15: As Death Nears & End of Life

Transcription

1 Section 15: As Death Nears & End of Life Section Author(s): cspaziani & wbethurum

2 Section 15: As Death Nears & End of Life 2 Section 15: As Death Nears & End of Life Field Guide

3 Section Contents Death Procedure... 5 Resources on As Death Nears... 7 Sample TDH Nurse Death Visit Profile... 8 EMR: Documenting a Death Visit... 9 Cultural and Spiritual Considerations in End-of-Life Care How Different Cultures Deal with Dying & Death Baha i Buddhist Christian Orthodox Hindu Hmong Islam Mormon Roman Catholic Additional Resources Cultural Issues of Death & Dying American Indians Arab Americans African Americans Brazilians Cambodians Central Americans Chinese Americans Colombians Cubans Ethiopians & Eritreans Filipinos Gypsies Haitians Iranians Japanese Americans Field Guide Section 15: As Death Nears & End of Life 3

4 Koreans Mexican Americans Puerto Ricans Russians Samoans South Asians Vietnamese West Indians Judaism at the End of Life Various Sects of Judaism Death, Mourning and the Afterlife Jewish Life Cycle: Death Medical Ethics Jewish Definitions of Illness End of Life Care Issues The Roles of Chaplains and Nurses Visiting the Sick Care for the Dying and in the Moment of Death Immediately Following Death Preparation of the Body Funeral/Burial Returning Home Shiva Stages of Mourning Yizkor Yehrzeit Unveiling Further Resources on Judaism at End of Life Care Section 15: As Death Nears & End of Life Field Guide

5 Death Procedure Subject: Care of patient and family at the time of death and immediately thereafter Policy: To support patient and family as death approaches. To help patient experience death with dignity. To provide as much information and direct care as needed to assist patient and family. To minimize anxiety and confusion surrounding death process. Procedure: I. When death is imminent and nurse is called by family: a. Give family specific instructions, ie. Elevate head of bed, give meds, put on O2 or whatever is appropriate to promote patient s comfort, be aware of caregiver anxiety over actual death b. Offer support and inform family yo will be ther as soon as you can; give a time estimate. c. Call other IDT member as needed d. Document phone call and assessment of patient in objective terms. II. III. When death has occurred and nurse is called by family: a. Advise family of time frame when TDH nurses will arrive and what family should do now that death has occurred. b. Ask if caller alone. Suggest calling a family member, neighbor, or friend to come stay until TDH staff arrives. c. Assess need for chaplain or social worker support. After arrival at home or facility when death has occurred: a. There is a ritual of acknowledging the death, The tasks of pronouncement and death attendance are secondary to the role of bearing witness to the end of a human being s life and consoling bereaved. This is one of the most important moments in the lives of the survivors. b. The process described here does not necessarily follow in a step-wise order, but these are the element of a death visit for The Denver Hospice c. Assess patient for absence of respirations and apical pulse. Confirm to the family members that death has occurred. Take lead from family as to what is needed to support family members. Tell family what phone calls need to be made. Verify specific patient information prior to placing calls ie, birth date, social security number, date of last physician visit, etc. i. Is there anything specific we need to know now before we speak to the mortuary? d. Page physician for pronouncement of death.. e. Verify with family which mortuary they will be using. If mortuary has not been chosen, call TDH chaplain to assist. Have funeral plans already been made? f. Contact coroner s office of county in which death occurred.. Field Guide Section 15: As Death Nears & End of Life 5

6 IV. After coroner s investigator releases the body to named mortuary: a. Establish family s goals for mortuary pick-up and explain that timeframe for pickup is usually minutes from time of call. i. Body may stay in the home for up to 24 hours b. Call named mortuary. Provide information mortuary requests. Give pertinent information to mortuary such as directions to home, family will call when they are ready for body to be picked up, make sure universal precautions are used, need for extra help if patient is large of home arrangement will prevent easy removal of body. c. Post mortem care. Invite family to assist if they want/need to. i. Lower head of bed ii. Straighten body, clean blood, stool, or other drainage, diaper patient. iii. Remove SQ or peripheral infusion lines and foley catheters. Leave invasive lines such as central lines and chest tubes in tact. Leave ostomy bags on. Put dentures in or send with body. iv. Put clean clothers on patient if family wishes. Change into clean ones if current ones are soiled v. Do not cover patient s head unless family requests that you do. Revision 9/11 slaskerhertz 6 Section 15: As Death Nears & End of Life Field Guide

7 Resources on As Death Nears For families, your best resource is the Patient & Family Guide. o Pgs 31 and 32 review the changes to appetite at the end of life, and what families can do to provide comfort. o Pgs review the specific physiological changes that occur as death nears, and comfort measures associated with each symptom. For clinicians, some books we highly recommend are listed below: 1. Final Gifts by Patricia Kelly 2. Dying Well by Ira Byock The Resource Library located in the Education Dept on the 1 st floor has available for check-out multimedia resources for review at your convenience. Resources on As Death Nears Revised: 03/03/11 Author: cspaziani & wbethurum Field Guide Section 15: As Death Nears & End of Life 7

8 Sample TDH Nurse Death Visit Profile 8 Section 15: As Death Nears & End of Life Field Guide

9 For help with documenting a Death Visit, see the EMR Training: Electronic Medical Record Manual SECTION: Patient Care A copy can be obtained from the Education Department. Karl Shackelford Informatics Educator kshackelford@denverhospice.org EMR: Documenting a Death Visit Field Guide Section 15: As Death Nears & End of Life 9

10 10 Section 15: As Death Nears & End of Life Field Guide

11 Cultural and Spiritual Considerations in End-of-Life Care Section 15: As Death Nears & End of Life 11

12 12 Section 15: As Death Nears & End of Life

13 Section 15: As Death Nears & End of Life 13

14 ELNEC-Core Curriculum Module 5: Cultural and Spiritual Considerations Page M5-14 COH & AACN, 2007 Supplemental Teaching Materials Revised: January Section 15: As Death Nears & End of Life

15 How Different Cultures Deal with Dying & Death Complied by Horan & McConaty Baha i The Baha I faith teaches that there is a separate, rational soul for every human. Upon the death of the body, the soul is freed from its ties with the physical body and the surrounding physical world, and begins its journey through the spiritual world. How far one soul progresses into this world depends on how much effort one has shown toward spiritual development. Special Preparation of the Body The Baha I faith does not allow embalming, unless required by state law. Ceremony Ceremony usually takes place within two to three days. An open casket is rare, since the Baha i faith does not allow embalming. Viewing of the Body This is entirely optional and varies case to case. Final Disposition The deceased is buried within one hour s travel time from the place of death, since the Baha I faith teaches that we are all world citizens and should not be attached to any particular geographic site. Buddhist Life is a series of incarnations on the way to nirvana. Buddhists believe one enters a new incarnation immediately upon death. There are differences in the ways Buddhism is practiced by the Japanese (clergy is a minister or priest) vis a vis Cambodians, Vietnamese and Thais (clergy are monks). Special Preparations of the Body The body is embalmed and usually lies in state for several days prior to the services that can be at a mortuary chapel or at a Buddhist temple. A Buddhist monk in flowing robes is addressed as venerable sir. A Buddhist priest (Japanese) is addressed as reverend Ceremony Several ceremonies are held, the first held two days after the death at the family s home. The second is held two to five days after the death and is usually conducted by a monk at the funeral home. The third is held seven days after the death at the family home or the temple as a merit transference to give good energy to the deceased in his or her new incarnation. There is an open casket, always. Section 15: As Death Nears & End of Life 15

16 Viewing of the Body Yes, because Buddhism deems viewing the body to be a valuable symbol of the impermanence of life. Final Disposition Cremation and bodily burial are both practiced. There is a procession to the crematory. Cremation is more common among the Cambodian, Thai, and Vietnamese Buddhists. Burial is rare among Japanese Buddhists in Denver. When Japanese Buddhists do choose cremation, it is important to not process the cremated remains to a fine consistency. The family will often choose to sort through the cremated bone fragments with chopsticks to remove certain bones and leave the remainder to the funeral home for dignified disposal. Christian Orthodox Death is separation of the soul (the spiritual dimension of each person) from the body (the physical dimension of each person). Special Preparations of the Body Usually embalmed. Cremation is prohibited. Ceremony The ceremony takes place within one week; most often within two or three days. It is held in a church decorated with ornately beautiful religious icons. There is usually an open casket. Viewing of the Body At the conclusion of the funeral, the last kiss allows family and friends a final opportunity to say goodbye and pay their final respects. The funeral director will lead people through it. Those who are not Orthodox are not required to venerate (kiss) the icon or the deceased. Final Disposition At the burial there is a five minute prayer ceremony, where each person present places one flower on the casket. They come from the arrangements brought from the church. Cremation is prohibited. Hindu Although the physical body dies, the atman (AHT-mahn), or the individual soul, has no beginning and no end. It may, upon death, pass into another reincarnation, the condition of which depends upon the karma, or consequences of one s actions, reaped during the life that has just ended, as well as, during previous lifetimes. Special Preparations of the Body The body remains at the family home until it is taken to the place of cremation. Flowers are placed at the feet of the deceased. There is always an open casket. 16 Section 15: As Death Nears & End of Life

17 Ceremony The ceremony usually takes place within 24 hours. Takes place at the place of the cremation. Some Hindu families will restrict food intake until the cremation is completed. Viewing of the Body Viewing of the body by outsiders is practiced, but the body cannot be touched. Final Disposition Cremation is practiced. The eldest son initiates the cremation process (presses a button on the crematory control panel). The last food offering is symbolically made to the deceased and then the body is cremated. The cremation ceremony is called mukhagni (moo-kahg-nee). Hmong Death is part of the life cycle and the Hmong understand and accept this well. In addition, the Hmong believe that a person is born with a mandate (txojhmoo) to live to a certain age. To have a proper ceremony is of great importance to the Hmong for as a result the soul will prosper in the afterworld. It is preferable to die in one s own home or in the home of the same subclan. Elders in the family meet regarding any decisions that must be made about the dying person. Traditional Hmong religious beliefs say that when someone dies, this person will go to the next world with the same appearance they have at time of death. Special Needs Do not remove amulets from body. Shaman rituals may be performed in attempt to cure dying person. Body usually prepared for burial by family at funeral home. s Traditional Hmong usually will not donate organs, because they believe one of the body s three spirits stays with the body; therefore, the body needs to stay whole. Same as organ donation. Special Preparations of the Body If the death occurs at home, the family will want to keep the deceased person there for as long as they can. Since we have the 24 hour rule in Colorado, meaning that within 24 hours of the death, one of four things must happen: cremation, embalming, refrigeration, or burial, the deceased may legally remain at home for 23 hours. Soon after death, the person is given various paraphernalia to protect its soul from natural elements and malevolent spirits during the trip to the ancestral world. Section 15: As Death Nears & End of Life 17

18 Ceremony The ceremony takes usually takes place within three days. The ceremony may be conducted by a Christian minister who helped to sponsor a family to come to the US. After the Christian rites, a shaman (holy man) of the clan oversees that all preparations are done according to Hmong traditions. The family may wish to sleep at the mortuary on the night before the burial. Viewing of the Body There is usually an open casket and the viewing of the body. There is to be no metal or plastic to be used in the manufacturing of the casket or the preparation of the body. Final Disposition The deceased is buried in a casket that has no metal or plastic in it. The mourners go in procession to the burial site. Islam The vision of the Quran of afterlife is spiritual and physical. at a moment, known only to God, all will be called to a day of judgment, known as the Day of Decision or Day of Reckoning. For the good and the bad, heaven and hell will be fully experienced. Special Preparations of the Body Ritual washing is performed on the deceased. Men and women of good religious standing perform this important function for members of their own sex. This is presided over by an imam (the chief cleric). Ceremony The ceremony usually takes place within one to two days at a mosque. Women and men are separated. Women wear a head covering. Only Muslim men are allowed into the main worship area of the mosque. As one enters the mosque shoes should be removed. It is a sign of respect to greet a Muslim by saying As Salaam Alaikum (ahs SAH-lahm ah-lay-koom), meaning peace be upon you. The response to this is Wa Alaikum Salaam meaning and upon you the peace. Viewing of the Body There is never an open casket or viewing of the body by outsiders. Final Disposition After the ritual washing, and placing the deceased person in a wooden casket, the body is taken to the mosque for a brief prayer service, and then to the cemetery for burial. The body is taken out of the casket and put directly on the earth and turned to face the east (Mecca). Muslims are never cremated. Men only conduct the burial. Woman are instructed to stand away from the grave (most women do not attend the burial). Mormon The Church of Jesus Christ of Latter-Day Saints believe that all who have ever lived on earth are literally the spiritual children of God and resided with Him in a pre-mortal existence; the same with those who 18 Section 15: As Death Nears & End of Life

19 will ever live on earth. Through the resurrection of Jesus, all will be resurrected and through atonement to his gospel, all have the opportunity for salvation. Special Preparations of the Body The body (if the deceased was endowed, which is to say, having been through the Temple) is always dressed by members of the church. Endowed men will dress male members, and endowed women will dress female members. It is always encouraged that family members participate. This is not ceremonial or ritual. The temple clothing that the deceased is dressed in is purely symbolic. Much of the clothing is simply a reminder of each member s commitment to Christian principles and ideals. It is an outward sign of an inward commitment. There is nothing secret about the dressing process or clothing worn, but it is very sacred. Ceremony The ceremony varies greatly upon the family. It can be up to a week after the death. The ceremony is conducted by the bishop of the congregation to which the family belongs. Family and friends deliver eulogies. Viewing of the Body The casket is closed during and after the service, but is generally open before in another room where family can greet friends. The viewing is entirely optional. Final Disposition Burial is the custom. Cremation is discouraged, for the reason that members don t want to purposely destroy one of God s creations. Roman Catholic Roman Catholics deeply believe in immortality. They believe that God s love is immortal. On the the last day, when the Messiah has arrived, one s physical body joins the spirit in the beatific vision of heaven or the damnation of hell. Cremation was previously forbidden, since it would interfere with bodily resurrection. That view has changed. It is strongly encouraged that the body be present at the funeral Mass. Cremation, if it is desired, takes place after the Mass. Churches will allow cremated remains to be present at the Mass. Special Preparations of the Body Usually embalming takes place. Ceremony The ceremony usually takes place with two to four days. Often a vigil/prayer service or a rosary is conducted the evening beore the funeral Mass. This can be either at the funeral home or at the church. Viewing of the Body There is usually an open casket and a viewing. Section 15: As Death Nears & End of Life 19

20 Final Disposition Most often the deceased is buried in a consecrated or blessed cemetery. This can mean inground burial, placement in a mausoleum crypt, or placing of cremated remains in the ground or in a niche in a columbarium. Cremated remains are not to be scattered, as this is considered to be disrespectful to the belief that the body is the temple of the Holy Spirit. Additional Resources Books Death and Bereavement Across Cultures, Colin Murray Parkes, Pittu Laugani and Bill Young, Editors, 1997, Routledge, London and New York. How to Be a Perfect Stranger, A Guide to Ettiquette in Other People s Religious Ceremonies, Volumes 1 & 2, Stuart M. Matlins and Arthur J. Magida, Editors, 1999, SkyLight Paths Publishing, Woodstock, Vermont. Articles Hmong. Frequently Asked Questions: Death and Dying by Dr. Pao Saykao Death & Dying: Hmong Funeral & Burial Process by Dr. Gary Lee How Different Cultures Deal with Dying & Death Information compiled from materials provided by Horan & McConaty Jennifer A. McBride, Grief Support & Community Education Caregiver Resource Guide, June Section 15: As Death Nears & End of Life

21 American Indians Cultural Issues of Death & Dying Clinicians may want to suggest family meeting to discuss end-of-life issues. Most American Indian cultures embrace the present. Some tribes avoid contact with the dying. If families want to be preset 24 hours a day, this will include immediate and extended family and close friends. If family feels comfortable and welcome atmosphere may be jovial with eating, joking, playing games, and singing. Small children also included. Although outcome tacitly recognized, a positive attitude is maintained, and the family avoid discussing impending death. Strong Hopi cultural value is to maintain positive attitude. Sadness and mourning are done in private, away from the patient. Patients are encouraged and not demoralized by strong negative thoughts. Some may prefer to have an open window, or orient patient s body toward a cardinal direction prior to death. Once person is deceased, family may hug, touch, sing, and stay close to the deceased. Wailing, shrieking, and other outward signs of grieving may occur, a startling contrast in demeanor. Special Needs Be prepared to support or inquire if family want to bring in other kinds of healers to attend to spiritual health. Care of Body Care varies with culture and/or Christian beliefs. Traditional practices include turning and/or flexing body, sweetgrass smoke, or other purification; family (women) may want to prepare and dress the body. The Laguna for instance do not permit the body to be prepared by the mortuary; the family will wrap the body for burial. Generally not desired. Generally not desired. Arab Americans Arabs do not openly anticipate or grieve for dying persons before death. Inform designated head of family privately of death and allow him to decide how to inform rest of family. It may be difficult to get them to decide on DNR. In some families, young women are barred from being with dying or dead member. Section 15: As Death Nears & End of Life 21

22 Special Needs Arab Christians may request a minister s visit. Moslems do not need an Inam (the person who leads prayers in a mosque) to be present. An Inam reads the Koran after death, not before or during the process of dying. Family s grief is open, loud, and uncontrollable. Care of Body Special rituals follow after death, such as, washing the body and all its orifices. May not allow organ donation due to respect for burying the body whole and meeting creator with integrity. Usually refused. African Americans Report death to the eldest family member, open and public emotions expected. Cremation avoided. Taboo to donate organs, some religious restrictions (Jehovah s Witnesses) Will allow if there is a real need Brazilians In Brazil, burial takes place within 24 hours, and bodies not embalmed. Family and friends do not leave the body until burial. Not routine or a common practice. Not a routine or common practice; if medically indicated, provide information and support for family decision. Cambodians Inform the oldest family member. Special needs Monks and aacha need to be called to recite prayers. Death faced by family in quiet, passive manner. Incense may be burned. Family, monks, and aacha may want to wash the body. The body is shrouded in white cloth. Those in mourning wear white. 22 Section 15: As Death Nears & End of Life

23 Unlikely to allow organ donation. Body cremated. Due to belief in rebirth and possible reincarnation, desire body to be intact. Unlikely to agree to autopsy. If essential, careful explanation needed. Central Americans Eldest male of family should be informed of impending death. Catholic clients and families may want priest to administer sacrament. Special Needs Nurse can assure an atmosphere of privacy and quiet for sacrament of the sick. Traditionally, family members prepare the body for burial. Acceptable if body treated with respect. Cremation not common practice. Allowed if body treated with respect Chinese Americans Family may prefer that patient not be told about terminal illness, or may prefer to tell patient themselves. Special Needs Special amulets and cloths may be brought from home to be placed on the body. Believe that body should be kept intact. Organ donation not common. Belief that body should be kept intact so autopsies may not be allowed. Colombians Inform head of family. Will want services of Catholic priest to administer sacrament of the sick. Special Needs May be surrounded by all family members except small children. Family members may cry uncontrollably and loudly; women may be hysterical. All family members may want to see body before it is taken to morgue. Colombians generally buried within 24 to 36 hours of death. Cremation not common. Section 15: As Death Nears & End of Life 23

24 Acceptable Acceptable if viewed as necessary to clarify cause of death. Cubans Acculturated Cubans will want to be informed of their terminal illness. Less acculturated will probably follow cultural norms by information family. Family will wish to stay close to patient until death, including overngith. Special Needs Patient s family will insist on being present at all times, including overnight. Not common not common or desired Ethiopians & Eritreans News of death is to be disclosed to close friends and first before family is told so that friends will be there to provide emotional support. Never tell female family member first. Special Needs Great demonstrations of feeling are encouraged when a loved one dies. They cry loudly and uncontrollably. Women tear their clothes and beat their chests until they become sick with grief. Cremation acceptable. May be acceptable is unacceptable unless family is convinced is medically necessary Filipinos Notify head of family of the patient s death. Most likely will want Catholic priest present. Special Needs May ask for religious medallions, rosary beads, and other objects of spiritual significance, such as a figurine of a saint, to be near the patient. Death is given a very high regard, a spiritual event. Family may want to wash the body. 24 Section 15: As Death Nears & End of Life

25 May not allow organ donation. Body is given high respect. Cremation is not a common practice. The same thoughts prevail, not common. Gypsies Inform eldest in authority in family. Family will want window open prior to death but also afterward to allow spirit to leave. Special Needs May ask for religious objects in room. May even set-up small shrine. May want older female relative at window at all times to keep out Night Spirits and chase them away and to allow dying person s spirit to be released. Moment of death highly significant. Last words of dying patient are very significant. Will want to stay with body constantly until burial. Not acceptable Not acceptable Haitians Dernie priye is a special prayer service consisting of seven consecutive days of prayer. Usually takes place in the home. Purpose is to facilitate passage of the soul from this world to the next. Cremation is not acceptable because of deep respect for the body and the beliefs in resurrection and paradise. Iranians Special Needs When death is imminent, family will pray, cry uncontrollably, even hysterically. Religious medallions, pictures of saints will be important to have in patient s room. Final bath given by a family member. Neither dealt with or encouraged. Haitians very cautious about this procedure. However, if foul play or unnatural death suspected will request an autopsy to ensure that the patient is really dead. Notify head of family or spokesperson first. Death is seen as a beginning, not an end, in which mortal life gives way to spiritual existence, a cherished state of solidifying one s relationship with God. Section 15: As Death Nears & End of Life 25

26 Special Needs Prefer to have family around at all times. Praying or crying softly at bedside not uncommon. Family may prefer to wash the body, body not viewed after washing; therefore, embalming not practiced. Cremation not commonly practiced. Acceptable Acceptable Japanese Americans Spouse or eldest son or daughter will be in charge. Special Needs Family members may request to stay with patient if illness serious or terminal. Cleanliness important in preparing the body and maintenance of dignity and preservation of modesty for viewing the body. Strong feeling that when person dies, body should be kept intact. Same thoughts as on organ donation. Most often organ donation and autopsy not acceptable. Koreans Imminence of death should be told to spokesperson, who will relay information to family. Special Needs Family mourning and crying not unusual. Chanting, incense burning, praying, etc. maybe incorporated into hospital environment. Cremation not common; associated with destroying soul or spirit. Unacceptable associated with tampering of body/soul/spirit If sudden death occurs and reasons are not known, family may consider; however, attitude is same as toward organ donation. Mexican Americans Extended family will be present. 26 Section 15: As Death Nears & End of Life

27 Special Needs Religious medallions or rosary beads to be expected near the patient. Prayers commonly practiced at bedside of dying patient. Will want Catholic priest to administer sacrament of the sick. Wailing is common and socially acceptable as sign of respect. Death is very important spiritual event. Body extremely respected; majority will not agree to organ donation. Same principle applies to autopsy. Puerto Ricans Customary to have priest/clergy present when news of death is disclosed to family. Privacy is important. Special Needs Candles, rosary beads, special saint figurines, etc. will be placed near patient if Catholic. If Christian, music, Bible, praying gat bedside. Spiritual leaders expected to be with patient at last minute of life. Loud and unmanageable crying or thunderous talking to God or other deities very common. Some family members might feel sick, faint, or vomit. Be sympathetic to family members who express psychosomatic symptoms during this time. Acceptable. Seen as act of goodwill if done for great cause or benefit of another human being. Body is sacred and regarded with great respect. Autopsies usually seen as violation of body. Russians Inform head of family. Special Needs May need rabbi, priest, minister or other individuals to pray for patient. Family may wish to wash the body and put on special clothing. Some Jewish persons believe that body should remain intact; thus, severed limbs should be placed back on the body if possible. Most Russians do not believe in cremation. Most Russians believe that the body is sacred and thus do not believe in organ donation. For the same reason most Russians will refuse autopsy Section 15: As Death Nears & End of Life 27

28 Samoans Patient and family members prefer to be told prognosis early. Special Needs Ministers, church members, and family members provide major support to patient during the final days. Not acceptable and any such suggestion to family could be potentially offensive. Cremation very rare. Generally not considered by family South Asians Hindus, Muslims, and Sikhs believe that body dies, but soul remains alive and is immortal. Hindus and Sikhs also believe in reincarnation. Unusual to inform dying person of impending death. Special Needs Some families may wish to call spiritual leader who prays for dying person and gives holy water to drink to purify body internally just before death. Surviving family members express their grief openly for mourning and crying. For Muslims when a person dies the body, arms, and legs are covered with a sheet. The body then washed ritually just before burial. Body buried as soon as possible after death. For Hindus and Sikhs, the body is washed by close family members, dressed in new clothes, and prepared in Ganges (sacred river in India). Hindus, Muslims, and Sikhs do not allow organ donation. Most will not agree if they do they will ask that organs be returned to the body afterward. Vietnamese Inform head of family. Priest or monk may come to provide assistance. Special Needs For catholic families, religious medallion, rosary beads, or other spiritual objects are kept close to patient. Family may start praying. Priest present in room. For Buddhist families monk present in the room to start religious ritual. Family may start crying loudly and uncontrollably. The body is highly respected. Not allowed 28 Section 15: As Death Nears & End of Life

29 Not allowed West Indians Surviving partner should be informed of death as soon as possible, preferably in presence of adult children. Special Needs Family will want to be present at the moment of death and staff should leave family to themselves. Family members not likely to agree. Maintaining integrity of body an important consideration in this culture. Usually unacceptable Cultural Issues of Death & Dying Compiled from materials provided by Horan & McConaty Jennifer A. McBride, Grief Support & Community Education Caregiver Resource Guide, June 2011 Information taken from, Culture and Nursing Care: A Pocket Guide, edited by Juliene Lipson, Suzanne Dibble, Pamela Minarik; School of Nursing, University of California Press, San Francisco, Section 15: As Death Nears & End of Life 29

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31 Judaism at the End of Life Every healthcare worker must understand that death is approached in unique and powerful ways in Judaism and in all religious and ethnic traditions. Each Jewish patient and family is different. Some will turn to embrace every ancient tradition as a means of coping with death, while others will reject anything that traditional Jewish law teaches. Jewish law and ethics are not firmly based upon any single set of rules. Understanding this concept and applying it to end-of-life situations can be frustrating to the caregiver whose own religious background may carry a defined set of rules for action. Further, Jewish tradition does not define a clear concept of afterlife, as does Christianity and many Eastern religious traditions. For many, this sense of uncertainty is disconcerting and makes the dying process all the more traumatic. Asking Jewish patients and families to explain practices and wishes helps healthcare workers design care that meets each family s spiritual needs in a culturally sensitive fashion. Various Sects of Judaism There are various branches or sects of Judaism. It is important to differentiate between these sects because some differ from others in belief and observance of the Jewish traditions and laws. Orthodox: the strictest observers of Jewish law. While Modern Orthodox Jews continue to observe the law strictly, they do integrate into modern society. Chasidic Jews, on the other hand, choose to live separately and disconnected from the modern world. Conservative: accepts Jewish law, but believes it should adapt to aspects of the predominant culture. Reform: does not accept the binding nature of Jewish Law but retains many of the values and ethics, practices and culture of Judaism. o Liberal o Progressive Reconstructionist: includes a deep respect for the traditions of Judaism while integrating the ideas of contemporary social, intellectual, and spiritual life Jewish Renewal: a recent movement grounded in the mystical and prophetic traditions of Judaism. Members incorporate many modern social issues such as feminism and environmentalism. Humanistic: involves the belief in maintaining a meaningful Jewish lifestyle free from supernatural authority and embraces a human-centered philosophy Unaffiliated: members do not identify with a specific sect but choose to interpret the Jewish religion on their own terms. Section 15: As Death Nears & End of Life 31

32 Death, Mourning and the Afterlife Judaism sets a high value on human life, and it recognizes the need for a mourning process. The Jewish tradition has a great deal to impart about how to confront death, the way a person should be buried and grieved, and what is beyond the world as we know it, where the soul of the dead person will dwell. The idea of a soul (Neshamah in Hebrew) is fundamental to Judaism. It is seen as eternal. Although clear references to the human soul do appear in the Bible, most of what the Jewish tradition teaches about the soul comes from rabbinical (post-biblical) times. The soul comes from God, and it precedes the existence of the human body. As for where the soul is headed after this life, we are told in Ecclesiastes that the soul returns to God (thus, the idea of an afterlife): The dust returns to the earth as it was, and the spirit returns to God who gave it (12:7) The soul s components: o The Jewish conception of a soul is rather unique. In Judaism, the soul is not indivisible. Rather, it is more like an amalgamation of five basic elements that are in turn subdivided into even more elements. This is a very complicated subject that has a lot to do with Kabbalah (Jewish mysticism) and that will only briefly be summarized here. o The lowest constituent of the soul is nefesh, and it is the soul s most physical aspect. In ascending order, the soul s more spiritual elements are suach, neshamah, chayah, and yechidah. To refer to all five of these components, you can use the term narachai (an acronym of the five terms). Since the narachai is numinous, it seeks spirituality, which is why humans seek to pursue spiritual life. o After a person dies, that person s narachai will desire to leave the physical body. If the person has led a life of spirituality, this desire will be fulfilled. The narachai of those who were focused on the material aspect of the world, however, may remain rooted to the physical. Jewish Life Cycle: Death Two overriding principles govern the Jewish approach to death and mourning: Kavod Ha-Met: honoring the dead Natural Process: facilitating its return from ashes to ashes, dust to dust Medical Ethics Jewish medical ethics are based on God s law, referred to in Hebrew as halacha. The foundations of halacha are based on the 613 mitzvot (or the commandments of the Torah). These are the basis for the Five Books of Moses (chumash). Written in Jewish tradition, there are 248 positive things a person should do, while there are 365 things that are negative. These have been practiced over time and are in the remaining 24 books of the Jewish Bible or oral law. 32 Section 15: As Death Nears & End of Life

33 Jewish Definitions of Illness Treifah: o Thought of as defects o A prognosis of 1 year or less Goses: o o End of Life Care Issues Patient described as actively dying During this state, no treatment or action can be pursued to delay or hasten death There are some situations associated with the processes of death and dying that may not have clear solutions within the Jewish religion. Therefore, it is often recommended to seek the advice of a rabbi as well as to demonstrate great sensitivity and respect in interaction with the patient and family. Some of the end of life care issues that may require further consideration in terms of religious beliefs are: Terminal illness in the Jewish law Suicide, assisted suicide and euthanasia Refusal of medical treatment Withholding and withdrawal of medical treatment Informed consent and truth-telling Pain and suffering CPR Artificial nutrition support and hydration Antibiotics Surgery, chemotherapy, radiation therapy Mechanical ventilator Advanced directives Organ donation The Roles of Chaplains and Nurses Nurses: o The nurse plays a crucial role in easing the dying process o It is important to possess a simple awareness of traditional Jewish prohibitions against moving or disturbing a goses, or patient considered actively dying o Basic knowledge of modern Judaism s stance regarding organ donation is also crucial Chaplains o The chaplain is an important member of the healthcare team o Unaffiliated or less observant Jews may not think to consult with a rabbi throughout the dying process, and in these cases, the Chaplain is able to provide a spiritual outlet Section 15: As Death Nears & End of Life 33

34 Visiting the Sick Respect and attention must be accorded to a sick person o Respect for the dead is a logical extension of the basic respect for the living o Some believe that there are rewards for visiting the sick whereas failure to visit the sick compares to the actual shedding of blood Comfort is the primary concern o One should not come in the early hours of the morning or the late hours of the evening Care for the Dying and in the Moment of Death During the last minutes of life, no one in the presence of the individual may leave, except those whose emotions are uncontrollable or those who are physically ill. It is considered a matter of great respect to watch over a person as he/she passes from this world to the next. As death draws near, the patient should be encouraged to say Vidui (confession). If the patient is unable to recite, then someone else can recite the prayer for the dying. Shema is recited with both confessional and prayer. Immediately Following Death The eyes and mouth must be closed and sheet drawn over the face The body should be positioned: o With feet facing the doorway o The body should not be touched except for own honor A candle should be placed at the head of the deceased Relatives and friends may ask forgiveness from the deceased Prayers and Psalm 23 are to be recited Discussion must focus solely on personal qualities or funeral arrangements All mirrors in the home should be covered All standing water should be poured out For members of the Orthodox faith: o The body cannot be moved on the Sabbath The body cannot be left alone: o Guard or Shomer must remain with the body from the moment of death until the funeral and burial Preparation of the Body Chevra Kadisha: The Holy Group o The Burial Society prepares the deceased for a proper Jewish burial. o The body of the deceased is shown proper respect, ritually cleansed and dressed in shrouds. 34 Section 15: As Death Nears & End of Life

35 o o A prayer shawl or tallit may be placed with the deceased. One of the fringes (tzizit) is removed to signify that the tallit will no longer be used for prayer by that person. The prepared body is then placed in a wooden coffin. Funeral/Burial Kevura or burial should take place as soon as possible after death This usually takes place on the same day or on the following day Burial will not occur on Sabbath or during the High Holidays Reform and other congregations allow time for distant relatives to come to the funeral and participate in post burial rituals Returning Home Shiva The mourners traditionally make a tear (keriah) in an outer garment o The tear is made on the left side for a parent o The tear is made on the right side for brothers, sisters, children and spouses o Today, the custom is preserved by pinning a black ribbon the lapel or clothing of the mourners and permitting them to tear the ribbon Cut flowers are not a part of Jewish tradition and are strongly discouraged o The flowers short life serves as a symbol for the loss of the deceased o Often, mourners are encouraged to make a donation of their choice instead Shiva is a weeklong period of mourning a death in the Jewish tradition. The process is often referred to as sitting Shiva during which guests visit the immediate family of the deceased to pay their respects. During Shiva: Mourners do not bathe for a week Mourners do not wear shoes or jewelry Men do not shave Walls and mirrors are covered Mourners sit on low stools or even on the floor which is symbolic of the emotional reality of falling low to grief The meal of consolation consists of hard boiled eggs or other round or oblong foods Stages of Mourning Aninut: intense mourning that lasts until the burial is over Avelut: immediately follows the Aninut during which the Avel (mourner) does nothing joyous unless absolutely necessary. Three distinct periods in this stage include: o Shiva: a weeklong period of grief and mourning o Shiloshim: thirty days o Shneim asar chodesh: twelve months Section 15: As Death Nears & End of Life 35

36 Yizkor Yehrzeit What are the Yizkor prayers? The Yizkor prayer service asks God to remember the soul of a departed relative. The Yizkor prayer is recited individually for each departed close relative. The name of the deceased is mentioned in the prayer. The prayer includes a pledge to make a donation to charity. El Male Rachamim: This memorial prayer asks God to grant perfect rest to the souls of the deceased relatives, who are again mentioned by name. This prayer also includes a pledge to make a donation to charity. Av Harachamim: In this memorial prayer, God is asked to remember the many Jewish communities destroyed throughout the ages. The Yehrzeit is the anniversary of a loved one s death. It is customary to light a candle in the memory of the deceased on the anniversary of death and to attend a synagogue service to recite Kaddish on that day. Kaddish is a traditional prayer that is said daily with a quorum of at least ten Jewish males or females who are over the age of thirteen. The mourner stands and says the Kaddish, and the quorum responds in unison with the appropriate phrase. The Kaddish is recited daily for the first eleven months following the burial and on the anniversary of the death. If there is no one to say Kaddish for he deceased, there is an organization that will ensure that this important service takes place. Unveiling The grave marker is unveiled during the first year after death, sometimes prior to Yahrzeit and other times after. There is no right or wrong when it comes to unveiling, but instead considered a local custom. It is traditional for visitors to leave a small stone on the marker as a sign that the have come to visit. This is explained as a reflection of the eternality of the soul. Just as a stone lasts forever, so too does the soul live on. 36 Section 15: As Death Nears & End of Life

37 Further Resources on Judaism at End of Life Care odern/end_of_life_issues.shtml?bfis This article provides a Jewish perspective on end of life care issues, including life support, ceasing medical care, living wills, and caring for patients. It is written with the intention to inform and educate hospital and/or hospice workers. This website focuses on death, mourning and hope in Jewish tradition. Further focal points include: end of life issues, closing moments, funeral and burial, shiva and mourning, and more. This is the website for the National Institute of Jewish Hospice. A manual intended for non-jewish professionals and volunteers who are seeking a clear sense of what different Jewish religious needs may be is included. Judaism at End of Life Revised: April 2011 Author: erosenberg Section 15: As Death Nears & End of Life 37