Healthcare During the High Holidays
Caring for patients requires medical, social, cultural, and religious considerations. During a 1-month period every year, the Jewish High Holidays are celebrated by religious and culturally affiliated Jews alike. Having a basic understanding of your patients’ customs and traditions can go a long way toward building trust and strengthening provider-patient partnerships, thereby leading to better health outcomes. Below we discuss important considerations and practices to provide Jewish patients culturally competent care during this time.
Common practices during Rosh Hashanah include sounding a ram’s horn (shofar), dipping apples in honey, and eating symbolic foods meant to be omens for an excellent new year. Many Jews spend much of the day in synagogue and having meals with family and friends. While specific practices might differ by denomination, the sentiment is the same: welcoming and anticipating the new year and reflecting on the past to build a better tomorrow.
Patients in the hospital might feel detached from the holiday. Providing apples and honey and traditional Jewish foods where medically appropriate is a simple, yet profound way to help Jewish patients feel connected. Permitting visitors to spend time and meals with the patients also allows them to celebrate in a meaningful way. Lastly, sounding the shofar is one of the most iconic and ritually important customs. In addition to these practices, providing opportunities for prayer and reflection will help many patients recreate some of what they are missing. Reviewing customs with the appropriate clergy and spiritual life staff in the hospital or from trusted community agents can ensure Jewish patients are comfortable, and that their spiritual needs are optimally addressed.
There are many considerations for those who observe the holiday in a more strictly traditional fashion. These may be familiar as they are similar to weekly Jewish sabbath observances. For those who observe in this fashion, numerous activities are restricted. For example, using electricity is not permitted, nor is driving a car. This includes use of cellular phones, operating an electric hospital bed, turning on lights, and using automated doors. Sabbath elevators that stop on every floor may be useful. Therefore, placing observant patients closer to the nursing station or periodically checking on those who may not be using devices for summoning help is beneficial. In cases of consent or contacting a healthcare proxy, unless it is urgent/emergent, phone conversations should be arranged before or after the holiday as the proxy might not be using the telephone. Additionally, signing forms and money exchanges may be forbidden and should be deferred. Offering ceremonial items related to standard Jewish holiday and Shabbat practice — including blessings over Challah and grape juice as well as lighting candles (can be electric in the hospital setting) — to welcome the festive day is also of benefit.
There is an idea in Orthodox Judaism that one should not cause others to violate the sabbath restrictions on activity, regardless of that person’s beliefs. This results in hesitation to overtly ask others to perform such forbidden tasks on their behalf. In order not to violate this prohibition, patients may state needs or desires in circumferential ways to staff or providers. An example of a culturally sensitive and effective way to help patients would be to ask in advance the preferred settings for their electronics (e.g., the thermostat).
Another feature of the High Holidays is time spent in prayer and self-reflection. When conducting rounds or checking in on patients, it is important to be mindful that some patients may be mid-prayer.
Yom Kippur takes place 10 days after Rosh Hashanah. Yom Kippur is a 25-hour fast starting at sundown and ending an hour after sundown the following day. The focus of the holiday is to take stock of prior actions over the previous year and repent for failures. It is customary to imitate the behavior of angels — dressing in white, and abstaining from food, drink, bathing, and sexual relations. Traditionally, most of the day is spent at synagogue, where five prayer services are recited. It is considered by many to be the most important holiday of the year. The day ends with the sounding of the shofar.
Each patient should consult their own rabbinic authority and physician to determine if it is safe to fast and if not, how much to eat. Jewish law states that matters of fasting, eating, and drinking are referred to medical providers and that the health and well-being of the patient is paramount. It is reasonable to cohort patients by having them room with other fasting patients. If a patient must eat for medical reasons, the patient is religiously obligated to eat under the law of pikuach nefesh, or preservation of human life. Similarly, essential medications must be taken. Each patient may have their own understanding of this practice and should be allowed to fast if they so choose, as long as it is medically safe. Considerations should include consults on insulin doses, routes of medication, and intravenous fluids. If a patient has a percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) tube, feeding can be continued, but initiating feeding should be discussed with the patient or surrogate. If feasible and medically acceptable, dialysis, operative procedures, imaging with contrast, NG tube placement, and other procedures should be postponed unless emergently necessary. For outpatient visits, discuss with patients how chronic conditions will be managed over the 25-hour period, including migraines, asthma inhalers, and renal disease. Lastly, meals for those fasting should be provided as soon as the fast ends, allowing patients to break the fast on time.
Along with the patient population in the hospital, providers too are worthy of consideration. The best way to support Jewish colleagues during this time is to have proper infrastructure to let them be home with their families. Offering to switch call or shifts is a small way to accommodate their observances. Consider adding Jewish Holiday dates to the main hospital calendars so everyone can be aware, and not schedule procedures and conferences on those dates.
Following Yom Kippur is Sukkot, or Festival of Tabernacles. Religious practice includes building a sukkah, or hut from wood or fabric, and covering the top with S’chach, or palm leaves. These heavily decorated huts are used as the primary dwelling for 7 days (8 days in the Diaspora), where Jews eat, socialize, and in some cases sleep. The themes of the prior holidays carry over, but this holiday is more joyous, and coincides with the agricultural harvest in Israel. Following Sukkot are the holidays of Shemini Atzeret and Simchat Torah, or celebration of the Torah. Shemini Atzeret focuses on praying for rain and Simchat Torah celebrates the end of the cycle of reading the entire Torah, after reading one portion each week throughout the year.
Hospitals should consult their local Jewish community to determine if building a sukkah for the hospital is achievable. Patients able to leave their rooms should be allowed to use the hospital sukkah for meals if medically cleared. If consistent with hospital policy, patients should be allowed to keep their ritual items in their rooms to facilitate their celebration of Sukkot.
Beyond the Above Recommendations
These proposals are not exhaustive. Each Jewish patient and community will have their own practices, needs, and restrictions on activity. During these coming holidays, Jewish patients who are hospitalized will miss important communal practices and may struggle with unique theological questions. We can support these needs with compassion and understanding, as having an opportunity to observe cultural traditions can benefit patient health. Healthcare organizations should consult with their local Jewish community and their Jewish chaplaincy staff to best serve their specific population. The traditional Jewish greeting for this time is “may you be inscribed for a good New Year.” With appropriate planning and sensitivity, hospitals and staff can go a long way in providing the start of a good New Year for their Jewish patients.
Zehavya Stadlan is a fourth-year medical student at New York Medical College, with an interest in public health, Jewish ethics, advocacy, and encouraging Orthodox Jewish Women in medicine. She is applying to general surgery residency. Lila Kagedan MEd, MTS, is the Institute on Human Values in Medical Ethics assistant professor and director of Medical Ethics and Humanities for the School of Medicine at New York Medical College. She is also a clinical ethicist and hospital chaplain/Clergy. Mill Etienne, MD, MPH, is associate professor of neurology and medicine at New York Medical College, where he teaches multiculturalism in medicine and serves as the vice chancellor for Diversity and Inclusion and associate dean for Student Affairs.