Palliative Care in Israel: The Nursing Perspective

Palliative care nursing in Israel started in the early 1980's when oncology nurses in the community were designated to care for cancer patients in their homes. This group of nurses became experts in palliative care and set the standards. They worked in close collaboration with the Hospice and the primary clinics; which helped them to enrich their knowledge and skills for the benefit of the patients. Four steps have facilitated the way to offer regulated palliative care in Israel: The Dying Patient Law Legislation in 2005, the directive policy statement in 2009, the recognition of palliative clinical nurse specialists in 2009 and the process of periodical inspection done by the Ministry of Health. Nurses in Israel provide palliative care for patients in all settings along the trajectory of the disease, including symptom assessment and management, patient and family support, education for self-care, hospice and end of life care.


Background
The State of Israel today numbers 8.3 million people, the majority (82%) are Jews, the rest are Muslims, Bedouins, Christians (14%), Druse (5%) and others [1]. Israel was established in May 1948 as a homeland for Jews from many countries, many of whom become refugees as a result of World War II. Jews throughout the Diaspora from Western and Eastern Europe, North Africa and from the Arab states of the Middle East came to Israel, Each group brought with them their language, cultural patterns and customs including those concerning death and dying.
Israeli society is well acquainted with death and dying on a national level. Throughout our short history as a state, the Israeli people have faced loss and grief while coping with security problems. They share the need to express feelings of pain and sorrow as a group during the mourning process. Cultural norms, customs, rituals and traditions such as lighting candles and singing songs in the city squares, dictate this process as a social expression of loss. On Holocaust Day and Memorial Day when the siren sounds, the public stands at attention for two minutes in memory of all those who died during the Holocaust and Israel's wars [2,3].
Innovations in medicine, advances in technology and treatments have prolonged life and produced temporary remissions in the course of serious illness. Therefore, many patients who live with chronic illness express their fears concerning death and dying. Generally patients say openly they are not afraid of death itself but, of losing selfcontrol and independence, choices, mental function, pain, loneliness, the existential pain and especially becoming a burden on their families and children. Target population for palliative care includes: cancer patients with considerable physical or emotional distress at any disease stage, including terminally ill cancer patients, Patients with end stage heart failure, patients with end stage lung disease, patients with end stage liver failure, patients with end stage renal disease, patients with severe stroke, patients with advanced neurodegenerative disease, and unconscious patients [4].
Globally, 20 million people are in need of palliative care services at the end of life; 80% of these patients live in low-and-middle income countries; 67% are elderly (over 60 years of age), and 6% are children. In Israel in 1949, 50% of the death from illness and old age took place at home, while in the year 2000 20% died at home. One of the explanations for this decrease is that people today are not familiar with the process of death and dying [5]. The public perceptions are based on movies and television and they believe that the place of dying is in a hospital, where the patient can get all the treatment he needs and the family forwards the responsibility of end of life care to the professionals.

Hospice Care
The development of palliative care started with the opening of the first in-patient hospice in 1983, in collaboration between The Ministry of Health and The Israeli Cancer Association. It was located in a small building in the premises of the "Sheba Medical Center". The Hospice admitted only patients suffering from advanced cancer who were approved by the committee [4, 6,7]. The Hospice became the place to teach health care providers from all over the country attitudes, knowledge and skills regarding end of life care. The patients were required to be aware of their diagnosis and prognosis which helped the staff to maintain open communication with them and their family. The average length of stay was about two weeks; some patients were admitted for family respite [4]. During the first years, a representative of the primary care givers in the community presented the patient to the committee and was involved in the decision. Later on, a second Hospice was opened in Jerusalem in the Mount Scopus Hadassah Hospital. This Hospice is caring for all the different cultural population in Jerusalem area including non-cancer patients. Both Hospices provide home hospice care services.

Home Palliative Care
Home Care services have a major influence on the development of palliative care for cancer patients. A need for these services started during the "Yom Kippur" war, in 1973 when there was urgent need to release many patients from hospitals to care for the wounded. At this time, the Health care funds developed in a very short time Home Care Units all over the country. A physician, nurses, social worker and physiotherapist staffed each unit [2]. Since then many home care units developed specializing in treating chronically ill patients, some of them offer 24/7 hours care [8]. Gradually skilled oncology nurses joined these units and they provided symptom management and end of life care.
The health insurance companies (HMO) have about 80 continuing care units in the country. They provide medical, nursing and rehabilitative home care for patients, many of whom are elderly and suffer from a variety of chronic and functional disabilities. Most of them are cancer patients. They treat 3,000-4,000 patients a year.
HMO services are included in the basket of healthcare services in accordance with the Law of State Health Insurance and are provided to their members following principles: existence of a designated palliative care service at the patient's home, availability 24 hours a day. Hospitalization services may be used for this purpose in relevant cases, as well as consultation services in the field of palliative care in every HMO district [4].
The Israeli cancer association (ICA) plays and will continue a crucial role in the development of palliative care in the country by funding education for professionals of all disciplines, nursing and social workers positions, scholarships for fellowship programs nationally and internationally. The ICA affiliated home palliative care is still run since 1989, treating 30 patients at a time, providing 24 hours service all year round [9].

Hospital based palliative care
Offered by nurses trained in oncology and palliative care, and/or physicians who are specialist in anesthesiology or pain management. This team provides services to medical staff and patients in those hospitals. There has been progress in provision of consultation services in the field of palliative care in geriatric hospitals and nursing home (institutions for chronic diseases including nursing care, rehabilitation). These institutions make the arrangements necessary for providing palliative care to their patients, including training of the team members, utilization of consultation services as required, evaluation of pain, addressing the physical and psychological needs of the patients, ability to provide analgesic drugs including opioids [3,10].

Bedouin mobile unit
A unique service offer to Bedouin population residing in villages, temporary structures or tents throughout in the Negev desert. The mobile unite funded by the "Clalit" health insurance in collaboration with the ICA, provides medical, nursing and social working care [11]. 3. The recognition of palliative clinical nurse specialists: In 2009, the nursing division in the ministry of health recognized this nursing specialty.The process requires the following steps: Establishment of palliative care training, certification and professional description, Specific skills characterization and legal acknowledgment. The 1st step in the process was a selection of 40 nurses who were recognized as the "pioneers" and certificates were conferred. These nurses came from home care units, hospices, and hospital based palliative care teams. They were likely to lead the next generation of palliative care nursing. They were also involved in the process of writing the course curriculum and program. Those nurses will become later on the mentors, teachers and leaders in the topic of palliative care in the country. The course of specialization in palliative care entrance criteria were: Master's degree, Participation in an educational program consisting of theoretical and clinical studies approved by a special academic committee, 3 years supervised clinical experience guided by an expert nurse and a Certification exam [14].
4. The ministry of health regulation to establish a palliative care service in every health care facility in the country within four years. The level of actions was: In February 2005, a national committee presented guidelines. Later, there was a joint collaboration between pediatric, geriatric, oncology and community health national councils performed, the committee agreed on several principles on how to provide national palliative care service. The dissatisfaction with the previous situation brought the public, nurses, doctors and the Government to act towards quality improvement of palliative care for all the population. This ongoing process envisions the way and implements the plan [13]. Designated team for providing palliative care services in medical institutions: The institutional administrations define the roles of the designated team for providing palliative care services. The team includes at least a physician, a nurse, a psychologist and a social worker. In addition to its routine responsibilities, the team will operate exclusively or in a cooperative manner, based on the needs and conditions of the institution. This team is part of the clinical team, and is responsible for consultation and implementation of the principles of palliative care within the institutional practice, and for further training of the relevant institution employees [15].

Advance directives
In 2005 the Israeli parliament passed the "Dying Patient law", this law allows a competent person even if he/she is healthy, to leave written instructions known as advance medical directives, in which they explain their wishes in detail with respect to future medical treatment [12,13]. Since 2005 and until recently not much happened. Recently the ministry of health initiated programs in order to raise the medical staff awareness regarding end of life care in general and the provision of advance directives. The program included educational software located on the ministry of health website open to professional and the public, a simulation activity with actors for selected group of medical and nursing leaders was conducted in M.S.R (medical simulation ) center, also, in service education was held in all settings on this topic followed by control evaluation. The progress has been slow and there is a need to increase the awareness of the general population and to prepare advance directives. Family physicians, oncologists and geriatricians need to be more involved in this process [16].
The Ministry of Health issued a directive policy statement describing standards for the development and provision of palliative care services for hospitals and the health insurance companies (HMO). This program became essential to turn palliative care into an integral part of all the treatment processes and disease stages for both adults and children. Palliative care is provided according to common international professional criteria for assessment and management of pain and symptoms for the patient and family: physical, emotional, spiritual, psychological and social.

Education
Educating health care providers is a major challenge as it involves the requirement to assess the adult's attitudes, skills and knowledge as a basis of being able providing palliative care. It is necessary to ensure compliance of the basic training level of the palliative team with the requirements defined by Committee for palliative care in the hospital and community units as required [17].

Nursing education
Basic principles of palliative care are taught in all basic programs in nursing Schools, A palliative Care Module is taught in the post basic course in Oncology Nursing and other chronic post basic courses (geriatric), those programs include knowledge and skills on topics such as the history of palliative care, ethic issues, symptom management and end of life. Many other programs started as a local initiative in community and hospital settings as a short or long course, study days, conferences and special events. We hope that in the near future the ministry of health will approve a special program for master education in palliative care [4,5,11]. Nurses should be supported to the full extent of their scope of practice and capacity in order to enhance the delivery of palliative care to patients and families in need [17].
INPACT -The Israel National Palliative Care Training. Train the trainers Course, 43-hour program for Physicians, Nurses, Social workers and others. The aim is to develop and implement a national inter disciplinary program. This will increase the awareness and knowledge of the participants, in the principles of palliative care, enable a dialogue and exchange ideas. The program expands the scope and quality of palliative care provided to the patient and families. To date 1400 students have taken part. Two third of them are nurses [5,18].

Physician's education
A university level palliative care education program has been provided to 130 physicians since 1996. At present various palliative care studies for medical students and continue education programs are offered at four faculties of medicine. This unique platform has provided physicians an expert training to function in various fields in community services as well as hospitals and hospices. Recently medical palliative care has been recognized as a specialty by the Israeli medical association [18,19].

Professional's Organizations
"Tmicha" -The Israeli association of palliative care, was established as a voluntary association in 1993 and represent all the profession involved in palliative care. It is active in encouraging professional and public education and in promoting service development. It organizes an annual professional conference [19].
The Israel palliative medical society (IPMS) -was established in 1996 as a branch of the Israeli medical association. The aim of the IPMS is to represent physicians practicing palliative medicine and to promote medical services and research. Both Tmicha and IPMS are members of the European association of palliative care.
The Israeli oncology nursing society (IONS) -The majority of the palliative care nurses are members of the Israeli Oncology Nursing Society. The society has initiated a wide variety of palliative care programs during the last thirty years, for adults and pediatric nurses and has offered short courses and study days. Two special publications of the society journal: "Seud Oncology" published articles and guidelines for symptom management and end of life care. About 50 oncology nurses were trained in the "Mc Millan" program in England in several courses on palliative care, the main purpose was to prepare a group of nurses to teach nurses and nursing students in basic and post basic program this topic and to write guidelines and update national learning programs [11].
Palliative care for all-during the last three years there has been an increased awareness among policy makers and advanced practice nurses to teach and implement initiatives of palliative care programs for non-cancer patients, for example: an educational program in dialysis clinics for end stage renal disease, special comprehensive courses for intensive care nurses in general and cardiac units with emphasis on communication with patient and families. In Geriatric nursing -a special module in the post basic course is dedicated to knowledge, skills and attitudes in palliative care and end of life issues for this group of patients. There is also a new initiative in the field of emergency care to identify, monitor and care for patients who need palliative care and to have the ability to refer those patients to appropriate facilities.

Summary
Palliative care is increasingly viewed as an essential component of comprehensive care throughout the life course and as a fundamental human right. Nurses in all positions: management, education and bedside care regard palliative care as a unique area of specialty. They lead and are part of multidisciplinary teams, that are responsible for the provision of all aspects of palliative care, and they have a special national training as a certified oncology nurse. Nurses play a major role in providing public education about palliative care in many settings. There is a need for developing and providing palliative services in the day-care hospitalization and outpatient settings where oncology nurses meet and care for terminally ill patient and can offer special care according to their needs.