Rabbi Ed Bernstein

Best-selling author and surgeon Dr. Atul Gawande’s prescription for a meaningful conversation with loved ones consists of three questions: What are your fears? What are your goals? What trade-offs are you willing to make?

There’s a story about a man who hoped for his whole life to be in the movies. Years went by, but he never had his chance. Finally, a film crew came to town, and they were looking for extras to appear in a Civil War picture. The director gave him one line: “Hearken unto the cannons!” The man was so excited to land a speaking part, and for days he would practice his line: “Hearken unto the cannons!” The big day came for the shoot. On his way to the set, the man says to himself over and over, “Hearken unto the cannons! Hearken unto the cannons!” He puts on a Union Army costume practicing his line, “Hearken unto the cannons!” Then, they finally start shooting the scene, and there’s a gigantic blast of a cannon, and the man shouts, “What the hell was that!”

As we go through life, we are not always prepared for the roars of the cannon, momentous changes that alter the course of our lives.  For example, any one of us or our loved ones may seem perfectly healthy one day, then receive a serious diagnosis of illness the next.

During this season, we create a communal cannon blast, as it were. It’s sort of a fire drill to prepare us for the real cannon blasts that shake up our lives. We gather in large numbers on Rosh Hashanah and Yom Kippur and put on a display of pageantry through our services to remind us of God’s grandeur. This pageantry is designed to create a framework in which we can do the real work to bring God’s presence into our lives by bringing healing to our relationships and our world. That work is called Teshuvah (return). If we do this work well, we will be better equipped to deal with the unexpected cannon blasts that shake up our lives.

Teshuvah is not easy. Teshuvah  requires thought. Teshuvah requires intentionality. Teshuvah requires action.

For ten days we have sung in synagogue the plaintive melody of Avinu Malkeinu. We cry out to God as a parent, Abba, someone who is close to us; we also call to God the Melekh,the distant ruler of the universe.   At the end of that prayer we say aseh imanu tzedakah vachesed—do with us acts of tzedakah—righteousness— and loving kindness. We say to God: “this is what we are doing. We are inviting you—even imploring you—to join us on the way. If you join us, then You, God, will have no choice but l’hoshiainu, to redeem us.

We all have times when our faith is challenged. We see loved ones suffer from illness. We see people around the world suffering from natural disasters and man-made disasters, such as war and terror. We ourselves suffer from illness and hardship.

The first Lubavitcher Rebbe, Rabbi Schneuer Zalman of Liadi (1745-1812), taught that there will come a time in everyone’s life when we lose faith in God. Too many things may have happened to us. We have too much knowledge of bad things that happen to good people. “At that moment,” the Rebbe says, “go take care of someone who is sick. Go visit someone who is lonely. Go do an act of tzedakah, of hesed. You will feel God in your hands and your faith will be restored.”

As we prepare to say the Yizkor service, I’d like to suggest specific actions we can do and words to say to a dear one with serious, perhaps life-threatening, illness. My hope is that when we take such action those who are suffering in some way, particularly those near and dear to us, feel cared for and valued as human beings.  Through simple action and words, we have the potential to strengthen the relationships that matter to us most. Through the bonds of those relationships, we will feel God’s presence.

The action that I propose is derived from Dr. Atul Gawande  and his remarkable book Being Mortal. Dr. Gawande is an accomplished surgeon at Women’s and Brigham Hospital in Boston, a professor at Harvard Medical School and a columnist for the New Yorker. In his book, he notes that the medical profession has developed great technology for treating disease and keeping people alive. At the same time, he writes, “Our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer.”

Gawande notes that for much of the last century there have been two kinds of doctors. One could be described as “paternalistic,” an all-knowing priest-like figure whose advice a patient does not question. Another form of doctor is “informative.” This doctor will give you the facts of your disease and then offer different choices of treatment. The course of treatment is up to the patient, the doctor is just providing information. Gawande, however, advocates for a different model: the “interpretive” doctor-patient relationship.  Here the doctor’s role is to help patients determine what they want in the big picture. Interpretive doctors ask, “What is most important to you? What are your worries?” Then, in response to the patient, they provide appropriate guidance for treatment based on the patient’s priorities.

Gawande shares lessons not only from his own career and how he has grown in his practice of interpretive medicine but also from his personal experience of the medical system. He describes his father’s battle with a rare form of tumor in his spinal column that threatened to make him quadriplegic and kill him. Gawande’s father and mother are both doctors who immigrated from India.  Their entire family speaks the language of science and modern medicine. The father, therefore, was able to ask very sophisticated questions about his own condition and potential treatments. Gawande contrasts two neurosurgeons whom his father visited for consultations. Both agreed that the tumor could not be removed; it could only be decompressed. In both cases, the neurosurgeons described the benefits and risks of surgery. Their styles, though, differed greatly when it came to answering the father’s questions.

Gawande writes that one neurosurgeon wanted to operate immediately and was annoyed by his father’s many questions. “He was fine answering the first couple,” he writes. “But after that he grew exasperated. He had the air of the renowned professor he was—authoritative, self-certain, and busy with things to do.”

Gawande continues: “Look, he said to my father, the tumor was dangerous. He, the neurosurgeon, had a lot of experience treating such tumors. Indeed, no one had more. The decision for my father was whether he wanted to do something about his tumor. If he did, the neurosurgeon was willing to help. If he didn’t, that was his choice.” The elder Dr. Gawande made a choice—not to use this surgeon.

Gawande reports that the next surgeon also exuded confidence. “But he recognized,” Gawande writes, “that my father’s questions came from fear. So he took the time to answer them, even the annoying ones. Along the way, he probed my father, too.” This surgeon reflected that the father was more worried about the harm the operation might cause than the tumor itself.

Gawande continues, “My father said he was right. My father didn’t want to risk losing his ability to practice surgery for the sake of treatment of uncertain benefit. The surgeon said that he might feel the same way himself in my father’s shoes.” The neurosurgeon spoke to his patient as a fellow human being rather than a diseased specimen to be treated, and he won the trust of the author’s father.

As Gawande tells the story of his father along with the maturation process of his own surgical practice, he highlights three questions that doctors should ask patients, particularly when confronting terminal illness. He calls this a “hard conversation” and that doctors need to muster the compassion, courage and skill to engage in these conversations. The questions are:

1. What are your biggest fears and concerns?
2. What are your most important goals?
3. What trade-offs are you willing to make or not? For example, Gawande describes one patient before agreeing to a risky operation who asked if after the surgery he would still be able to watch football and eat ice cream.

Of course, for any of us who are caring for loved ones with serious illness, this is a template for the hard conversations we all should have. In times of illness, each of us should sit with our loved ones, hold their hand and be fully present. We then should ask: What are your fears? What are your goals? What trade-offs are you willing to make in the face of this battle? When we have such a conversation, we reaffirm the humanity of our dear ones. We fulfill the words of Avinu Malkeinu and literally bring God in our midst to be with us as we perform an act of hesed, loving kindness.

Returning to Gawande’s story, these three questions played a significant role in his father’s treatment and final years of life.  The senior Dr. Gawande was an accomplished and respected surgeon in his own right who enjoyed his practice. His greatest fear, it turns out, was not death but quadriplegia. His goals were to practice medicine as long as he could and continue other community activities that he enjoyed. In terms of trade-offs, if surgery were to save his life but leave him paralyzed, he would forego surgery.

The father delayed surgery and continued in his medical practice for a time and in a respected community leadership position. He monitored his symptoms, such as tingling in his hands. He established a red line with the neurosurgeon as to when he would have to have surgery. Some two-and-a-half years passed with the father living a fairly normal life until pain and numbness had advanced. He retired from medicine and eventually opted for surgery. The tumor was decompressed and he was able to maintain mobility, at least for a while.

Some time after his father’s surgery, Gawande was invited to give the commencement address at a university near his parents’ home. His father’s health had declined, and he was confined to a wheelchair. The tumor had indeed taken its toll. For a while, Gawande feared his father might not survive long enough to hear his speech. When it became apparent he would, the planning turned to logistics. Originally, his father would sit in a wheel chair on the floor of the basketball arena housing the ceremony. But when the day came, the father was adamant that he would walk and not sit in a wheelchair on the floor.

“I helped him to stand,” Gawande writes. “He took my arm. And he began walking. I’d not seen him make it farther than across a living room in half a year. But walking slowly, his feet shuffling, he went the length of a basketball floor and then up a flight of twenty concrete steps to join the families in the stands. I was almost overcome just witnessing it. Here is what a different kind of care—a different kind of medicine—makes possible, I thought to myself. Here is what having a hard conversation can do.”

A “hard conversation” is actually quite simple when we break it down to its component parts. We ask three questions: What are your fears? What are your goals? What trade-offs are you willing to make, or not? Our challenge is to  discover within ourselves the courage, compassion and love to make these conversations possible. And then we must listen. Asei imanu tzedakah va’hesed. According to our prayer when we perform loving kindness God will be imanu, with us, right by our side.

As we prepare to remember departed loved ones in Yizkor, my hope is that we will tap into the best of their values for which we remember them. As they were there for us, let us be present for our dear ones who need us today. We may not know when cannons will fire that will shock us into our mortality. We can at least be better prepared for when they do. Let us have the courage to have hard conversations with our loved ones about our fears, our goals and the aspects of life we most cherish.

Avinu Malkeinu, give us the strength to be fully present for our dear ones who turn to us for purpose and hope. Asei imanu tzedakah va’hesed—we’re not going to sit by silently. We’re going to take action and have conversations of lasting importance. We invite You, God, to be with us when we perform this act of hesed. In our work together with You, God, we pray v’hoshi’einu, that you will save us through the power of Your presence in our sacred relationships.

Amen.

Tags: Atul Gawande, Avinu Malkeinu, Being Mortal, hard conversations, Hearken unto the cannons, Schneur Zalman of Liadi, teshuvah, Yizkor, Yom Kippur