By Rabbi Yair Hoffman for 5tjt.com

Invariably, there will be some people that will attack this article, because medicine is not the field of the author.  Even so, the information contained herein has been looked over by doctors, and information that needs to be said sometimes, well, just has to be said.

Nutritionists and their field are often the awkward step-child of many hospitals that treat cancer.    

True, in theory, everyone agrees that maintaining the proper nutrition of the patient during cancer treatment is crucial.  But as the great Baalei Mussar say, “Often the path from the mind to the heart is quite long and curved.”

There are many times when a patient undergoing chemotherapy, surgery, radiation and/or any combination of the three – just doesn’t survive because he or she did not get the necessary nutrition and are malnourished.  One reason, of course, is that the patient just doesn’t want to eat because it is too painful.  Another reason is that the patient struggles to swallow or there is some sort of opening in the stomach or even above there in the esophagus.

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What follows is a discussion of two types of nutrition for cancer patients.  The first is not controversial.  The second type is very controversial. Following that is a halachic discussion of the Mitzvos involved.  In all cases, the author recommends reaching out to Agudath Israel’s Chaim Aruchim program – (718) 278-2446.

• The first type is Enteral nutrition – when nutrients are absorbed into the blood through the intestines.
• The second type is Parenteral nutrition – which is often given when there are complications with enteral nutrition.  This is broken down nutrition which goes straight into the veins themselves. This second type can be done either as a supplement to regular nutrition – called PPN (Partial parenteral nutrition) or as the only means of nourishing the patient – called TPN (Total parenteral nutrition).

ENTERAL NUTRITION – Feeding tubes

Feeding tubes do often help, contrary to some misinformation out there.  There are generally 3 major types of feeding tubes.

• NG-tube – Nasogastric tube which goes through the nose then the esophagus [the veshet], and then into the stomach. No surgery is required for it.
• G-tube – Gastrostomy tube which is inserted directly through the belly.  It can be put in as an outpatient procedure.
• J-tube – Which goes through the skin of the belly into the midsection of the small intestine. It can be placed either as inpatient or outpatient and delivers both food and medicine and is generally used when the patient cannot digest food in the stomach.

The latter two tubes are more comfortable than the NG-tube, even though there may be some initial discomfort.  Some of the tubes inserted may use a pump, a syringe or gravity.  Cleanliness is essential because the patient is often at risk of developing an infection.

In this author’s experiences, even enteral nutrition is often treated as a step-child by many hospitals and doctors and patients can often pass away because nutrition is not treated as importantly as it should.  Many doctors have expressed the same thoughts as this author.

THE CONTROVERSIAL PARENTERAL NUTRITION

Some doctors and nutritionists believe that parenteral nutrition is actually too dangerous for most cancer patients because it can often lead to infections and other complications.  Indeed, two of the top experts in the field of nutritional support for cancer patients, Dr. Mark Schattner and Dr.Moshe Shike, write in the tenth edition of Modern Nutrition, “Results of numerous clinical trials support the use of specialized nutritional support only in limited situations during anti-cancer therapies.”  Both Dr. Schattner and Dr. Shike are leaders in their field at Memorial Sloan Kettering hospital.

Others, however, believe that wider use of TPN can both extend and save lives.  It can save life by keeping the patient around and healthier so that the chemotherapy can kick in.   Whether or not this has been borne out by studies is a matter of medical debate.

The actual decision of when and whether to apply parenteral nutrition should not be made by well-meaning family members.  It can and should only be made qualified health professionals, and the implementation of it can vary greatly for each individual patient.

The undeniable reality is that many oncologists and cancer specialists – even the top ones – overlook the importance of nutritional issues.  There are studies that back this up.

“I have a colleague at work who is literally wasting away by not eating,” remarks a fundraiser at a Bucharian Jewish Mossad. “That person sees the oncologist regularly, and would you believe that no recommendation was ever made to see the hospital nutritionist?  Isn’t there supposed to be a team there?  Why should this be brought up by work colleagues and not the hospital??”

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THE WAY ISRAEL LOOKS AT IT

Many medical professionals are of the opinion that TPN and PPN are very much underutilized. In an article entitled, “Parenteral nutrition – Guidelines of the Israeli Society for Clinical Nutrition (ISCN),” Israeli author Dr. Pierre Singer points out in the summary that the Israel Ministry of Health was willing to update the National Recommendations for Parenteral Nutrition administration and asked the Israel Society for Clinical Nutrition to write newer guidelines.

The study notes that enteral nutrition should be the first choice for nutritional support in the critically ill. However, no difference in mortality rate was observed between the two groups.

It further noted that a study was performed in patients receiving mixed enteral and parenteral nutrition and demonstrated improvement in morbidity and mortality in patients receiving the mixed nutritional support.

WHAT CAUSES THE LOSS OF WEIGHT?

It is also important to know what it is that causes the actual loss of weight in cancer patients.  There are a number of contributing factors.  There is the tumor itself which can cause blockages and a subsequent loss of appetite.  There is also the change in the body’s metabolism that the cancer has brought about.  The body no longer efficiently absorbs proteins and carbs, and even vitamins or essential minerals.  There is also the depression factor and the changes in the body’s tastes.

“Food no longer tastes the same to me – especially when undergoing a chemotherapy session,” remarked a mortgage broker undergoing treatment.

TPN FOR END-OF-LIFE ISSUES

Another issue that is a matter of some controversy is whether TPN should be used for patients who have been placed on palliative care.

A Manhattan doctor who moonlighted in a Suffolk County Emergency Room made a fascinating and not politically correct distinction between patients who came from Staten Island and those who came from Manhattan.  He said, “Many of the Staten Island patients are Italian and very much want their parents to remain alive in any manner possible.  They are similar to the Chassidic Jews from Brooklyn.  I have seen them argue that their parent in palliative care  should get the same nutrition that the parent had received while in the ICU.  On the other hand, the Manhattan children of patients – when they find out that the parent is terminal – well let’s just say that they do not go through heroic measures.”

OPPOSING VALUE SYSTEM

“There was  a case of a young cancer patient with stomach cancer,” remarked Rabbi Zischa Ausch, a Rabbinical coordinator at Chaim Aruchim, an Agudah sponsored health organization. “The doctor said that the TPN would feed the cancer. I responded, ‘But the patient will starve to death if he doesn’t receive nutrition’.”

Drs. Shils and Shike, however, remark, “In terminally ill patients TPN should be avoided.  The concern that such patients should not be ‘starved to death’ is not a justification for TPN.”

The Sloan Kettering doctors continue, “A non-controlled study of terminally ill patients with cancer who were hospitalized at a long term care facility suggested that these patients did not experience hunger or thirst, and in those patients who experienced such symptoms, small amounts of food alleviated the symptoms.  In such patients, the utilization of TPN either in the home or at health care facilities cannot be justified.”

FOREIGN TO THOSE BROUGHT UP ON TORAH VALUES

This type of thinking is quite foreign to those brought up with Torah values.  The Sloan Kettering doctors state, “the median survival on TPN is only four months.”

A Rabbi from Queens whose mother had received TPN reacted sharply to this statement.  “What? Are they serious? “Only four months?” Four months is four months of my children seeing my mother!”

Chaim Aruchim deals with about 1000 TPN cases a year wherein they actually extend life, and in about twenty of those cases they truly save lives.  These people were placed on TPN and were eventually weaned off of it – after the chemotherapy protocol proved to be effective.

Rabbi Ausch continues, “TPN is often an end-of-life issue, and, unfortunately, from my own experience, the vast majority of hospitals do not allow it for the purpose of merely extending life.  When a patient is not able to eat on his or her own – we actually advocate the use of it.

They [the doctors] do try to discourage it, by saying that it leads to infections and it is too dangerous, but most of the time it’s simply not true.  Most of the time they actually refuse it is because of financial and ideological reasons.”

However, Shoshana, a mother of a child receiving TPN, says, “Central lines that are used for TPN because of the high glucose content – people are much more likely to have infections.  A sepsis episode is a scary and life-threatening thing.  Cancer patients have much less wherewithal to fight something like that and bounce back.  Ultimately, HaKadosh Boruch Hu decides every step of the way but it is and can be very traumatic.”

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WHAT IS THEIR MINDSET?

So what is the rationale for doctors placing high value on the extension of life for four months through a chemotherapy drug, but placing little regard for that equal extension of life when it comes to adequate nutrition?

One doctor pointed out, “It is all in the mindset – nutrition is a dead end.  But the doctors can learn from the ways and methods that the chemo-drug was effective.  Maybe this time it is four months, but perhaps later it can be extended to six or eight months.”

Dr. Yossi Gelbfish, a noted cardiologist remarked, “the decisions of applying what might be effective therapy are often social decisions and not medical decisions – even though the doctors are the ones making it.  It depends on what the culture says, and the culture today is that active euthanasia is not accepted but passive euthanasia is accepted.  It is not something we do, because we as Torah Jews value chayei sha’ah – temporary extension of life – but this is zeitgeist in American medicine today.”

THE FIVE MITZVOS INVOLVED IN GETTING THE PATIENT THE RIGHT NUTRITION

1. Hashavas Aveidah. The mitzvah is not just for lost items. The verse in Parashas Ki Seitzei (Devarim 22:2) discusses the mitzvah of hashavas aveidah, returning a lost object, with the words, “V’hasheivoso lo,” “and you shall return it to him.” The Gemara in Sanhedrin (73a), however, includes within its understanding of these words the obligation of returning “his own life to him as well.” For example, if thieves are threatening to pounce upon him, there is an obligation of “V’hasheivoso lo.” This verse is the source for the mitzvah of saving someone’s life. It is highly probable that it is to this general mitzvah that the Shulchan Aruch refers in Shulchan Aruch Orach Chaim 325. This is certainly the case with following COVID-19 protocols, they save lives.
2. ‘Lo Saamod al dam rayacha. Do not stand idly by your brother’s blood.’ There is a negative mitzvah of not standing idly by your brother’s blood (Vayikra 19:16). This is mentioned in Shulchan Aruch (C.M. 426:1) and in the Rambam. If people get sick and chance death because of our inaction, we are violating the commandment of “Lo sa’amod al dam rei’echa.”
3. ‘Lo Suchal L’hisalem.’ There is yet another negative commandment associated with the positive commandment of hashavas aveidah, and that is the verse in Devarim (22:3), “You cannot shut your eyes to it.” This verse comes directly after the mitzvah of hashavas aveidah. The Netziv, Rabbi Naftali Tzvi Yehudah Berlin, in his HeEmek She’eilah, refers to this mitzvah as well.
4. ‘V’chai Achicha Imach.’ Rav Achai Gaon in his She’iltos (She’ilta #37), based upon the Gemara in Bava Metzia 62a, understands the words in Vayikra (25:36), “v’chai achicha imach,” “and your brother shall live with you,” to indicate an obligation to save others with you. The Netziv in his HeEmek She’eilah understands it as a full-fledged obligation according to all opinions. He writes that one must exert every effort to save his friend’s life, until it becomes a matter of pikuach nefesh for himself. The Netziv’s position would certainly advocate that Covid-19 protocols are obligatory.
5. ‘V’ahavta L’rei’acha Kamocha.’ The Ramban, in Toras HaAdam Sha’ar HaSakanah (pp. 42–43), understands the verse of “And love thy neighbor as yourself” as a directive to save our peers from medical danger as well.

We thus have a total of five Torah mitzvos involved in getting cancer patients the right nutrition.  Once again the author reiterates the need to reach out to Chaim Aruchim – (718) 278-2446.

Rabbi Yair Hoffman has served on the board of ethics of a Long Island hospital for over 15 years and served as one of the directors of a 400 bed rehabilitation facility.  The author can be reached at [email protected]

*** A YOUNG LADY IN A DIFFICULT FAMILY SITUATION NEEDS TUITION ASSISTANCE FOR SEMINARY – IF YOU CAN HELP, PLEASE REACH OUT TO THE AUTHOR [email protected]***