Should a psychiatrist say Kaddish for his patient?

COMMENT

I feared the worst when my usually reliable patient didn’t respond to my emails. No, not the worst, because suicide is definitely the worst, and suicide was very low on my differential, given that individual’s unwavering will to live, even under the most difficult of circumstances. Yet physician discussion boards frequently comment on ways to deal with a patient’s suicide, so this dreaded outcome is clearly on many psychiatrists’ radar. Earlier in the pandemic, it was not uncommon to hear my residents detail their distress at seeing so many patients die in New York City, which has suffered far more than its fair share of pandemic-related deaths. In the 1980s, and even in the 1990s, I myself lost several patients, as well as medical colleagues, during the AIDS epidemic.

Perhaps there is something about epidemics and mass deaths that either endures you to such losses, or at least causes you to be prepared and prepared for them. Consultation-liaison (CL) psychiatrists who work in hospitals are no doubt confronted on a regular basis with the problems of the end of life and the death of patients, just like psycho-oncologists, geriatric psychiatrists and psychiatrists who work in palliative care and palliative care. But for me, as an outpatient psychiatrist in private practice, it’s rare to follow a patient long-term through a life-threatening medical illness that required intensive treatment, but eventually came to an end – not 2 weeks after diagnosis. initial, as predicted by a surgeon at a general hospital, but 2 years later, through aggressive medical interventions available at a specialty hospital known for its “Hail Mary” approaches to otherwise incurable medical conditions.

During these years, this patient shared far more of his hopes and fears, his accomplishments and his aspirations than he had revealed in previous years when confronted with psychiatric symptoms alone, without no indication of what was to come. The last date was about the mounting pain they endured during their recent hospital stay, but this individual still maintained his dignity and humanity.

When this picky patient failed to confirm his twice-weekly appointment despite repeated emails, a veil of terror descended on me. Eventually we reconnected and they told me about a 2 week hospitalization that prevented access to cell phones. The announcement of a 2-week stay in a tertiary care hospital was worrying enough, but not hearing from the patient after his last appointment was even worse. At the request of the patient, I had forwarded the contact details of 2 pastoral counselors, but did not get the expected acknowledgment from this typically gracious person who recently asked me to pray for them – even though they knew we practiced different religions and were quite committed to their own religious traditions.

“Any prayers would help,” the patient insisted, undeterred by religious differences. They were desperate words, spoken when one feels one’s time is running out.

Even though the last appointment had not been confirmed, I called the patient anyway. When my patient’s phone didn’t answer at our usual time, I left a voicemail, consoling myself that their voicemail was still active, while wondering about the worst. Then I dialed the spouse’s phone number, knowing it was time to contact the emergency contact whose name had been listed several years earlier. This phone answered immediately. I introduced myself and the spouse immediately recognized me. They called me by my name, as if they were waiting for my call. Without delay, they gave me the worst news, news I had been waiting for, but dreaded to hear.

After wiping away my tears, stifling my spontaneous sobs and hearing the spouse’s uncontrolled sobbing, we talked for a while, using the time I had reserved for my now deceased patient’s appointment and knowing that they and I would never have another date. .

My initial inclination after ending that call was to say Kaddish, the Jewish prayer for the dead, but I stopped, but not because the patient was not Jewish. The patient had, after all, begged me to add a prayer for the sick to the Saturday morning Sabbath service at the synagogue, although they themselves followed a very different faith. It was not a question of religion that stopped me. My second thought was about crossing boundaries, which in itself is close to a cardinal sin in psychiatry.

It is always difficult to draw the line between compassion, benevolence and excess in clinical care, but exceptional circumstances allow more leeway than is usually granted. I considered consulting the American Psychiatric Association (APA) Committee on Religion and Spirituality. It occurred to me to call my rabbi for advice, until I remembered that Kaddish is said for only 7 people: a spouse, a son or a daughter, a sister or a brother, or a mother, or a father. (These gender-specific rules were devised long before non-binary identities appeared.) Some people say Kaddish for those who perished in the Shoah/Holocaust without leaving any survivors.

In Orthodoxy, only men say Kaddish, and grieving women must find a man to pray on their behalf. This tradition is so entrenched that some 19th-century Yiddish authors, writing in the first person, call their son “my Kaddish” — and don’t allude to “my son, the doctor,” like most Americanized stereotypes. For having a son – rather than a daughter – guaranteed that a parent’s memory would live on forever when the son recited this prayer for the dead.

Aside from gender roles, sexism, and religious regulations, there were other valid reasons for my hesitation. If people said Kaddish for all who passed by, the world would be in a state of constant mourning, and that is not the goal of most religions (except perhaps those religions that renounce the world and aspire to such sad states). But there was another, equally important reason why it was inappropriate for me to say Kaddish for this patient – ​​or any other patient. Even though the death of this patient caused me such pain, saying Kaddish would imply that I felt the same degree of grief as the bereaved spouse, and that presumption would disrespect the spouse’s distress. Never having been a widow, I could hardly imagine how painful it must be to lose a spouse, especially so young.

And so, I answered my own question without consulting a rabbi or a committee on religion: No, it is not appropriate for psychiatrists to say Kaddish for their patients. I cannot talk about mourning practices in different traditions – and I am well aware that there are also very many varieties of Jewish practices and beliefs – but I felt relieved to realize that the rules of my own religion provided useful limits that went beyond the clinical practice of psychiatry. To channel my distress, I instead wrote this article, expecting that other psychiatrists themselves have encountered similar dilemmas, and perhaps this article will help them put their own situation into perspective.

Doctor Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Icahn School of Medicine at Mount Sinai in New York, New York.

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