1. Advance Care Planning For the Jewish Patient
Mrs Nava Kestenbaum
The Interlink Foundation

2. Aims and Objectives AIMS:
Part 1:To inform health and care professionals about ways to manage ACP with Jewish patients, taking into account their principles of faith, attitudes and social structures.
Part 2: To educate Jewish organisations and individuals about ACP within existing health and care frameworks such as the Gold Standard Framework GSF or Preferred Priorities for Care (PPC).
OBJECTIVES:
Define Jewish attitudes to palliative care
Identify key Advance Care Planning (ACP) documents
Completing a Preferred Priorities for Care document or a Thinking Ahead (GSF) document.
Understand the decision making process and relevant contact personnel for further guidance or support.

3. Gold Standards Framework (GSF) END OF LIFE CARE TOOLS
Advance Care Planning
Preferred Priorities for Care (PPC)
GSF Thinking Ahead
Advance Decisions- Living Will
Lasting Power of Attorney (LPA)
Rapid Discharge Pathway (RDP)
Liverpool Care Pathway for the Dying (LCP)
(Eg. Diagnosis of life threatening disease, Alzheimers or admission to Residential Care)
Advancing Disease
Increasing Decline
Last Days of Life
First Days after Death
Death
END OF LIFE CARE TOOLS

4. Jewish Attitudes to Palliative Care
Jews do not own their body but are invested with guardianship over life and soul including making significant efforts to preserve life despite prognosis.
Nothing may be done to hasten death – including withdrawal of water, nutrition, oxygen or medication.
Information should be presented to sustain hope and avoid despair leading to the patient giving up.
Each family is encouraged to consult a competent Rabbi who can assess every risk benefit decision carefully for Halachic implications.
A Rabbi will always take account of a patients pain or suffering in decisions to provide palliation or ‘heroic’ treatments.

5. Jewish preferences in care
Except at risk to life, Jewish patients will want to practice rituals and have kosher food as far as possible.
Generally, elderly Jewish people prefer to be addressed by their title and surname or familiar first name – which may be a Jewish name.
Families will frequently keep a vigil by the bedside of a seriously ill relative.
Patients and families will often be concerned about signing a DNAR .

6. The Jewish patient – social structure Spheres of influence
Rabbi, Family , friends
Community support (Bikur Cholim, family support), GP,, care home, Chai cancer care
Wider community organisations -
Strong influence on decision making
Clinicians, care team
Social
services

7. LEGAL FRAMEWORK FOR ADVANCE DECISIONS

8. Least to most legally binding
Key Documents
Jewish Advance care Planning
Statement of Wishes and Preferences
Preferred Priorities for Care
(GSF Care Homes)
GSF Thinking Ahead
Advance Decision Making
Interlink’s Halachic Living Will
DNAR instruction
Advance Decision to Refuse Treatment
Lasting Power of Attorney (LPA)
Least to most legally binding

11. I do not wish to have a DNAR offered to me
I do not wish to have any post mortem procedures performed including an autopsy or organ removal.
I do not wish to have a DNAR offered to me
Yes, held by spouse / GP / care home
I wish my care to adhere to my Jewish values and customs. I do not want ANH or medication withdrawn without consultation.
Please see my Advance Decision document for who I wish to be consulted in deciding my treatment or changes to care

12. In use by health and care personnel

13. I do not want any nutrition , hydration or other life sustaining treatment to be withdrawn without prior consultation with representatives including my Halachic consultee.
Information should be presented in such a way that I do not despair and give up hope.
I request all my food to be strictly kosher unless permitted by Halacha.
Pain relief which can shorten life should be given only with clinical, family and Halachic consultation.
I wish to be enabled and supported to pray or perform other Jewish practices where possible.

14. I do not wish to have any post mortem procedure performed including an autopsy or organ removal.

15. Enter patient representative and Halachic consultee

19. PART 2: Guidance for Organisations and families

20. Decision Making for the Patient
Does Patient have Mental Capacity?
Test if unsure
Has patient completed any ACP documents
Safeguarding Adults
Change of Residence
Serious Medical treatment
Best Interest meetings based on MCA principles for
Any Lasting Power of Attorney appointed?
Does Halachic Living Will , PPC or GSF document identify consultee
Patient should be consulted directly.
Preferred Priorities for Care should be referenced
Family/ representative should support patient in decision process
yes no
yes no

21. Key Contacts: Position Role Name Contact details
Adult Safeguarding Officer
(Hospital, PCT or Local Authority based)
Helpful when there are concerns about standard of care eg. Feeding, personal care
MCA/DOLS Officer (Mental Capacity Act /Deprivation of Liberty)
Decision making about requirements and implementation of Best Interest meetings
Director of Nursing
Questions about treatment options or care pathways
Palliative Care Lead Officer.
IMCA – Independent Mental Capacity Advocate
Represents patient at Best Interest meetings where no family available
Rabbi
Ecclesiastical Authority
Halachic, ethical decisions.

22. Guidance for patients and families
Patient diagnosed with dementia, terminal illness or entering care home
Begin Advance Care Planning
Does patient have mental capacity?
Use planning documents:
Preferred Priorities for care
Thinking Ahead (GSF – care homes)
Halachic Living Will
Lasting Power of Attorney
File documents with GP, hospital case notes, patients representative
Review every year or sooner if change in circumstances
Relevant for individuals 18+
A Lasting Power of Attorney supersedes an Advance Decision directive and may invalidate it.

23. Best Interest Meetings
For the following 3 types of decisions:
Serious Medical treatment
Change of Residence
Safeguarding Adults
Multidisciplinary input. Must take account of views of relatives or anyone interested in patients welfare.
Age, appearance or behaviour are not to be basis for decision
Beliefs, views and preferences of patients must be considered
May involve a patient advocate
Balanced scorecard involving Medical , Emotional and Welfare assessment of advantages and disadvantages.
Can appeal decision through second opinion, complaint procedure.
Decision to withdraw or withhold ANH from patients in vegetative or comatose state requires Court ruling