on? How could they live with themselves if they “got it wrong”? For people in the “end of life” trade like myself, the question comes down to quality of life.

I don’t mean the kind of generalized pleasantries that make a city a desirable place to live. In a medical setting, quality of life refers to each individual’s highly personalized idea of what they would need to be able to do to make their own life worth continuing. For many, it forms a dividing line with regard to medical decision-making. 

In this week’s parsha, Vayelech, we find out what Moses considers his own quality-of-life standard. God tells him that he will die soon, so he looks at his life to see if he feels ready to let go, and he concludes that he is. He says, “I am 120 years old, and I can no longer latzet v’lavo  — go out and come in” (Deuteronomy 31:2).

According to Rashi, Moses means he can no longer lead the nation in battle, as he has done so many times before. He sees that more battle will be needed for the Israelite people to take the land of Canaan for their own, and he can’t carry the burden of it any longer.  

But even if Moses meant what he said literally — he can no longer leave his home, or get out of bed — any of these could be enough to make his life not worthwhile, by his own definition. He sees self-sufficiency as essential, and that makes sense for a man as strong and visionary as Moses. Days spent unable to work, dependent on others for his care, are days he does not want to prolong. It’s time to let go, he concludes. 

What is your dividing line? Answer this question for yourself: “If I could no longer do ‘X,’ I would no longer be myself, and there would be no point extending my life.”

Don’t worry, this is not a suicide pact. You are not asking others to end your life if you should reach that point — that would violate both U.S. and Jewish law. Rather, we are discussing an invitation to stop spending tens of thousands of dollars a day on surgery and machinery, aggressively extending a life that you would not want for yourself. 

For some, quality of life is being physically active or independent. For some, it is a level of mental acuity — the ability to handle one’s finances, for example, or to recognize loved ones’ faces. I worked with a family once who said their father would not be himself if he could no longer make himself a sandwich. 

For me, I feel that if I could not pray, if my mind no longer held this capacity, I would want my family to stop bringing me to the hospital. It wouldn’t be me.

In the modern world, the time we are asked our definition of quality of life is when we complete an advance health care directive. Our decision-makers want to act in our best interest, and giving them a clear picture of when we want them to switch from aggressive intervention to comfort-oriented medicine through a document like this can bring them much relief. 

The problem with feeding tubes and breathing machines is that they blur the distinctions between vibrant and moribund, living and dead. How do we make decisions for a person of indeterminate status?

By knowing what they want us to do, and ascertaining that the boundary has been crossed, we can act with assurance, with an understanding that this is what they would have wanted. We are bringing kindness to their soul. 

Once the family I supported in ICU learned from the doctor that the chances were almost zero that Dad would ever open his eyes again, they were able to act without hesitation. Dad would not want to be kept around indefinitely, unconscious but alive, by a machine. The life he wanted for himself had ended with the surgery. The life-support machine was an unkindness that needed to be discontinued.


RABBI AVIVAH W. ERLICK is a board-certified health care chaplain working in home hospice and institutional settings. She owns a referral agency for clergy in private practice (lacommunitychaplaincy.com) and is a provider of creative Jewish after-death ritual (sacred-waters.com).