Hashem Prepared Me

Rabbi Katz is a Kohein, so he’d never really considered any kind of involvement in medicine growing up. He’s a Flatbush native with solid yeshivah credentials: Torah Temimah, Yeshiva Tiferes Torah in Staten Island, and beis medrash at Toras Moshe in Eretz Yisrael, where he became close to the rosh yeshivah, Rav Moshe Meiselman. As a child, his grandfather, Reb Shmuel Schick, served as an important role model for him. Mr. Schick served as the chairman of the Diamond Club, and used to tell the young Naftali, “I like being the chairman, because when I call the banks on someone’s behalf, they take my calls.”

“He showed me how to use every situation to help others,” Rabbi Katz says.

About 14 years ago, while still single and in his late twenties, Naftali Katz was offered the opportunity to fill in for Rabbi Eytan Feiner at Camp Simcha, as a maggid shiur and as a directing presence in the beis medrash. During that summer, he befriended a fellow named Rafael Shachar Weisberg, a young man in his mid-twenties with a terminal disease. They became so close that the following spring Shachar’s mother called Rabbi Katz to say, “Shachar isn’t coming back to camp unless you’re there.”

Rabbi Katz returned in the capacity of a caregiver and companion (Shachar was in an electric wheelchair at that point), and in the process learned tremendously about dealing with illness, both on the physical and emotional levels. “I tried to keep his spirits up, but was also realistic about his illness, and open about his sense of vulnerability and loss of bodily privacy during medical care,” he says.

For the three summers that Rabbi Katz was at Camp Simcha, Rav Elimelech Bluth ztz”l, a talmid of Rav Moshe Feinstein and the posek for Chai Lifeline and Camp Simcha, was also at camp. The two of them discussed many medical sh’eilos during those weeks, such as how to handle electric machinery for cholim on Shabbos, and Rav Bluth worked with him to set up halachic guidelines for the counselors at camp. Rav Bluth had become a rebbi and mentor for him.

Meanwhile, Naftali Katz married Sharona, a CPA, and joined the kollel at BMG. And later, when the couple found themselves in that long-haul hospital stay, Rabbi Katz was prepared with a vast amount of knowledge related to halachic aspects of a choleh who needs special care. “Hashem had set me up to handle those challenges with a Torah frame of mind,” he comments when we meet in his Lakewood home. Now in his early forties, Rabbi Katz serves as the rosh chaburah for a seder of about 45 yungeleit in Rav Avraham Lefkowitz’s Kollel Bnei Torah.

Every Minute of Life

When he finally returned to Lakewood from Boston after that long medical haul, someone told him that Rabbi Eliezer Gewirtzman (today one of the members of Agudath Israel’s Machon Chayim Aruchim medical advocacy organization) was starting a night kollel devoted to the study of medical-related issues. It piqued his interest, and he called to find out more. “It was a misunderstanding. He hadn’t planned on opening a kollel,” Rabbi Katz remembers, “but he told me the Agudah was planning to set up a course in medical halachah.”

That course was the brainchild of Rabbi Shmuel Lefkowitz of Chayim Aruchim, who raised the funds and invited avreichim from Lakewood and Brooklyn to participate in a course to train rabbanim to man the Chayim Aruchim hotline, answering sh’eilos and advocating for families whenever the need arose.

Yet he hesitated at first. He called his rosh yeshivah, Rav Meiselman. “This would be such a big responsibility — someone else should do it,” he said. “I’m not sure I feel confident in my ability to handle it properly.”  Rav Meiselman retorted, “Who else should do it?  You’ve been there! You know that world!” Given this encouragement and backing from his rav, Rabbi Katz signed on.

For close to a year, a small group of avreichim — both yeshivish and chassidish yungeleit — met weekly in Boro Park to hear shiurim from Rav Zvi Ausch, the posek for Chayim Aruchim, A.T.I.M.E, and the Yoshev Rosh Bais Hora’ah D’Karlsburg. They also heard lectures from a lineup of doctors associated with Chayim Aruchim, including Dr. Beth Popp, an expert in palliative care at Mount Sinai, Dr. Howard Lebowitz of Specialty Hospital in Lakewood, and Dr. Yashar Hirshaut, an oncologist at Mount Sinai.

“The doctors taught us what we needed to know, medically, to be able to answer halachic queries,” Rabbi Katz relates. “And so we learned how to ask families and doctors the right questions.”

He explains that Chayim Aruchim was created because of the profound shift in attitude in society, and in the medical community, regarding end-of-life issues. While Orthodox Jews believe that every moment of life is precious, secular society, for the most part, puts sole importance on “quality of life.”

“Doctors will balk at doing certain interventions, saying they carry only risk and no benefit,” Rabbi Katz says. “So we have to clarify what ‘benefit’ means: Is it someone’s definition of ‘quality of life,’ or simply maintaining life? I once witnessed a situation where a doctor told a husband that his very sick wife’s quality of life was so compromised that it made her life no longer worth preserving. ‘She won’t ever be able to go to the mall,’ the doctor told him. So we’re trained to be able to tell the doctors, firmly and respectfully, ‘I understand, but we believe that every moment of life has value.’ ”

The Steipler Gaon was once asked about the value of life for a person in a vegetative stage (in that particular case, it was a rosh yeshivah who’d been a gadol b’Torah). The Steipler responded that according to the Gemara in Kiddushin (40a), a person who wants to do mitzvos but is prevented from doing so by circumstances beyond his control is considered to have actually done the mitzvah, and is rewarded accordingly.  Thus, for every moment the Rosh Yeshivah was alive, he was earning sechar for the mitzvos he would have done had he been able.

We must also never assume that life has lost value because a person is elderly, Rabbi Katz stresses. Just last year, a 104-year-old woman was hospitalized with heart failure in New Jersey. The doctors there advised her daughter to put her into hospice and wait for her to die, since she was too frail for major surgery. But her son refused to give up.

He called Chayim Aruchim, and learned that his mother could be treated using a new technique called transcatheter aortic valve replacement (TAVR), a procedure that replaces aortic valves that no longer open. Minimally invasive, it’s well suited to elderly or frail patients.

The woman was transferred to Mount Sinai Hospital, where Dr. Samin Sharma performed the procedure. The woman recovered, and the following year — at age 105 — she attended the wedding of her great-granddaughter.

Rabbi Katz says the phrases “If it were my mother…” or “There’s nothing more to do” should raise red flags. “Families should explore all the options, with their risks and benefits, and get second opinions.”

Talk So Doctors Will Listen

Most doctors assume that rabbis are laypeople with little understanding of their profession, and don’t take kindly to being addressed in an adversarial fashion or with histrionics.  If approached with sensitivity by a rabbi who is clearly knowledgeable and reasonable — they are more likely to hear the other side.

In dealing with medical professionals, Rabbi Katz takes his cue from Rav Ausch. “He is extremely sensitive when he deals with people, but he can be extremely strong as well,” Rabbi Katz says. “We have to know our religious rights and stand our ground, explaining to them that we simply have a different system for doing things, a system that works and that we’re proud of.”

Sensitivity is important not only when working with doctors, but also with family members who are not religious and have different ideas about end-of-life protocols. “It can get sticky,” Rabbi Katz admits.  But when he gets on the phone with such people — who often expect an Orthodox rabbi to be ignorant of medical advances and technology — and shows them that he understands the medical issues and has a common language with the doctors, they become more amenable to his point of view, and often makes a kiddush Hashem in the process.

Standing one’s ground doesn’t necessarily mean threatening to sue or going to court.  If an accommodation can’t be reached with a hospital, sometimes a patient can be transferred to a different hospital. One patient in a small hospital in New Jersey needed a feeding tube, but the doctor refused to put one in. Mordechai Biser, the legal advisor for Chayim Aruchim, became involved, and in the end the patient was transferred to another hospital that agreed to give a feeding tube. The patient went home shortly afterward, and lived more than two years longer.

“We Jews always want to find the best doctors for our family members,” Rabbi Katz comments. “But often it’s more important to find the best doctor who will treat the patient. Sometimes it’s not the most prestigious doctor who has the best ideas; when Rav Aharon Kotler was hospitalized in Manhattan at the end of his life, his talmid Rav Shlomo Miller reported that it was a young, unknown doctor who had the best idea how to proceed with treatment.”

It’s expensive to provide end-of-life care, which unfortunately means that it’s not financially worthwhile for hospitals to extend care. Chayim Aruchim’s many contact people can sometimes prevail upon hospitals to provide better care or transfer patients to hospitals or other facilities more willing to go the extra mile.

Rabbi Katz notes that in New York and New Jersey, certain tests cannot be performed without consent. One important example is the apnea test, meant to determine whether or not a patient is brain dead.  In a recent case, a child had been having seizures, and the doctors wanted to perform the test. But Rabbi Katz told them not to allow the test to be done, based on a letter by many poskim including Rav Dovid Feinstein ztz”l and ybdlch”t Rav Ausch.

“It’s a vigorous test that’s very hard on a compromised patient,” Rabbi Katz explains.  “The test has no medical benefit, and if the test says the patient is brain dead — the legal criterion for death — the insurance companies will no longer pay for treatment.”

Not So Fast

Sometimes what appear to be signs of end-of-life decline are really just signs of infection that are often treatable. Rabbi Katz tells about the neighbor of an elderly, widowed Holocaust survivor with no immediate family. “This neighbor is a very special person. He made sure to always be around on Shabbos and Yom Tov for her, and checked on her daily,” Rabbi Katz recounts. The Katzes were getting into the car on the way back from a family Chol Hamoed trip when the man called to tell him that the hospice nurse said the woman was dying.

“I wasn’t convinced,” Rabbi Katz says. “I asked some pointed questions, and told them to wait. I put the man in touch with Leah Horowitz, Chayim Aruchim’s discharge specialist, and the woman lived another two and a half years.”

A while later, the neighbor woke up Rabbi Katz in the middle of the night with an emergency (once a rabbi has established contact with a family, they may call him whenever they need him): The woman was in the ICU, and doctors were asking her to sign a DNR (Do Not Resuscitate).  Again, Rabbi Katz wasn’t convinced she was moribund; he explains that when a patient’s condition changes dramatically, often the culprit is an infection and not imminent death. He told the man to ask for tests; in the end, the woman had a urinary tract infection that cleared up with antibiotics. She lived for many more months, passing away at the age of 99 at Specialty Hospital in Lakewood.

A lack of nutrition or hydration may also produce symptoms that doctors interpret as impending death — disorientation, confusion, weakness. In end-stage dementia, patients often stop eating and lose weight. Once the patient declines from lack of nutrition and hydration, it may be difficult to reverse the downward progression. “If you’re proactive, and make sure the patient gets enough hydration and nutrition — even if it means giving then a PEG tube — you can stave off decline much longer,” Rabbi Katz says.

This applies equally to hospice care. Technically, during hospice care, treatment is only discontinued for the primary disease (cancer, Parkinsons, etc.). But patients should still be given adequate nutrition and hydration, and treated for secondary conditions such as infections or bedsores. Administering pain medication for such fragile patients can be tricky, because a patient given too much morphine may not survive.

“Rav Moshe Feinstein stated that it’s important that a patient not be in pain, because pain shortens life,” Rabbi Katz says. “But you also can’t overdo administering the pain medication, and it has to be given in a halachically acceptable way.”

Patients and their families should be aware of the consequences of signing a DNR form.  The form is supposed to stipulate that, after a catastrophic event occurs, the heart should not be artificially restarted. At times, it’s halachically permissible to sign this sort of paper, but in practice, doctors perceive a signed DNR as meaning that they shouldn’t take extreme measures of any sort.

“DNR becomes Dying Not Recovering,” Rabbi Katz says.  A study at Brigham and Women’s Hospital in Boston found that mortality rates were twice as high for patients who had signed DNRs.  Similar risks exist for patients who sign Do Not Intubate forms.  Hence, a competent rav should be consulted before signing either of these forms.

Furthermore, he says, people should make sure to have a halachic will in place, a signed document that declares the person is a religious Jew and includes the name of the rav they’d like to make halachic decisions in the event of a medical emergency.

Call of the Hour

What does day-to-day life look like for a rabbi who’s available 24/7 to answer emergency questions?

In the mornings, Rabbi Katz is  a rosh chaburah at Kollel Bnei Torah. In the afternoon, he takes the 2:00 to 4:00 shift for the Chayim Aruchim hotline. Some questions that come in are familiar, issues he’s dealt with before and had previously discussed with leading poskim. However, he always has Rav Ausch and the other rabbanim to reach out to for more complex sh’eilos. Sometimes, thanks to random Googling, he’ll get calls about kashrus or Torah Judaism (he refers those people to the appropriate kiruv organizations); one recent caller wanted to know how to handle a child who’d become a messianic Jew.

The calls come in from all over the world — Europe, Canada, South America, all over the US. Some of Rabbi Katz’s most interesting sh’eilos come from Chabad shluchim posted around the globe. He once dealt with a woman in Florida who wasn’t religious, but had become affiliated with Chabad. Her husband was very sick, and she wanted to do what he would have wanted, which probably would have meant pulling the plug on his life support.

“I spent a lot of time on the phone with her,” Rabbi Katz says, “and in the end she opted not to, and he died on his own. She wrote a letter expressing that now she feels at ease, that she did the right thing and doesn’t have the responsibility for his death.”

Many doctors report that family members go through a very hard time emotionally after making the decision to end a family member’s life, whereas people who follow halachah have the comfort of knowing they didn’t make the decision on their own, and did their best halachically.

Rabbi Katz sometimes gets calls from people who just need moral support and compassion. He once received a call from a woman who was sobbing because her mother, a woman in her nineties, was dying. “We only get one mother,” Rabbi Katz says philosophically. While he hasn’t had specific training in counseling, a family friend, a skilled professional, advised him, “Just listen.”

At any rate, he says, many frum people have a support network of friends and family in place, and call for halachic and medical guidance rather than psychological support.

The onset of the Covid crisis intensified the halachic dilemmas. All sorts of new sh’eilos came up: hospitals were overwhelmed, and people weren’t always getting the best care. Every decision to hospitalize meant a sh’eilah evaluating the risks and benefits. Rabbi Katz himself caught the virus, but continued answering queries even while sick.

“The Hatzolah people saw awful things — people leaving their homes bentshing their children, not expecting to make it back,” he recalls. “One time I was on the phone talking to the doctor and the family, and the patient died during our conversation.”

Rabbi Katz doesn’t believe there’s a particular personality most suited to doing this job, or that one needs a certain amount of heavy life experience. “Being good at this is more about putting your heart and mind into continuing to learn more and more, and about really caring about people. Sincerity and ratzon count for much more than personality type when it comes to success.”

And how does he define success? “Success is following halachah,” he says. “Whatever the final outcome, our job is to make sure not to compromise.”

Not Over Yet  

Jeffrey Gootkin was just 67, but the once-vigorous man who enjoyed 100-mile bike rides was dying of stage 4 bladder cancer. He’d had two seizures, was declining neurologically, had stopped eating, and doctors predicted he’d be dead within 72 hours.

Mr. Gootkin had first been diagnosed six years prior, but had gone into remission and resumed his active lifestyle. Now the cancer was back in the bladder and lymph nodes. Chemotherapy, followed by immunotherapy, kept the disease under control for six months, but then Mr. Gootkin had two seizures within a couple of months and began declining precipitously. He was disoriented and anxious. Mr. Gootkin’s medical team told his family confidently that the neurological issues were a result of the cancer.

Gootkin’s daughter and son-in-law, Alexandra and Daniel Bellehsen, flew from their home in Boston to be with their father in Los Angeles. There, doctors told them the cancer had spread to his brain, even though the following week a scan showed no such metastases. Still, because they considered his case hopeless, the hospital began withdrawing treatment, hydration and nutrition. They discharged him, refusing to admit him back for further treatment.

Daniel Bellehsen asked the advice of an oncologist friend, who was sure doctors weren’t on the right track. “It was pretty clear to him that the doctors were off the mark and had thrown in the towel,” Bellehsen says. “And although they refused to do a neurological assessment, my friend kept pushing us not to give up.”

Gootkin’s doctors insisted he was actively dying, and the family was only prolonging the agony and the inevitable. As the Bellehsens, horrified, watched their father’s mental state decline, they reached out to the Bostoner Rebbe, who put them in touch with the Chayim Aruchim end-of-life advocacy hotline. When they connected with Rabbi Menachem Horowitz, one of the hotline rabbis, things began to turn around.  With tremendous patience and persistence, Rabbi Horowitz battled the doctors and hospital staff to allow Mr. Gootkin to be re-admitted in order to begin receiving nutrition through a feeding tube and to look for other causes for his symptoms, despite the daily attempts to discharge him. And slowly the patient improved until he was well enough to be discharged to a nursing home. Within a month, his mind was clear. Following this near-debacle, Mr. Bellehsen switched his father-in-law’s health care provider. His new doctors discovered he’d been suffering from vascular parkinsonism, which can cause small strokes that had perhaps triggered the seizures.

(Originally featured in Mishpacha, Issue 875)