Caring for Holocaust Survivors Rabbi Barry M. Kinzbrunner, MD Chief Medical Officer Vitas Innovative...

Caring for Holocaust Survivors

Rabbi Barry M. Kinzbrunner, MD

Chief Medical Officer

Vitas Innovative Hospice Care

Who is a Holocaust Survivor?

“A holocaust survivor will be defined as any Jew who has lived in a country at the time when it was:

• under Nazi regime• under Nazi occupation• under the regime of Nazi collaboratorsas well as any Jew who fled due to the above

regime or occupation.”

Holo-Stats: Number of Living Holocaust Survivors; Israeli Prime Minister’s OfficeTranslated from Hebrew (transmitted by AMCHA on [[email protected]], 13 Aug, 1997) National Journal: http://globalfire.tv/nj/03en/history/holostats.htm

Concentration Camp: Photo by Arthur Kaye, US Army Air Corps, 1945

Concentration Camp Barracks: Photo by Arthur Kaye, US Army Air Corps,1945

Concentration Camp Survivors: Photo by Arthur Kaye, US Army Air Corps, 1945

Concentration Camp Survivors Showing Numbers Photo by Arthur Kaye, US Army Air Corps, 1945

Estimates of Holocaust Survivors

Holo-Stats: Number of Living Holocaust Survivors; Israeli Prime Minister’s Office

Translated from Hebrew (transmitted by AMCHA on

[[email protected]], 13 Aug, 1997) National Journal: http://globalfire.tv/nj/03en/history/holostats.htm

Generation of Holcaust Survivors Disappearing. Accessed 2/2/12 at http://matzav.com/generation-of-holocaust-survivors-disappearing

Country Holocaust Survivors 1997 2011 (estimate)

Israel 360,000-380,000 208,000

Former Soviet Union 184,000-220,000 113,000 USA 140,000-160,000 84,000

Western Europe 80,000-100,000 51,000 Eastern Europe 50,000-80,000 37,000 Other Countries 20,000 11,000

Total 834,00-960,000 504,000

Holocaust Survivors Living in USA: 1997

140,000-160,000 living holocaust survivors• 33,000 refugees arrive in US: 1933-1937• 124,000 refugees arrive in US: 1938-1941• 119,373 refugees arrive in US: immediately after the

war.• 24,090 arrive in US during 1950’s and 1960’s• 49,416 arrive in US from FSU during recent wave of

immigration

Mortality rate based on average white American life span

Allen Gliksman: Polisher Research InstituteHolo-Stats: Number of Living Holocaust Survivors; Israeli Prime Minister’s Office Translated from Hebrew (transmitted by AMCHA on [[email protected]], 13 Aug, 1997) National Journal: http://globalfire.tv/nj/03en/history/holostats.htm


• United Jewish Communties Report• From National Jewish Population Survey of

2000-01• Published in December 2003• Estimated 122,000 “Nazi victims” in US

– More economically and socially vulnerable than non-victims

– Poorer health, more disabilities, and greater social service needs than non-victims

Nazi Victims Now Residing in the United States. Findings from the National Jewish Population Survey 2000-01United Jewish Communities Report, December, 2003


Demographic DataCountry of OriginPre-1965• Germany: 41%• Poland: 21%• Austria: 11%• Czech: 6%• Hungary: 6%

Post-1965• FSU: 93%

– Ukraine: 66%– Belarus: 11%– Russia:

10%• Poland: 3%• Romania: 3%



Demographic Data• Age: 71 (mean) (+ 7 years to 2008)• Gender: 62% female• Region: 53% NE; 26% W; 13% S; 8% MW • Marital Status: 70% Mar; 7% Div; 17% Wid• Education: 52% College degree or more• Employment: 59% Ret; 14% employed

23% Disabled and unable to work



Financial Data• Financial State

– Comfortable; very comfortable; wealthy: 63%– Just managing; Can’t make ends meet: 37%

• Income– < $35,000: 44% – $ 35,000-$75,000: 13%– > $75,000: 9% – Unreported: 33%

• Below US Federal Poverty Line: 25%– 99% are post-1965 immigrants from FSU

• Social Security at 1/3 of household income: 42%



Health Data• Social Isolation; Living alone: 25%• Health Assessment

– Poor: 26% – Good: 30%– Fair: 34% – Excellent: 10%

• Health conditions– Limited activities: 34%– Assistance or supervision: 24%

daily or several times a week



Health Data• Cost of health assistance program

– Paid by government program: 29%– Paid by personal savings: 8%

• Social Service Needs– Home health care: 16%– Home nursing care: 5%– Live in retirement home or ALF: 10%

• English as a second language: 6% (all post-1965)


Holocaust Survivors and Cancer Risk

• Compared:– 1.8 million Israelis born 1920-1945-to Israel after WW II– 464,000 Israelis born 1920-1939-to Israel before 1939.

• Overall survivors 2.4 times the risk of cancer– Colorectal ca: 9 X the risk in male survivors, 2.25 X in females– Breast ca: 1.5 X the risk in femal survivors– Breast ca risk also double for women who were under 10

during the holocaust• Believed to be related to exposure to starvation during childhood

and adolescence when the body is in a period of accelerated growth

• 5 year ca survival rates 5-13% lower among survivors

Sinai R. Study: Cancer risk over twice as great for holocaust survivors. Ha-aretz, 4/14/07. Accessed on 1/14/10 at http://www.haaretz.com/hasen/spages/848529.html

Holocaust Survivors and PTSD

Post-Traumatic Stress Disorder (PTSD)• PTSD is an anxiety disorder that can

develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.

NIMH: Post-Traumatic Stress Disorder (PTSD). Accessed on 2/4/10 at http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/index.shtml


Symptoms of PTSD• Re-experiencing

– Flashbacks– Bad dreams– Frightening thoughts

• Hyperarousal– Being easily startled– Feeling tense or “on edge”– Having difficulty sleeping– Having angry outbursts

NIMH: What are the symptoms of PTSD. Accessed on 2/4/10 at http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/what-are-the-symptoms-of-ptsd.shtml


Symptoms of PTSD• Avoidance

– Staying away from places, events, or objects that are reminders of the experience

– Feeling emotional numbness– Feeling strong guilt, depression, or worry.– Losing interest in activities that were enjoyable in

the past.– Having trouble remembering the events that

triggered the PTSD

NIMH: What are the symptoms of PTSD. Accessed on 2/4/10 at http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/what-are-the-symptoms-of-ptsd.shtml

Holocaust Survivor Syndrome

• Exaggerated reactions to chronic pain• Depressive Reactions• Anxiety states• Somatic complaints• Intellectual impairment• Contact abnormalities• Sleep disturbances• Chronic functional gastrointestinal symptoms

Barile A: Geriatric study of survivors. International Society for Yad Vashem, Martyrdom and Resistance. March-April, 2000, p. 14.

Holocaust Survivors and Pain

Goals of the study• To define chronic pain characteristics of

Holocaust survivors 50 years after WW II• To compare survivors with controls who did

not experience WW II atrocities• To investigate the connection between past

trauma and chronic pain

Yaair A, Eisenberg E, Adler R, Birkhan J. Chronic pain in holocaust survivors. J Pain Symptom Manage 17:181-187, 1999.



33 Holocaust survivors and 33 control patients


Conclusions• Holocaust patients had:

– High pain intensity– Moderate to severe depression– High activity levels

• By remaining active, Holocaust survivors fight back their pain, distress, and depression.

• Holocaust atrocities affects survivors’ chronic pain even years later.


Holocaust Survivor Health Issues

Aging• Retirement: after working hard to build new lives:

– free time may be daunting and/or threatening.– free time may reduce defenses and allow room for intrusive

thoughts and other symptoms of post-traumatic stress disorder

– needed relocation to a facility may raise memories of prior loss of home and freedom

• Increased need for health care and exposure to hospitals, nursing homes, and ALF’s– Raise memories of Nazi medical experimentation

Pelly, S. “Aging Holocaust Survivors”, in Caring for Aging Holocaust Survivors, A Practice Manual. Baycrest Centre for Geriatric Care, Toronto, Canada, 2003.


Challenges that May Elicit Difficult Memories• Exaggerated grief reactions:

– Vulnerability to loss, separation, illness, and institutionalization

• Need to Bear Witness: – telling their story or refusing to tell their story

• Absence of Kin: – contemporaries are aging and dying, bringing

back memories of prior losses.

Pelly, S. “Challenges that May Elicit Difficult Memories”, in Caring for Aging Holocaust Survivors, A Practice Manual. Baycrest Centre for Geriatric Care, Toronto, Canada, 2003.


Dementia and Cognitive Loss• Blurs and confuses events of the past in time and

place• Increasing dependence

– Invasion of privacy– Increased exposure of vulnerabilities– Institutionalization: authority and regimentation

• Behaviors associated with such as hoarding or preoccupation with food

Goodman, R. “Aging Survivors with Cognitive Loss”, in Caring for Aging Holocaust Survivors, A Practice Manual. Baycrest Centre for Geriatric Care, Toronto, Canada, 2003.


Complicated grief and bereavement issues• Multiple layers of profound loss

– Premature loss of family– Loss of homes, communities, lifestyles, years, and sense of

security

• No one to share grief with• Recent losses compound losses during holocaust• Death of spouse:

– loss of dependence – need to be placed in a facility

Grief CJ. “Grief and Bereavement” and David P. “Grief and the Holocaust Survivor” in Caring for Aging Holocaust Survivors, A Practice Manual. Baycrest Centre for Geriatric Care, Toronto, Canada, 2003.

Holocaust Survivors Coping with Aging & Cancer

2000 Israeli study published in 2007• 150 Holocaust survivors with cancer vs. 50 controls• Typology of survivors (Danieli)

– Victims: keep to themselves, trust only those who are very close, avoid contact with non-survivors, believe it could happen again (17.3%)

– Numb: emotionally numb, constrained, socially isolated, lack in vitality (0%)

– Fighters: sense of strength, deny weakness and depression, most active socially and politically (39.3%)

– Those who “made it”: tend to deny the impact of the holocaust on their lives, distance themselves from other survivors, and are drive to succeed to indicate a “victory” over the Nazis (43.4%)

Hantman S, Solomon Z. Recurrent trauma: Holocaust survivors cope with aging and cancer. Soc Psychiatry Psychiatr Epidemiol 42:396-402, 2007.


Adjustment to aging• Percentage of patients who reported the Holocaust

made it more difficult to cope with old age– Victims: 76%– Fighters: 41.8%– “Made it”: 37.9% (p < 0.001)

Stage of Cancer• No significant association between stage of cancer and

PTSD symptoms, psychiatric symptoms, or psychosocial adjustment to symptoms was found in any of the groups.


Triggers that affect Holocaust Survivors

• White coats or uniforms• Commanding voices• Foreign accents• Handling individuals roughly or with force• Darkness and night hours• Fire alarms, strobe lights, sirens, whistles• Dogs

Bier D, Supporting Resilience in Aging Populations, The Impact of Earlier Trauma. Learning from work with survivors of the Holocaust and elderly survivors of other trauma. Holocaust Community Services, Jewish Child and Family Services, Skokie, Ill. January, 2008.


• Waiting in line, crowded conditions• Being counted off or directed• Food: Hiding or hoarding; eating too fast• Separation

– Into new environment: i.e. from home to ALF or NH

– from family after visits• Distressing sounds, cries, screams



• Use of the shower or bath • Upsetting smells, or being unclean• Staff changes and new routines• Limits on freedom• Seasonal or religious holidays• Current events and/or political turmoil



Illness, Hospital Care, Medical/Dental procedures• Giving blood or urine • Injections• Wristbands • Being shaved• Anesthesia • Restraints• Undressing and being given hospital gown• Weight loss and change in body image• Lack of disease modifying therapies for illness• “Experimental” therapies• Advance care planning or terminal prognosis


Advance Care Planning

• Holocaust survivors may refuse to discuss advance care planning issues or be willing to execute an advance directive

• Survivors have been so intent on survival that they cannot accept the idea that they may die and so discussing these concepts may be too painful for them.

• Recommendations– Be particularly sensitive when discussing these issues– Involve children and other family members

David P. “Environment factors and potential triggers” in Caring for Aging Holocaust Survivors, A Practice Manual. Baycrest Centre for Geriatric Care, Toronto, Canada, 2003.


• Religious belief and practice may affect end of life decision-making

• Holocaust survivors have a wide variety of beliefs and practices that cover the entire spectrum of Jewish practice in the US– Orthodox– Conservative– Reform– Reconstructionist– Unaffiliated


• Qualitative analysis by interview of 15 Israeli Holocaust survivors

• Question of whether Nazi policies are similar to or different from modern concepts of euthanasia– Withholding food and fluid may be unacceptable because

Nazi’s often starved people to death

• Part of a larger study looking at attitudes of elderly toward life-sustaining therapies– No distinction perceived between active and passive or

voluntary and involuntary euthanasia– Previous life experiences were important to individual

meanings and attitudes toward euthanasia

Leichtentritt RD, Rettig KD, Miles SH. Holocaust survivors’s perspectives on the euthanasia debate. Soc Sci & Med 48:185-196, 1999.


Results• Participants were not familiar with the idea of

choosing one’s own death• 9 pro euthanasia; 6 con euthanasia• All participants concluded that profound differences

exist between Nazi Germany and socially assisted dying regardless of their attitudes

• Themes of similarities– Confined to the idea that the final outcome was—

Death



ResultsThemes of differences• Physicians as actors

– Authority taken vs. authority requested– Intervention to kill vs. intervention to assist

• Participants as actors– Wish to live vs. the wish to die– Motivation to survive: continuity of the Jewish

people vs. the survival of the individual– Decision of self vs. the decision of others



ResultsThemes of differences• Physician-participant relationships

– Power differentiation vs. Power equality– Abusive vs. respecting relationships

• Social context– Social ideology vs. individual needs and

preferences– Decision by dictator vs. democratic procedures– Injustice vs. justice and fairness



Results• Survivors cautioned philosophers about comparisons

between the holocaust and other human behaviors• They perceived that such a comparison has negative

consequences for:– Their own well being– The dignity of their family members– The next generation– Israeli society


Children of Holocaust Survivors

Relationship with parents• Closer• Have more difficulty separating from them• Protective and act in a protective manner at an

earlier age than American Jewish peers• Call or visit parents more significantly than controls• Closeness with parents may interfere with their

ability to establish close relationships outside the family

• If asked “Have you ever found yourself acting like your parents?” they knew what was meant; controls did not

Gorko S. Myths and realities about offspring of holocaust survivors: An overview of research findings. Accessed on 8/28/08 at


• There is an increased vulnerability to PTSD and other psychiatric disorders among offspring of Holocaust survivors – Yehuda et al, Am J Psych 155:1163, 1998

• Dreams, fantasies, and associations that have holocaust content– Believing they are riding on a cattle care rather

than the subway– Epstein, “Children of the Holocaust,” Putnam, 1979.



Fogelman & Savran, Am J Ortho-Psych 50:96-108, 19807 Psychosocial effects in children of survivors• Need to identify with parents’ suffering to understand

them better and to feel more intimate with them• Difficulty communicating with parents about holocaust

for fear of causing themselves or parents pain, or of discovering what their parents had to do to survive

• Conflict between the need to express themselves openly and the attempt to protect their parents from further suffering by remaining silent about their own pain and anger


Children of Holocaust SurvivorsFogelman & Savran, Am J Ortho-Psych 50:96-108, 19807 Psychosocial effects in children of survivors• Struggle with the fantasy of compensating their

parents for the loss of family, friends, and entire communities

• Problems in coping with their own rage, shame, mistrust, guilt, fears, or scarred feelings because of what happened to their parents

• Inability to mourn people they never knew• Searching for a personal way to express their thoughts

and feelings about the holocaust and develop continuity with the family’s past


Caring for Holocaust Survivors Rabbi Barry M. Kinzbrunner, MD Chief Medical Officer Vitas Innovative...

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