On Yom Kippur we separate from all aspects of life, we abstain from performing melacha, eating, and drinking and we focus on prayer and repentance. For a sick person and those taking care of them, there is no break on Yom Kippur; a dementia patient’s caretakers involve themselves in this throughout the year for a period of many years. Involving oneself in true chessed nowadays is a tremendous zechut – even if the matter comes at the expense of Tefillah in shul.
Aside from a patient’s normal treatment, this day presents extra challenges dealing with the halachot of Yom Kippur, the fast, and the extended tefillot. When is a sick person or a person with dementia obligated to fast and when are they exempt? How should one eat shiurim (incrementally) and which sick people are obligated to perform this? If one is eating – how should they act regarding berachot, kiddush, and netilat yedayim? Is it proper for a person with dementia to come to shul and for how long?
1. A critically ill patient (choleh sheyesh bo sakanah) is exempt from fasting. When there is concern that the fast will sap their strength and put them at risk, the patient must eat1. If the patient can subsist on liquid alone, it is best to avoid eating. When there is no urgency for food or drink, one can eat and drink shiurim; however, if eating shiurim would impact the sick person negatively – he can eat normally2. It is proper to clarify before Yom Kippur with both a doctor and rabbi the level of severity of the illness and how to act in practice.
2. A person who is sick not critically ill (choleh she’ein bo sakanah) is obligated to fast, even if they are suffering significantly. Observing the fast is more important thandavening in shul and therefore it is best to rest all day in bed so they will be able to fast.
3. A person who is in the early stages of dementia is not defined as exempt from mitzvot and it is their right to be part of the congregation of fasters. Therefore, if they forget the fast day and wish to eat, it is the responsibility of those around them to remind them that it is a fast day – in a way that will not cause them embarrassment3.
4. In the intermediate stages, where the person is still not in a state where they do not understand the basic concept but already lack the capability to be responsible for their own eating or fasting: if they request to be fed, one should feed them4. If there is a way to feed them shiurim, and this would not have a significant toll on the patient or caretaker, it is preferrable to feed them in this manner5.
6. The precise definition of the mental and physical condition of a person with dementia is complex and dynamic and the boundaries between the cases in the previous subarticles are not obvious. Therefore, it is recommended to consult with medical professionals and a rabbi before the fast, in order to define what is permitted and forbidden.
7. The obligations in the rest of the Yom Kippur afflictions, such as the prohibition of bathing or wearing leather shoes, are more lenient than the obligation to fast. When it is sufficient to remind a person with dementia of the situation, one must remind them and prevent them from transgressing prohibitions. However, when observing these prohibitions becomes burdensome or confuses him, and definitely if they are not aware of the prohibition, one should allow them to act as they can and wish8.
8. A person who eats on Yom Kippur is not obligated in kiddush, even on Shabbat, and is not obligated in lechem mishneh. If they eat bread, they should perform netilat yedayim as usual, despite the prohibition of washing. They should make a bracha before eating, and if they eat or drink beyond the minimum measurement, they should make an afterbracha. In birkat hamazon they should add “ya’aleh veyavo”; on Shabbat they should add “retzei”; and in the bracha me’ein shalosh they should add “vezachreinu letova beyom hakippurim hazeh”. In both brachot, if they forget to add this, they should not go back and recite it over9.
1. A person who is not critically ill but requires medication – should take bitter or tasteless medicine10. If the medicine is sweet, they should mix bitter flavoring into it (if this does not impact the quality of the medication) and swallow it together. A critically ill patient should take medication as normal.
2. A person with dementia who takes medication routinely should continue to take them on Yom Kippur as normal.
3. A person with dementia, as well as any other patient, who routinely takes sedatives or anti-anxiety medication should continue to take the medication on Yom Kippur, even if it seems that they have no direct medical need11.
4. If they require water in order to swallow the pill, they should drink less than a shiur, use bitter water that is unfit for drinking or mix the medication into the water12.
5. If a dementia patient has difficulty drinking in this manner and there is a genuine need for the medication, they should swallow the pill with water as intended13.
6. If the medical guidelines dictate that one must take a medication with food and a person is in a condition where they are obligated to fast – they should eat less than a shiur or should juxtapose several incidences of eating less than a shiur, as explained earlier. If one cannot eat in this fashion, the decision as to whether they are permitted to eat and take the medication is dependent on the importance of the medication, and one should consult a rabbi and physician14.
4. Tefillah and the Daily Service
1. The prayer service for Yom Kippur is long, and there are a variety of different levels of obligation for different parts of davening, as detailed in the footnote. It is proper to plan ahead – together with the dementia patient, if possible – how long they will spend in davening, and according to this determine when – and at what stage of davening – it is best to arrive15.
2. Following the order of importance detailed in the footnote, we propose that a person with dementia who wishes to go to shul should arrive in the morning at “Barchu” and stay as long as they are able (or wish to). One can offer them to daven Minchah at home and return to shul for the Neilah service.
3. A person with dementia who stays at home on Yom Kippur can sense the difference compared to normal days; for example, that they do not go to the clinic, that family is not visiting; no television, music, or phones, etc. It is proper to organize an appropriate experience and accompany them – making sure not leave them confused or lonely.
You are not alone! Caretakers and family members who are debating how to act are welcome to refer to Tzohar Ad 120’s call center for answers to their questions. The rabbis and social workers at the center are at your service and will assist you in bearing the burden of taking care of family members.
- Shulchan Aruch, Orach Chaim, 618:1
- Ibid. 7-8. Eating shiurim is also biblically prohibited yet is the preferred action of a critically ill patient. There are many methods and measurements for eating shiurim, and we will bring here a short summary of the practical halacha (see Peninei Halacha, Yamim Noraim, chapter 8, halacha 5; Rabbi Moshe Harari, Mikra’ei Kodesh: Hilchot Yom HaKippurim, chapter 6). Eating shiurim is eating less than the amount of food qualified as “eating” in one sitting, taking breaks between each meal. The amount of “eating” is around 30 cm3. The amount of drinking shiurim is less than a cheekful (melo logmav). This measurement is different from person to person and since it is difficult to evaluate this for a person with dementia, the amount of liquid should be less than 40 cm3. The break between each meal or between each drink should ideally be 9 minutes, and if necessary, can be shortened to 4 minutes; for drinking one may even shorten this to a minute. It is preferrable, if they are capable, to subsist just on sugar water and abstain from eating. When this is properly prepared for, one can drink shiurim in a manner which allows for a significant amount of liquid which will satisfy the needs of the patient.
- Rabbi Asher Weiss (Teaching Methods: A Collection of Shiurim, Responsa, and Psak Halacha on Sickness on Yom Kippur, Jerusalem 5769, article 2:2, page 8) writes that when the patient has mental competence, one should withhold them from violating a prohibition, however the family members are not obligated to overburden themselves with this, and therefore the family is not obligated to sit all day alongside the patient in order to prevent them from eating. See Rabbi Yonatan Rosensweig and Dr. Shmuel Harris, I Ask For My Soul: Halachot of Mental Health, Jerusalem 5782, chapter 8, article 5, page 124.
- See the definition of the obligation later, footnote 6.
- As we have written previously, footnote 3, family members are not obligated to overburden themselves in order to make sure the patient fulfills the mitzvah. Even the level of burden of the patient is limited, as we have discussed in the article ‘Obligations of a Dementia Patient on Fast Days and in Mourning Rites of the Three Weeks’ https://bit.ly/3Y2lE9q, Therefore, when a person with dementia experiences difficult eating shiurim or this causes them tremendous discomfort, they may eat normally.
- We have expanded on this in other places and proposed that the issue of a dementia patient’s obligation in mitzvot varies from mitzvah to mitzvah, based on the level of understanding and comprehension necessary for the specific mitzvah. Mitzvot which he understands and is able to fulfill independently – he is obligated in like one who is mentally competent; mitzvot which he does not understand or is unaware of – he is considered unable to fulfill and is exempt. See what we have written in the article ‘Obligations of a Dementia Patient on Fast Days and in Mourning Rites of the Three Weeks’ (in the previous footnote).
- Even when a person is exempt from mitzvot, one should not actively feed them prohibited foods. This is the halacha regarding a minor eating neveilot (Shulchan Aruch, Orach Chaim, 343:1) and is also the ruling regarding one who is mentally incompetent (shoteh), according to the Chatam Sofer (Chatam Sofer Responsa, volume 1, article 83). Even though this is a matter of discussion, many Achronim have ruled stringently following his opinion. See Chashukei Chemed, Yoma 78b; I Ask For My Soul, pages 124-125 and footnotes 11-13). The Magen Avraham (article 616:2) holds that one should not actively feed a minor on Yom Kippur (Mishneh Brura ibid., subarticle 5 brings his opinion there, and agrees regarding a minor who must finish the fast but does not apply this ruling regarding minors who are being educated to fast in smaller increments). However, other authorities have written that one should differentiate between eating a forbidden item and eating on Yom Kippur for a number of reasons: 1) that which is prohibited is specifically to feed a prohibited item but on Yom Kippur, the food itself is permitted and the eating is that which is forbidden (Zichron Yaakov Responsa, Orach Chaim, 6; Nishmat Avraham, Orach Chaim, article 618:1 in the name of Rabbi Yehoshua Yeshaya Neuwirth; Teshuvot VeHanhagot Responsa, volume 4, article 150; volume 5, article 192), 2) For the sick person, eating is a mitzvah and is not included in a prohibitive category (Zichron Yaakov Responsa, ibid.) 3) placing food before a sick person is not considered actively feeding (ibid. however regarding a dementia patient there are times where one must actively feed them). 4) A person with dementia who needs food can potentially be in a critical state and is not able to express themselves clearly (Teshuvot VeHanhagot Responsa, ibid; Rabbi Yitzchok Zilberstein, Shabbat Shabbaton, second edition – 5759, article 16, page 77), however, when there is no gentile and the patient normally eats with the assistance of someone else, one may – and it is a mitzvah to – feed them even on Yom Kippur (Teshuvot VeHanhagot Responsa, ibid.; see as well I Ask For My Soul, pages 124-125, article 6 and footnote 14).
- The status of the rest of the afflictions is more lenient than the prohibition to eat and drink, and a non-critical patient is exempt from them. This is the ruling of the Rambam, Mishneh Torah, Hilchot Shvitat Asor, chapter 3, halachot 2-9, and the Shulchan Aruch, Orach Chaim,614:1 regarding the prohibition of anointing oneself, and subarticle 3 regarding wearing leather shoes, as well as the Rema ibid., 613:9 regarding bathing. Therefore, a person with dementia who struggles with these afflictions, even slightly, is exempt from them.
- Kiddush – Rabbi Akiva Eiger (on the Shulchan Aruch, Orach Chaim, article 618) writes that on a Yom Kippur that falls on Shabbat one must make kiddush before they eat, however from the Mishneh Brura, ibid., article 29 it seems that even on Shabbat one should not make kiddush, and this is the opinion of most poskim. See the Har Tzvi Responsa, Orach Chaim, volume 1, article 155; Igrot Moshe Responsa, Choshen Mishpat, volume 1, article 39; Shmirat Shabbat KeHilchata, chapter 39, article 31; Chazon Ovadiah, Yamim Noraim, pages 307-308. Lechem Mishneh – the Knesset HaGedolah writes that one needs lechem mishneh, yet the Magen Avraham, article 618:10, Shulchan Aruch HaRav, article 618:18, and the Shmirat Shabbat KeHilchata, ibid., write that there is no need. Netilat Yedayim – the Shmirat Shabbat KeHilchata, ibid., writes that one should wash their hands as they do during the week, up to the wrist joint, since this is not considered pleasurable washing. This is also written in the Chazon Ovadiah, ibid., article 308. Rabbi Eliezer Melamed (Peninei Halacha Yamim Noraim, chapter 8:7) writes that one should perform netilat yedayim up to the finger joints, as one is accustomed to do in the morning on Yom Kippur (Shulchan Aruch, Orach Chaim, 613:2). If they drink in shiurim, they do not make a beracha after drinking; however, if they eat in shiurim, it is possible that they may require a beracha after eating, since the measurement for eating on Yom Kippur is greater than the measurement of eating for a beracha. See the Peninei Halacha, ibid. Saying Ya’aleh Veyavo – according to the Shibulei HaLeket one should not say Ya’aleh Veyavo, and this is the ruling of the Taz, Orach Chaim, article 618:10. However, the opinion of the Maharam, Rosh, Hagahot Maymoniyot, and the Tor is that one should say it, and this is the ruling of the Shulchan Aruch, Orach Chaim 618:10, as well as the opinion of most poskim – the Magen Avraham, subarticle 10; Shulchan Aruch HaRav, ibid.; Mishneh Brura, subarticle 29, and the Shaar HaTzion, subarticle 21; Shmirat Shabbat KeHilchata, ibid.; Chazon Ovadiah, ibid., pages 308-309. Since the poskim have disagreed on the matter, if one forgets, they do not repeat Shemoneh Esrei (Mishneh Brura, ibid.; Chazon Ovadiah, ibid., page 309). Even though one who eats on Tisha B’Av should not eat decadent foods (Machzik Beracha, Kuntrus Acharon, article 1; Kaf HaChaim, article 551:31, amongst others), on Yom Kippur there is no aspect of suffering or mourning, and therefore one who eats can eat normally.
- A person who is not critically ill is permitted to take bitter or tasteless medications on Shabbat. See Igrot Moshe Responsa, Orach Chaim, volume 3, article 91; Shmirat Shabbat KeHilchata, chapter 39, article 8; Rabbi Moshe Harari, Mikra’ei Kodesh: Hilchot Yom HaKippurim, chapter 9, article 38, and the sources quoted there.
- Distress and inappropriate behavior are part of the symptoms of dementia, and the treatment for them and keeping the patient regulated is part of their treatment – without which their condition will decline. Therefore, one must take the medication on Yom Kippur just like any other medication. Even if close patient supervision is able to calm them without medication, family members are not obligated to overburden themselves for this purpose (see footnote 3 earlier).
- See Shmirat Shabbat KeHilchata and Mikra’ei Kodesh (earlier footnote 10). See Rabbi Yitzchok Zilberstein, Shabbat Shabbaton, article 84-87, pages 198-208, who discusses this extensively and writes that the amount of bitterness that one should add is enough for a person to abstain from drinking the liquid due to its bitter taste. It is recommended to prepare chamomile tea or a similar drink for this purpose before Yom Kippur, concentrated with no sugar. Rav Zilberstein also writes there that the most halachically advisable way to do this is to crush the pill into water, and then the water itself is considered medication, however one should clarify regarding each medication that this does not impact its efficacy.
- The Halachot Ketanot Responsa (volume 2, article 282-284) writes that drinking water does not carry with it the punishment of karet since they do not nourish the body, and according to him it is permitted to drink clean water in order to swallow a pill. Many of the Achronim disagree with him, yet Rabbi Ovadiah Yosef (Yabia Omer Responsa, volume 2, Orach Chaim, article 31) writes – after rejecting his opinion – that one may utilize this opinion if there is a need to be lenient. Generally, one may take medication in one of the ways mentioned in the previous footnote, however a person with dementia can have difficult receiving medication in an abnormal manner. Therefore, it is possible, when necessary, to swallow the pill with water as normal. See I Ask For My Soul, page 123, footnote 9.
- Taking medication is permitted for a sick person who is not critically ill, yet eating a shiur of food is permitted only for a critically ill patient. Therefore, the heter to eat before taking medication requires a ruling as to what the patient’s medical and halachic conditions are.
- The piyyutim are a significant portion of the prayer service. From a halachic perspective, they are of lower importance, but on the other hand specifically through piyyutim is a unique experience expressed which can raise the spirit of a dementia patient. This is the order of importance of the parts of Shacharit and Mussaf (compare to footnote 6 earlier): 1) the Shemoneh Esrei of Shacharit (without the Chazzan’s repetition); 2) from “Barchu” until the Shemoneh Esrei; 3) the Shemoneh Esrei of Mussaf (without the Chazzan’s repetition); 4) Vidui during the Chazzan’s repetition of Shacharit; 5) Vidui during the Chazzan’s repetition of Mussaf; 6) Chazzan’s repetition of Shacharit; 7) Chazzan’s repetition of Mussaf; 8) Torah reading; 9) Pesukei DeZimra; 10) the rest of tefillah.