Unending Loss:
Caring for Survivors of the Holocaust

Laurie Bernick, RN, MScN, GNC(C)
Laurie Bernick is a Clinical Nurse Specialist at Baycrest Centre for Geriatric Care, Toronto, Ontario.
Anna Grinberg, RN, BScN (Candidate)
Anna Grinberg is a Nurse Clinician at Baycrest Centre for Geriatric Care, Toronto, Ontario.
Lucie Holynaty, RN, GNC(C)
Lucie Holynaty is a Rehabilitation Nurse at Baycrest Centre for Geriatric Care, Toronto, Ontario.
Marilyn Rodgers, RN, CRRN, GNC(C)
Marilyn Rodgers is a Nurse Manager at Baycrest Centre for Geriatric Care, Toronto, Ontario.

Baycrest Centre is a multi-level health care system that serves more than 2,000 seniors daily.

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Originally published in Canadian Nurse, March 2001, Vol. 97, Number 3, (with permission from the editors)

"Nothing prepared me for the heart-wrenching experience of seeing a tattooed number on my patient's left arm. … I was caring for someone who had survived."

Acknowledgment
The authors thank Paula David and Eileen Bourret of Baycrest Centre for Geriatric Care for reviewing this manuscript.

The Holocaust or Shoah was the deliberate Nazi extermination of six million Jews during 1933 to 1945. It was a systematic, methodical, planned genocide, following the official Nazi policy to eliminate every Jew in occupied Europe.

Much has been written on life and death in ghettos and concentration camps, yet little is known about the care needs of survivors or their second generation.(1) Nurses and other health professionals need to become informed and attuned to the unique needs of the elderly survivors and their families as their advancing age may bring them into hospitals and long-term care facilities.

In particular, nurses need to be sensitive and knowledgeable about those care situations that may trigger traumatic memories for the older survivor. Caring for every older person with dignity, respect and a high regard for human values is a nursing priority. Caring for the older survivor presents the additional challenge of a backdrop of memories, experiences, latent thoughts and acute awakenings.

Who are they?
Of the over six million Jews who had lived in Europe before the Second World War, an estimated 500,000 survived.(2) About 20,000 to 25,000 emigrated to Canada in the late 1930s to late 1940s, and an estimated 15,000 are still living. (3) Because the young and the old were the first executed, the survivors were largely in their 20s and 30s and have now entered into old age. (4)

Despite or perhaps because of the profound horror of the Holocaust, the catastrophe was not dealt with openly by society. This "conspiracy of silence" created barriers for the survivors, as they could not mourn their losses and were left with feelings of isolation, loneliness and mistrust. (5) The long-term effects include a wide range of responses, one of which is the "survivor syndrome". This syndrome can include chronic anxiety, depression, guilt and recurrent nightmares with awakening in terror. (6) Despite the massive trauma and suffering, most survivors coped, adjusted and established full and successful lives. Nonetheless, their children have also had to deal with the long-term effects of the Holocaust, as the experience influenced family dynamics and the relationship between family members.

Nursing care that attends to the unique needs of the person while preserving his or her humanity and dignity (7) brings on new meaning when caring for survivors of the Holocaust. For a survivor, invasive health care activities can hold different meanings. The suffering, tragedies, fears and painful memories embedded in the survivor's life history demand highly sensitive nursing care. Nurses must be deliberate in their choice of caring actions to be sensitive to the needs of the survivor.

Personal Responses to Illness
One of the key components of nursing practice is to understand and attend to the individual responses a person has to his or her health or illness. For survivors, the response may be affected by meanings that are deeply embedded in their memories. For example, a patient who experiences chest pain and shortness of breath may associate the symptoms with fear of suffocation in the gas chambers.

The importance of including the client's personal history in the nursing assessment cannot be over-emphasized. Information on the client's past is not always easily accessible. First, not everyone is willing to share her or his story of the Holocaust; the nurse may not know that someone is a survivor. Second, elderly clients may not be able to communicate because of medical or cognitive challenges and may not have family members to speak on their behalf. Simple questions that help to identify a Holocaust survivor include place of birth and when they emigrated to Canada. Signs may include a European spoken language, lack of family members of their own generational age or a numeric tattoo on the arm.

Once a patient is identified as a survivor, the nurse and other health professionals should be sensitized to the potential impact the hospital environment may have. There are many possible triggers within the clinical arena that could cause past memories to resurface. It is important for nurses to explore the client's preferences with personal care and the meaning behind the client's reactions or behaviours. Specific idiosyncrasies need to be understood and respected (e.g., hoarding of food or other items). Furthermore, nurses need to be attuned to the potential effects of certain policies and technological procedures, especially those that may contribute to a sense of confinement, discomfort or loss of control, such as having a blood sample taken, using an electrocardiograph, catheterization, using a mechanical lift and participating in a mass immunization program.

Suffering, perceived pain and the person's response to an acute change in health need to be examined. Bathing, smells (e.g., antiseptics), medical procedures, certain sounds (e.g., tone of voice, accent) and visual stimuli (e.g., lab coat, darkness) can trigger a catastrophic reaction.8 Even how groups of clients are organized can affect a person's sense of being. Dividing clients into groups may trigger the memory of how the older and frail were separated out for extermination. If people are divided into groups, such as for health programs designed for participants of varied learning needs, the rationale for such groups needs to be explained to the people involved.

The nurse's sensitivity and knowledge of the uniqueness of each person will help bridge the gap between the person's response to a situation and the provision of care that is meaningful and appropriate. How the person copes with change and loss, such as loss of co-residents, moving into a nursing home or even being moved within an institution, can affect his or her being. Coping strategies and routines need to be explored and understood. Similarly, expressions of anger, guilt, depression and wanting to die, refusal to eat, resistance to care and fears also need to be probed. As with any client, the nurse uses a comprehensive nursing assessment, in collaboration with other team members, the client and the family, to identify the approach to care that will meet the unique needs of the individual.

Care-related situations that can trigger past memories

Trigger	Associated Past Memories of the Holocaust
Showers	Showers were associated with death as they were gas chambers
Bathtubs	Horrible human experiments occurred in the bathtubs, including electrocution
Staff speaking in a "thick accent"	The police and guards spoke German
Departure of a family member	Families were separated and many members never saw each other again
White lab coats, hospitalization procedures	Human experiments were performed by Nazi "doctors" in the concentration camps
Smells; antiseptics, faeces and urine	There were no facilities in the transport boxcars and sanitary conditions in camps were poor
Darkness	Horrible things happened in the dark
Hiding or hoarding food	Food was drastically scarce in the camps
Rigid routines and schedules	People were forced to follow strict routines while imprisoned
Sound of people crying or screaming	Similar sounds echoed in the ghetto or concentration camp

Adapted from David, P., and Goldhar, J. Holocaust resource project (handout from), Baycrest Centre for Geriatric Care, 1999.

Approaches to care
Everyone needs to feel a sense of purpose and self-worth, but this need is particularly strong for Holocaust survivors. For them, a sense of purpose in life helped them to adjust, to make meaning of having survived when so many did not.9 This sense of purpose must be sustained and integrated in the later years of life. Care providers working with institutionalized older survivors must endorse this philosophy.

Personal stories
Many survivors have a strong desire to tell their personal stories, which can include those of families being "wiped out", children becoming orphans, hiding and witnessing catastrophic killings of one's own family. Although pain, suffering and loss were experienced by all, each story is unique to the person. As the older Holocaust survivor experiences end-of-life changes, deep-rooted memories and feelings of grief and loss may be triggered. The majority experienced so many losses that there was no grief resolution. Sharing their stories may help the survivors resolve some feelings of grief, anger and guilt and provide the nurse with direction for nursing practice. Some health professionals have also been affected by the Holocaust. Thus it is important to listen to their stories too, as their life experiences shape their professional practice and provide valuable information for others.

The way in which the nurse engages with the client is critical. Nurses need to receive the stories of survivors as a gift, something to be cherished. When a survivor's story of personal suffering is heard and acknowledged as real, the person's identity is reconfirmed, memories are valued and feelings are validated.

Nurses may find it particularly challenging to listen to survivors who need to repeat their stories again and again due to their forgetfulness. However, if nurses do not listen to their patients, they can miss important information that is relevant to care. The client's experience and how it affects his or her current health situation should be explored to incorporate those findings into a valid care plan that addresses the unique needs of the person.

Personal control
Emergency care offers many fearful associations for the Holocaust survivor - the smell of antiseptic, clothing being removed, needles being jabbed into an arm, strangers dressed in white. The medical need for rapid assessment and treatment strips the person of personal control and privacy. It can be frightening to anyone, and for the Holocaust survivor it can be a devastating emotional trigger.
Nurses can make the difference. A quick introduction, a smile, eye contact and a personal touch are very important. Asking the patient what she or he would like to be called introduces a personal connection. No one should be known as a room or chart number.

Where possible in the hospital or institutional setting, consideration should be given to allowing clients to wear their own clothes and use their own personal belongings.
For the cognitively impaired Holocaust survivor, the distinction between past and present may be clouded. Also, although they may have lost their capacity to comprehend, reason or communicate, their emotional responses remain intact. These responses may be expressed in ways that are difficult to interpret, bringing on new challenges for those around them.

Family
Family members of patients in long-term care face a variety of complex and difficult decisions. End-of-life decisions are particularly difficult for the children of Holocaust survivors, who know that their parents overcame extreme odds to stay alive. In some cases, both parent and child may be survivors, compounding the difficulty. An 84-year-old woman who was cognitively impaired, aphasic due to a prior stroke and being fed via a gastrostomy tube became septic. She was admitted to a concentrated care unit where more intensive nursing care and medical interventions could be provided. When discussing resuscitation decisions with the care staff, the family could not come to terms with their mother's poor prognosis and asked that everything be done to keep their mother alive. During the Holocaust, their mother had kept them hidden, and thus they had survived. Now it was their turn to save their mother's life, even if that meant life on a respirator.

The family's devotion may be seen by the countless hours spent at the bedside of their relative. The patient may experience fear of abandonment if they don't see their loved ones every day. A sense of trust and personal control need to be established through a partnership between the family, patient and the nurse.

Implications for nursing
In response to the needs of the aging survivors at Baycrest Centre, a Holocaust Survivor Outreach Committee was established in 1994. Members include administrators, health professionals, chaplaincy, educators and survivors. The committee's primary mandate is to maintain, support and develop resources for aging survivors, their families and the people who work with them.(10) Other activities include consultation with the community and health care organizations, the establishment of support groups for survivors and the observance of a Holocaust Memorial Service (Yom HaShoah). Yom HaShoah is a day that recognizes survivors and allows staff to support them through their annual mourning ritual.(11)

A museum, designed to pay tribute to Baycrest's survivor population, was established as a celebration of life in the face of monstrous death. There, a visual display of the stories helps to "reinforce their [the nurses'] awareness of the sensitivity to the number and magnitude of losses that confront the Holocaust survivor." (12) Other media such as videos, an Internet journal and a wide variety of literary works can be used to help health professionals to begin to know and understand the importance of attending to the individual needs of the aging survivor.

The tremendous diversity, resilience and strengths each person and his or her family brings to the caring relationship can only help nurses to learn more and thus better meet the needs of the hospitalized elderly survivor. Elderly survivors are not a homogenous group; rather, each individual and family is unique, with a distinct heritage, past and present. When planning and providing care, nurses need to understand what is meaningful for each person and to build upon individual strengths and coping capacities.

Nursing is much more than the physical doing - feeding, bathing, dressing and walking patients, providing treatments and administering medications. Rather, the doing of nursing takes on many hues, as the nursing caring relationship is shaped by human values. Together with patients, their families and other health professionals, nurses can expand the profession's capacity to provide care that is meaningful, supportive and respectful to the hospitalized elderly survivor and her or his family.

REFERENCES

1. Rosenbloom, M. The Holocaust survivor in late life, in Gerontological Social Work Practice in the Community, New York, Haworth Press, 1985, 181-91.
2. Rosenbloom 1985.
3. Telephone conversation with Mr Rubin Freedman, Canadian Jewish Congress, 19 January 2001.
4. Cohen, B.B. Holocaust survivors and the crisis of aging, Journal of Contemporary Human Services, 72, 1991, 226-32.
5. Danieli, Y. As survivors age: Part 1, Clinical Quarterly, 4(1), 1994, 1-6.
6. Cohen 1991; Epstein, A. Mental phenomena across generations: The Holocaust,
Journal of the American Academy of Psychoanalysis, 10(4), 1982, 565-70; 7. Robbinson, S., Rapaport, J., Durst, R., Rapaport, M., Rosca, P., Metzer, S., and Ziberman, L. The late effects of Nazi persecution among elderly Holocaust survivors, Acta Psychiatrica Scandinavica, 82(4), 1990, 311-15.
7.. Watson, J. Nursing: Human science and human care, New York: National League for Nursing, 1988.
8. Menorah Park Center for the Aging. Painful memories: Understanding the special needs of aging Holocaust survivors (discussion guide), Cleveland, OH, Menorah Park Center for the Aging, 1993.
9. Rosenbloom 1985.
10. David, P., and Goldhar, J. Understanding and caring for the aging Holocaust survivor and their family: A community, institutional and individual response. Holocaust resource project, Toronto, Baycrest Centre for Geriatric Care, 1999.
11. David, P. Meeting the needs of the aging holocaust survivor, Mature Medicine Canada, Nov/Dec, 1998, 45-47.
12. David P, Dickinson, P., Goldhar, J., Bourret, E., Sanders, A., and Vandelman, A. The Holocaust project: The therapeutic use of a museum, Long Term Care, Sept/Oct, 1998.