Guardianship and Advance Directives

Tzohar Ad 120

A Primer to Filling Out the Guardianship Documents and Advance Directives

Guardianship and advance directives according to the Patient Nearing Death Act can be issued by filling out the proper forms from the Ministry of Health. The forms must be submitted to the Ministry of Health. It is recommended to prepare a few copies that, when the need arises, can be given to the different bodies involved in taking care of the patient.

We are available for counseling, Tzohar Call Center – *9253.

*The information which follows is stated regarding adults who are considered legally competent according to the relevant laws. It is not intended as a substitute to practical advice in any sense, including legal counseling. Our goal is to present the overall picture and assist patients and their families. In any practical circumstance it is important to refer to proper legal, ethical, and halachic counsel.

Advice for Filling Out the Guardianship Forms

  1. It is recommended to appoint a guardian as soon as the time comes, before the patient is legally considered a “patient nearing death”, and certainly before they become mentally incompetent. At this stage one can sign for guardianship using the abridged version, without physician involvement.
  2. When signing the complete version of guardianship, at page 4 of the document, “סמכויות מיופה הכוח” (guardian authority), it is recommended to select variant [1], which grants the guardian the ability to make any decision regarding performing treatment or abstaining from it. When choosing this option, there is no need to define in the form which specific treatments one may abstain from. For both options in articles 1-2 (abridged or full version variant [1]), it is recommended to add an accompanying letter from the patient stipulating that there should be consultation with a rabbi, as will be elucidated later on.
  3. If variant [3] is chosen, which grants the guardian authority over certain treatments, we advise adding in article 4ג of the form, “הוראות אישיות שאינן מנויות לעיל” (personal directives not previously mentioned), guidelines for the guardian identical to those detailed later on in the advice for advance directives (including the article requesting consultation with a rabbi). It is important to focus on differentiating between different states of disease. 

Advice for Filling Out Advance Directives

  1. Our opinion from a halachic and medical perspective is that it is both proper and recommended to choose the option opting to withhold medical treatment under certain circumstances (part 1 of the form, pages 3-6) and not the option opting to receive life-prolonging treatments even if the medical team recommends abstaining from them (part 2 of the form, page 7).
  2. On page 6, article 5א, “הוראות אישיות שאינן מנויות לעיל”, it is recommended to add guidelines in the following language (Hebrew text below):
  • In the case of “patient nearing death”, I instruct not to withhold artificial nutrition, aside from situations where the medical team has determined that the nutrition is causing harm or prolonged serious suffering.
  • In the case of “terminal patient”, I instruct that artificial nutrition be ceased and replaced with administration of saline containing salt and glucose, if the medical team evaluation determines that there is no benefit from nutrition, and of course in cases where it causes harm or serious suffering, and if withholding of nutrition does not cause suffering.
  • In the case of “patient nearing death” or “terminal patient”, in circumstances of great distress, I instruct that morphine be administered to me or any other medication that will alleviate pain, even if there are risks involved.
  • In the case of “patient nearing death”, if I am in extreme distress, I instruct not to disconnect me directly from a mechanical ventilator; however, I allow withdrawing pharmaceutical support supporting my ventilation, and lowering the oxygen administration to levels of oxygen in normal air, after consultation with a rabbi.

3. In addition to these directives, it is recommended to add an article that obligates consulting a rabbi.

Accompanying Letter – Consultation with a Rabbi

In both the advance directive and the guardianship, it is proper to add a request to consult with a rabbi, as detailed later. In the guardianship form, in variants 1 and 2, the request should be attached as an accompanying letter. In variant 3 and the advance directives one should add an article under “הוראות אישיות שאינן מנויות לעיל ”. 

When the need arises to make a medical decision regarding my case, while I am considered a patient nearing death or in terminal stages, and on condition that the time constraints permit it, I hereby request to consult with Rabbi ________  or alternatively with a rabbi who my family/guardian deems similar in halachic matters to the rabbi that I have chosen, and grant his recommendation weight as if it reflects my own wishes. I request that my family/guardian invests reasonable effort into making sure this consultation takes place as stated. If the matter does not assist the process, this should not be enough to negate the power of my family members/guardian.

For additional reading:

  • “I Am with Him in Suffering”: The Accompaniment of the Sick According to Jewish Sources
  • Position Paper: Medical and Nursing Care of Parents
  • Withholding Treatment of an Infant with Invasive Bacteria

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