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Differences make communication vital
Home health staff who work with Jewish patients may be unaware of the cultural differences between Jews and Christians or even among people raised in different Jewish traditions.
An inservice that points out some basic information about Judaism and Jewish religious practices can give non-Jewish nurses and aides the tools they need to deal respectfully with those of another faith.
The lack of information can be a problem in home care because the Jewish population in general is older than other ethnic or religious groups, says Rabbi Charles Lippman, doctor of divinity, senior chaplain, and coordinator of spiritual care at Jacob Perlow Hospice at Beth Israel Medical Center in New York City.
"We have a very low birthrate, the lowest birthrate of any ethnic or religious group," says Lippman, a member of the National Association of Jewish Chaplains. "This means we have more elderly, proportionately. We have a very large population of elderly women."
He conducted an inservice for home health aides at the Jacob Perlow Hospice to better acquaint them with Jewish faith and traditions.
"I think that we all tend to see things from our own ethnocentric point of view," he says. "There are people from other cultures and other value systems, and certainly as death approaches, many times the values and customs that people were raised with become increasingly important. Sometimes home health aides, nurses, and other hospice professionals aren’t even aware of what some of these customs or value systems are."
Lippman cites what he terms an extreme example, a case in which he visited an elderly Jewish woman who was being cared for in her home by a home health aide. The home health aide greeted him at the door by saying, "Rabbi, there’s no God in this house. She doesn’t believe in Jesus." He notes that there were signs of the woman’s religious identity — a picture of her son’s bar mitzvah, for example — throughout the house, but the aide didn’t understand the woman’s faith.
"The woman told me that the home health aide was trying to convert her, and she didn’t know what to do," he says. "The patient was totally dependent on the home health aide for everything. I tried to talk with the home health aide, but it wasn’t possible to reason with her, to explain that someone could believe in God but not believe in Jesus. It wasn’t part of her way of looking at the world."
The situation finally was resolved only when the patient left her home and was admitted to the hospice unit for other reasons.
Lippman says he has heard of other examples of home health aides having difficulty with the Jewish faith. "I was told by someone from the Alzheimer’s Society [of New York] that this is a very common issue in New York, with home health aides who don’t understand what it is to be Jewish."
One faith, many practices
One point that Lippman made in his inservice was the wide range of observances and practices among people who identify themselves as Jewish. Of the 6 million Jews in the United States, he estimates that at least a few million are secular Jews, who identify themselves ethnically as Jewish but who aren’t religious.
"Probably when dealing with them, it’s not very different than dealing with a Unitarian or a liberal Protestant when it comes to issues of hands-on care," Lippman says.
Another large group of American Jews is affiliated with Reform institutions, the most liberal religious branch of Judaism in the United States. For those patients, as well, Lippman says, there would be few religious issues that differed greatly from those of a liberal Protestant. "It’s when we are dealing with Conservative Jews or certainly Orthodox Jews that other religious issues might come to the fore," he says.
He says it is important not to stereotype Jewish patients or families but to ask them respectfully when coming into their homes if there are any religious issues that need to be addressed.
As an example, Lippman points to the traditional Jewish practice of keeping kosher, following rules regarding the preparation and serving of food. In a kosher home, beef or chicken is purchased from a kosher meat market, which adheres to certain slaughtering practices. Pork and shellfish are not eaten. Dairy and meat are prepared and eaten separately using separate dishes and utensils.
"So there would be two sets of dishes and two sets of silverware, sometimes even two different racks for the dishwasher," he says. "It would be very important for a traditional Jew that the dishes not be confused with each other. The home health worker would have to have a lesson in how that kitchen is set up."
He says it would be inappropriate for anyone to bring nonkosher foods, such as pork, into a kosher home even for their own lunch or dinner. But again, not every Jewish family keeps kosher, and home health workers should ask to find out what the practices are in that particular home.
"I would say the most important thing would be to consult the family," Lippman says. "It may be that the family couldn’t care less, and they’re about to have pork roast for dinner themselves. On the other hand, it may be a family that’s very strict about this."
In his own research into this topic, Lippman has learned that strict Orthodox patients may require that a change in medication or treatment be cleared with the patient’s rabbi.
"There are some patients where to change a course of treatment, the rabbi needs to be consulted either by the head of nursing, a nurse, or even a social worker," he says. "That would be an extreme case, and the family undoubtedly would clue workers in that this had to happen."
Gender issues also can come into play since it’s considered unseemly in the Jewish tradition for a man to be seen naked by a woman or vice versa. "We might find, particularly among Orthodox patients, that a male patient may want a male aide, and a female patient may want a female aide, for reasons of modesty," Lippman says.
He says some patients, particularly traditional men, may want to wear a yarmulke, or skullcap, at all times, and to pray privately at certain times of the day. There are also concerns relating to food and the withholding of hydration and nutrition at the end of life. "This is an issue discussed at our inservice," Lippman says. "The issue for Jews is, is the nutrition and hydration medication, or it is basic sustenance? If it’s coming through an IV, it may be more likely to be considered medication, an extraordinary measure that can be withheld."
A completely different set of issues surrounds one particular group of Jewish patients — those elderly people who were interned in concentration camps during the Holocaust. Lippman says he has observed behaviors and attitudes among Holocaust survivors that are unlike those he’s seen in other Jewish patients. Many distrust doctors or other health professionals, an outgrowth of experimentation or other ill treatment in concentration camps.
"You have to prove yourself to them," he says.
A more startling attitude is the suggestion by some survivors that they expect to be saved, even from terminal illness. "Even though they will tell you that they have cancer and that they’ve been told that they’re terminal, many of them believe that a miracle is going to happen and that they will beat this," he says. "We see that even more believe that than among the general hospice population."
Lippman says one man who was imprisoned at Auschwitz described to him horribly barbarous acts that the man had witnessed in the camp. "He said, Every day I lived, it was a miracle. I could have been killed any day, and over and over it was a miracle, so why shouldn’t today be a miracle too?’ But of course, the difference is that this is cancer."
The effects extend to the children of Holocaust survivors, who often believe they have extraordinary obligations to their parents because of the parents’ experiences, Lippman says.
With all Jewish patients, family needs and responses can be complicated by differences in faith practices. Because of intermarriage, a patient may have family members who aren’t Jewish, which may affect the degree to which the family practices Jewish traditions.
"Actually, I’ve made some home visits with our Christian chaplain because sometimes the patient will be one religion and the spouse or children another, and they all need care," he says. "That adds confusion, I’m sure, for home health nurses and aides as well."
Above all, he says, it’s important to take cues from the patient and the family. "I would say the most important thing would be to talk with the family and ask the family what their needs are and how the family or patient being Jewish affects what they want from the worker. If we really want to be with the patient and with the family, we have to find out where they’re coming from." n
• Rabbi Charles Lippman, Senior Chaplain and Coordinator of Spiritual Care, Jacob Perlow Hospice, Beth Israel Medical Center, 305 First Ave., New York, NY 10003. Phone: (212) 420-4493. E-mail: cdl@ tuj.org.