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  • Edith M. Meyerson (a1), Diane E. Meier (a2) and Allison Kestenbaum (a3)

Palliative care is an interdisciplinary approach to caring for individuals and families who are suffering with serious illness. Medical and psycho-social-spiritual symptoms and needs are assessed and addressed. Much of palliative care is about working with patients and families to bring their context to light, that is, to understand not only their medical situation but also their wishes, values, cultural background, previous experiences, and quality of life. As palliative care clinicians, we have seen how popular understanding and misunderstanding about what it means to “honor thy mother and father” can influence medical decision making. Whether or not adult children of patients have familiarity with the honor commandment, the biblical text “honor thy father and mother,” or whether they identify with a particular religious tradition, this theme plays a central—and often unaddressed—role as adult children strive to make decisions with and for a seriously ill parent. In this article we examine the commandment to honor one's father and mother by exploring its religious, spiritual, textual, and cultural origins, as well as subsequent Jewish commentary. We also contextualize the honor commandment in the palliative care setting through clinical case studies that illustrate the concerns of adult children who wish to honor their parents but are perplexed or conflicted about what this mandate means in the face of difficult medical and psycho-social-spiritual circumstances.

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1 World Health Organization, “WHO Definition of Palliative Care,” accessed January 31, 2016,

2 National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary,Journal of Palliative Medicine 7, no. 5 (2004).

3 Richardson, Patrice, “Spirituality, Religion and Palliative Care,Annals of Palliative Medicine 3, no. 3 (2014): 150–59.

4 Sukanya Mitra and Nalini Vadivelu, “Multidisciplinary Approach and Coordination of Care,” in Essentials of Palliative Care, ed. Nalini Vadivelu, Alan David Kaye, and Jack M. Berger (New York: Springer, 2013), 7–21.

5 Sukanya Mitra and Nalini Vadivelu, “Guidance with Complex Treatment Choices,” in Vadivelu, Kaye, and Berger, Essentials of Palliative Care, 89–105.

6 Mitra and Vadivelu, “Multidisciplinary Approach and Coordination of Care.”

7 Colleen M. Mulkerin, “Palliative Care Consultation,” in  Oxford Textbook of Palliative Social Work, ed. Terry Atilio and Shirley Otis-Green (New York: Oxford University Press, 2011): 43–51.

8 Back, Anthony L. and Arnold, Robert M., “Dealing with Conflict in Caring for the Seriously Ill: ‘It Was Just Out of the Question,’Journal of the American Medical Association 293, no. 11 (2005): 1374–81.

9 Goold, Susan Dorr, Williams, Brent, and Arnold, Robert M., “Conflicts Regarding Decisions to Limit Treatment: A Differential Diagnosis,Journal of the American Medical Association 283, no. 7 (2000): 909–14.

10 See “National Consensus Project for Quality Palliative Care”; “New Survey Reveals ‘Conversation Disconnect,’” press release, The Conversation Project, September 18, 2013,

11 Rao, Jaya K. et al. , “Completion of Advance Directives among U.S. Consumers,American Journal of Preventive Medicine 46, no. 1 (2014): 6570 .

12 Goold, Williams, and Arnold, “Conflicts Regarding Decisions,” 910.

13 See Diem, Susan J., Lantos, John D., and Tulsky, James A., “Cardiopulmonary Resuscitation on Television. Miracles and Misinformation,New England Journal of Medicine 334, no. 24 (1996): 1578–82; Goold, Williams, and Arnold, “Conflicts Regarding Decisions,” 911.

14 Ziettlow, Amy and Cahn, Naomi, “The Honor Commandment: Law, Religion, and the Challenge of Elder Care,Journal of Law and Religion 30, no. 2 (2015): 229–59.

15 The authors were invited to contribute to this symposium issue of the journal exploring the biblical commandment to honor one's father and mother and its influence on contemporary elder care. The authors, two board-certified chaplains and a palliative medicine physician, all with extensive palliative care clinical experience, analyzed the biblical commandment as it appears in scripture and in subsequent commentary.

We explored the linguistic and textual context of the honor commandment and selected prominent interpretations that we then analyzed through the lens of palliative care practice. We draw on personal observations of how uncertainty about what it means to honor one's parent in medical decision making plays out in the palliative care clinical setting. The authors wrote case studies (altered to protect confidentiality) that illustrate these perspectives about the honor commandment. The case studies are drawn from experience as palliative care providers in acute care medical centers/teaching hospitals in urban areas. Each case study concludes with an explicit discussion of the spiritual dimensions of the vignette, with special reference to the role played by the “honor” commandment.

We acknowledge that of the four cases, one is about a Jewish family. The other three cases portray a variety of cultural, spiritual, and religious backgrounds and traditions. The two board-certified chaplain authors are molded by their Jewish professional training and clinical experiences. However, as professional interfaith chaplains, they are trained to allow Jewish ethics, texts, and thought that may have universal relevance to inform their clinical understanding of matters such as those explored in this article. Certainly other cultures or faith traditions might apply varying interpretations to these cases.

16 Exodus 20. Biblical translations and references are taken from Tanakh: The Holy Scriptures (Philadelphia: The Jewish Publication Society, 1985).

17 Exodus 20:12. See also Deuteronomy 5:16.

18 See Bernard Lo, Resolving Ethical Dilemmas: A Guide for Clinicians, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2012); Goold, Williams, and Arnold, “Conflicts Regarding Decisions,” 911.

19 In fact there is a biblical and rabbinic teaching that the obligation to honor one's parents does not allow one to transgress a commandment in a manner that might lead to a violation of Jewish law. Biblically, this is reflected in Leviticus 19:3. The rabbinic teachings are reflected through the eleventh-century French rabbinic commentary of Rashi, who comments specifically on the biblical verse Leviticus 19:3, as well as the rabbinic teachings found in Bava Metzi'a 32a in the Talmud.

20 Shai Held, “Honoring Parents: (Sometimes) the Hardest Mitzvah of All—Parshat Yitro,” Mechon Hadar, accessed March 30, 2016,

21 See Thai, J. N. et al. , “‘It Just Consumes Your Life’: Quality of Life for Informal Caregivers of Diverse Older Adults with Late-Life Disability,American Journal of Hospice & Palliative Medicine (May 2015): 16 ; Gott, Merryn et al. , “‘No Matter What the Cost”: A Qualitative Study of the Financial Costs Faced by Family and Whānau Caregivers within a Palliative Care Context,Palliative Medicine 29, no. 6 (2015): 518–28; Oechsle, Karin et al. , “Anxiety and Depression in Caregivers of Terminally Ill Cancer Patients: Impact on Their Perspective of the Patients’ Symptom Burden,Journal of Palliative Medicine 16, no. 9 (2013): 16 .

22 N.Y. Pub. Health Law § 29 (2010).

23 Maimonides (1138–1204; also Moses ben Maimon, or his Hebrew acronym Rambam) was one of Judaism's foremost scholars and philosophers. His writings about Jewish ethics and law, including the canonical fourteen-volume Mishneh Torah, continue to influence Jewish thinking and practice today.

24 See “Gallup Poll on Religion,” accessed February 12, 2016,; “Spirituality in Cancer Care—Health Professional Version (PDQ®),” National Cancer Institute,

25 Shields, Michele, Kestenbaum, Allison, and Dunn, Laura B., “Spiritual Aim and the Work of the Chaplain: A Model for Assessing Spiritual Needs and Outcomes in Relationship,Palliative and Supportive Care 13, no. 1 (2015): 7589 .

26 These paradigms are not intended to offer a comprehensive taxonomy, but rather highlight various details that we have found provide deeper understanding in the care provided to patients and their families when uncovered by clinicians and professional aiding in their care.

27 The authors acknowledge limitations in our methods and case studies and further work that could be done to expand the discourse on this topic. First, the analysis of the honor commandment was done primarily from a Jewish perspective. It would be worthwhile for spiritual caregivers from other faith traditions to offer their unique exegesis and present corresponding case studies. It would also be worthwhile for spiritual caregivers from non-Abrahamic faith traditions who do not have a personal religious or spiritual connection to the Bible to comment on the values and teachings of their tradition that relate to the parent-child relationship in palliative care. In general, more case studies are needed that explore other prominent spiritual themes to help the medical community at large to better understand the role and purpose of the spiritual domain.

Another limitation is that the clinical scenarios of this article were inspired by experiences in academic medical centers in large metropolitan areas. It may be worthwhile for caregivers in other settings, such as community hospice or hospitals, to reflect on these issues. Further study about how gender, ethnicity, culture, and national origin influences the spiritual domain may also be instructive. In addition, all of the cases were written about consultations with a palliative care service. We acknowledge that there are many clinical situations where the primary or front-line medical team also faces these issues.

Finally, we acknowledge that these cases were written from the perspective of clinicians, although we have tried to present some of the perspective of the patients and their loved ones. More can be done in this area. Perspectives from other members of the care team, such as social workers, psychologists, psychiatrists, and nurses could deepen these accounts. We would also welcome insights from legal professionals working in health care, such as those working in risk management or elder law.

28 Using the framework of palliative care, caring for the whole person, each discipline represented speaks to the various dimensions of a person that has an impact on his or her medical care. Typically a palliative care team will have a roundtable discussion about demographic information, medical history, current medical condition, and reason for hospital admission; reason for palliative care consultation and psycho-social-spiritual assessment; and plan. These teams revisit each patient and make a daily assessment and plan until the reason for consultation is resolved. As mentioned above, palliative care is consulted for patients with serious illness who need pain and symptom management or counsel in complex medical decision making.

29 The team consisted of a palliative care board-certified physician, a nurse practitioner, a social worker, and a chaplain.

30 This case represents a common reason for palliative care consultation. There can always be medical interventions offered but the question is whether or not this is in line with patient's goals and the hoped-for outcomes.

31 The palliative care consultation service is often called on in such cases, where there is family discord and complex decisions that need to be made.

32 Part of the moral distress expressed by the staff related to this very long hospitalization. The palliative care consultation service provided support to staff on this issue.

33 While patients may not have a faith affiliation or religious beliefs, palliative care philosophy recognizes that there are spiritual needs that deserve to be assessed, addressed, and honored because these inform patients’ decisions and coping.

34 For one of the few examples of published cases, see George Fitchett and Steve Nolan, eds. Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy (Philadelphia: Jessica Kingsley Publishers, 2015).

35 Meier, Diane E., Back, Anthony L., and Morrison, R. Sean, “The Inner Life of Physicians and Care of the Seriously Ill,Journal of the American Medical Association 286, no. 23 (2001): 3007–14.

36 Anthony Back, Robert Arnold, and James Tulsky, Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope (New York: Cambridge University Press, 2009), chapters 9 and 10.

37 Andrew Wilson, “The Purpose of Life in the Family and in Society,” chapter 4 in World Scripture: A Comparative Anthology of Sacred Texts, ed. Andrew Wilson (New York: International Religious Foundation, 1991), 169.

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