Eleven organisations offer palliative care for adults in Israel delivering a total of 27 services mainly for adults via 7 home hospices (includes 1 mobile unit), 4 inpatient hospice units (3 are freestanding units, 1 is hospital based) and 2 hospitals offering inpatient palliative care. Around 6 of these services offer paediatric palliative support (Table 1).

Table 1 Palliative care provision in Israel, 2005

In addition to these specialist services around 80 community health centres will provide pain and symptom relief for patients at the end of life at home. Some oncology clinics also provide psychosocial palliative support. There are over 500 oncology nurses in Israel, most of whom have completed a formal postgraduate oncology nursing qualification which includes symptom management and palliative care. Around 30 oncology nurses have completed further palliative care training. These nurses work in hospital oncology units or in community health settings; some of those with further training are based in the specialist palliative care organisations.

A National Cancer Control Program (NCCP) for Israel was established during the early 2000s.^4,5 A National HIV/AIDS Policy was established in the late 1990s.⁶ These policies include an acknowledgment of palliative care as a component of the management in HIV/AIDS and cancer control. The NCCP has an advisory committee set up to examine palliative care needs.⁷

Tel-Hashomer Hospice, (Miriam and Max Freedman House), Sheba Medical Centre, Tel Aviv

Tel Hashomer provides end of life care and support to cancer patients and their families.⁸ The hospice is situated at the Chaim Sheba Medical Centre, a large regional 1,563 bed hospital. The hospice founded in 1983 by Dr Marian Rabinowitz,⁹ was the first specialist palliative care service to be established in Israel. The service has developed an interdisciplinary team (physicians, nurses, physiotherapist, social workers, clinical psychologist and spiritual counsellor) who are particularly experienced in offering specialist pain and symptom relief, together with psychosocial care and physiotherapy. The service includes:

• a purpose-built, 22 bed inpatient unit (staff and patients moved into the new building from the original, older facility in 2003)
• a homecare team providing 24 hour care for up to 25 patients from within a 25 mile radius from the hospice
• a palliative care outpatient clinic at the oncology department of the Sheba Medical Centre.

The service is based on an ethos of providing the best quality care at the end of life in a tranquil environment with adequate symptom management and support but with as little intervention as possible.¹⁰The service does not encourage unnecessary tests, routine use of oxygen or antibiotics.¹¹ The average duration of care is 16-18 days. Patients are referred by their physician or oncologist – dependent on approval from the Medical Centre’s health insurance provider.¹²

Ina and Jack Kay Hospice, Hadassah Mount Scopus, Jerusalem

The hospice, founded in 1986 by Dr Theodor Fink and Ruth Gassner RN MA and situated in the grounds of the 300 bed Hadassah Mount Scopus Hospital, provides end of life care and support to adults with cancer and their families. Working as a multi-professional team (physician, nurses, social workers, physiotherapist and occupational therapist) under the directorship of Ruth Gassner, the service offers specialist pain and symptom control, physiotherapy, occupational therapy and psychosocial support. A part time art therapist also attends the hospice at various times.¹³

The hospice service includes:

• a 14 bed inpatient unit (renovated in 2004)
• a homecare service providing 24 hour care for up to 20-25 patients
• links with the charitable organisation Yad Sarah that lends nursing and home care equipment (hire is free or in exchange for a donation)

In 2003, the inpatient unit cared for 170 patients. Fifty patients were cared for by the homecare service which provides 24 hour nursing care from a team of nurses working from the hospice.¹⁴  The hospice has developed a highly individualised service with dedicated and skilled psychosocial support led by social worker Malka Yehezkel. The team also works with trained volunteers who are able to offer general support to patients and their families. The social worker and other team members provide opportunities from the first assessment for patients and families to share anxieties and discuss concerns with hospice staff. Families are encouraged and supported to be involved in their relatives care equally at home or in the hospice unit. Members of the hospice team (the senior physician and home care nurses) run a counselling support service for patients in the hospital who transfer to the hospice.. The hospice also offers bereavement support.

Part of the palliative care in this service includes maintaining varying degrees of medical intervention. For instance, senior physician and researcher Dr Daniel Azoulay may, in addition to pain relief and symptom management, also prescribe antibiotics, oxygen and subcutaneous fluids to be used if appropriate.¹⁵

Patients, or their families, can self-refer or they are referred by staff in a hospital unit, or their family physician or oncologist.¹⁶

Cancer Pain and Palliative Medicine Service, Sha’are Zedek Medical Centre, Jerusalem

The Cancer Pain and Palliative Medicine Service, established in 1994, is part of the oncology unit at Sha’are Zedek, a large 500 bed medical centre in Jerusalem. The diverse, multi-professional, multi-lingual team includes physicians, general and oncology nurses, a research co-ordinator (who is also a clinical pharmacologist), social workers, a spiritual counsellor and a consultant psychiatrist. The team offers integrated oncology and palliative care including spiritual counselling to adult patients with cancer. The service has:

• an out patient unit
• a day care service
• a 22 bed inpatient unit (opened in 2003)
• inpatient consultation service

The inpatient unit was opened for the acute management of haematology and oncology patients and for those in need of palliative care. Dr Nathan Cherny explains:

‘The average census is that there will probably be about 12 palliative care inpatients at any one time. The sorts of problems that are dealt with are acute symptom control problems, patients who are imminently dying, patients who are not coping at home but are not imminently dying. We will generally stabilise them and in most cases pass them on to the hospice or the French Hospital. Occasionally they will stay with us until they die.’¹⁷

In 2004 a full time spiritual counsellor, Jonathan Rudnick, joined the Service and his role in the team has proved successful for many patients whether they are religious or secular, and is felt by staff to have provided a very positive contribution to the Service’s overall ethos of supporting the whole person.¹⁸ The Service provides palliative care for around 500 new patients per year, seeing around 1000 patients per month of which a third require palliative care. Patients are referred to the palliative care services by oncologists within the unit and from other departments.

Negev Palliative Care Services, Beersheva

The service works as a multi-disciplinary team (physicians, nurses, social workers) offering specialist pain and symptom relief and a range of psychosocial support for adults and children with cancer.¹⁹ The service was established in 1991 as a home care service for adults in the city of Beersheva. In 1994 a more extensive home based service was initiated and a hospital consultation service developed for adults.²⁰ Since the establishment of the children’s oncology unit at Soroka Medical Centre in 1999, the service also offers inpatient palliative care consultation for children.

Based in Beersheba, the only major city in the south of the Israel in the Negev desert, the service has to serve a large multi-cultural population dispersed over hundreds of miles.²¹ The organisation has responded to this challenge by developing several different multi-professional services including:

• three homecare teams working over a wide area from different urban locations
• Beersheva: up to 24 patients
• Qiryat Gat : up to 46 patients per year
• Rahat: between 4-6 patients (up to 14 per year)
• a mobile desert unit (set up in May 2004)  up to 26 patients
• a bereavement service based in Beersheva and run by trained volunteers
• Ma’agan House, a charitable drop-in day centre, situated in Beersheba; this centre offers psychosocial support including therapy support groups, art and music therapy
• hospital based adult and paediatric palliative care consultation and support offered at the only regional hospital, the 1,000 bed Soroka Medical Centre in Beersheva.²²

The homecare teams offer 24 hour support. Each year, the teams care for around 140 patients at the end of life. Roughly 78% of these patients are able to be supported to die in their own home. Seventy percent of those who die in hospital are only admitted in the last 24 hours of life. Admission to the homecare service is based on three criteria, as medical director Dr Yoram Singer explains:

‘There must be a main caregiver, so the patient is never alone and he must be in such a situation that he can’t get his medical care in the local clinic. He has to be more or less housebound. Average duration of treatment is 47 days, so we’re really talking about the very end. … ‘

The hospital consultation service is accessible all patients in Soroka Medical Centre, Beersheva: they have either to be referred by their physician or oncologist, or they or their family may request referral. Dr Singer reports:

‘This year [2004-2005] I’ve seen about 450 patients. I see patients at the oncology day care and I get called to the various wards to give consultations … Many services are supported by volunteers; for example, the bereavement service - currently being developed – is organised by social workers with a large group of trained volunteers.²³

Patients may self-refer to one of the three homecare service teams or be referred by one of the hospice service oncologists following a hospital consultation, or be referred by their own physician or oncologist from another department. 

The homecare service has strong team support for permanent and student placement staff (family medicine trainee physicians). The team convenes once weekly report and supervision meetings and senior team members provide 24 hour on-call advice.

Milton and Lois Shiffman Home Hospice in the Valleys

The hospice, founded in 1999, provides home based specialist palliative care including pain relief, symptom management and psychosocial support for adults at the end of life regardless of their illness, although the majority have cancer. The hospice has focused on developing a service sensitive to a culturally diverse, multi-religious population.²⁴ For example in Arab Nazareth the team may include a Jewish physician, Muslim nurse and social worker and Arab speaking Jewish nurses with additional support from Christian and Muslim volunteers and clergy.²⁵ The hospice service includes:

• 7 multi-professional, culturally diverse, multi-lingual teams (each with supporting physician, nurses and social workers): providing care for up to 45 patients at any one time
• good links with local community health centres
• strong support of trained volunteers
• palliative care training programmes for primary health care providers
• on call consultation services for community health care clinics in the area

A total of 162 patients were cared for in 2004, for an average duration of 60 days. Since 1999, the hospice has cared for around 600 patients. The emphasis is on supporting patients and families to cope with the end of life process; hospice staff will educate caregivers and also undertake to stay with patient and their families as long as they are needed.²⁶ Around 74% of patients are supported to die at home. Hospice director, Mali Szlaifer explains:

‘When you give [the family] good education - and also if you give them some tips what to do to feel better, so they can manage with [the patient] they are not afraid and they feel comfortable, confident in being there and they know that now it’s not an emergency.’²⁷

Patients can self refer but more usually they are referred by their physician or oncologist.

The hospice has also developed strong support for its staff. There are regular team meetings, group supervision (plus individual if needed) and 24 hour on call advice from senior team members.

Jerusalem Home Hospital

This large organisation, established in 1991 and run by health maintenance organisation (HMO) Clalit Health Services (Kupat Holim Clalit),²⁸ offers community based ‘home hospitalization’ for patients, the majority over 65 years old, suffering a range of sub acute and chronic illnesses, including cancer, renal and heart failure, and ALS. The service provides treatment, rehabilitation, and for patients at the end of life, specialist palliative care.²⁹ The service will also support young people and children at the end of life. The multi-professional team (physicians, specialist oncology nurses, nurses, physiotherapists, social workers, nutritionist, occupational and speech therapists) is led by geriatrician Dr Jeremy Jacobs and palliative care consultant Dr Ora Rosengarten. The service offers pain relief, symptom management, physiotherapy, psychosocial support, occupational therapy, speech therapy, nutritional advice, and home help. The service currently cares for around 300 patients at any one time. Roughly half of all patients admitted to the service are palliative care patients and on average 30% of these have cancer. The criteria for admission to the service include:

• Diagnosis is clear, but the patient no longer needs continuous monitoring
• The patient is in need of hospital level care
• The patient and family must both agree to home based care
• There must be a supportive caregiver for the patient at home (not necessarily a family member)
• The patient’s home is a suitable environment in which to nurse the patient
• The patient is insured with the Kupat Holim Clalit

The aim is to reduce hospital admission and maintain a high quality of total care for patients at home. Around 50% of palliative care patients are supported to die at home or within 24 hours if admitted to hospital in the last hours. Since the service was established it has cared for over 13,000 patients.³⁰

Nancy Caroline Hospice of the Upper Galilee Hospice of the Valleys

This hospice is a specialist, not for profit, home care service primarily for adults with cancer. The hospice was founded by Professor Nancy Caroline in 1994. She herself became ill and died in 2002. Since 2001 the multi-professional team has been led by medical director Dr Jim Shalom. The hospice provides pain relief, symptom management, physiotherapy, nutritional advice and dedicated psychosocial support.

The hospice is committed to highly individualised care with the focus on a holistic approach. The multi professional team (physicians, specialist oncology nurse, nurses, social worker who is also a family therapist, clinical psychologist, art therapist, music thanatologist - a harpist) are attentive to skilled symptom management but also in supporting a patient’s emotional and spiritual needs, drawing particularly on the use of creative therapies. House calls are typically made by a physician and nurse together.  Rather than replace existing services, the HUG team coordinates care with both the primary care team and the regional Oncology Department.

Trained volunteers are an important part of the team, offering personal support and assistance to the patient and families when requested. The hospice staff is equally involved in training volunteers.

As of 2005 the service can care for up to 35 patients at any one time, and the service is being expanded to increase care capacity. Patients are self referred or referred by their physician or oncologist. Around 70% - 80% of patients are supported to die in their own home.

Home Care Hospice of Kiryat Tivon, Northern Israel

The hospice is a small, not for profit, home care service run by volunteers for adults living in Kiryat Tivon with cancer at the end of life. The hospice was co-founded in 1983 by sociologist Dr Ilene Ora Cibulski and other multi-professional colleagues. Dr Cibulski is also a founder member and first chair of the Israeli Association of Palliative Care). Under her direction the hospice developed an emphasis on providing practical support for the patient and their family that includes:

• co-ordinating volunteer professional medical, nursing, therapeutic, and psychosocial support (the patient continues to receive care from their hospital physician and oncologist)
• arranging support from trained volunteers who as ‘friendly visitors’ offer:
• home help
• social support
• help with child care
• collection of prescriptions
• cooking, shopping or other special needs
• hospice volunteers provide a telephone information helpline for families living outside Kiryat Tivon
• support to other organisations around Israel to develop volunteer groups
• links with the other charitable organisations:
• the Association of Services for the Elderly
• Yad Sarah; that lends nursing and home care equipment (free or in exchange for a donation)

The hospice head nurse and social worker evaluate the needs of the patient and family caregiver, and they coordinate the visits of the volunteer multi professional team members (physician, nurse, psychiatrist, social worker, physiotherapist, occupational therapist and yoga teacher) who are supported by a dedicated group of non-professional volunteers. All volunteers do a basic course together and continue to meet on a regular basis. The service is able to care for between 10 – 18 patients at any one time, for an average of 3 months.

Hannah Eshed Hospice, Nof Hadar Hospital, Haifa

The hospice was founded in 1992 as a unit within the private Nof Hadar Hospital. A multi-professional team provides palliative care in the17 bed inpatient unit. The hospice has always worked closely with trained volunteers who provide support for patients and families.³¹ The unit is one of the 4 inpatient palliative care units formally recognized by the Israeli government.

French Hospital, St. Louis Mission, Jerusalem

This ‘free’ hospital is run by a French religious order, the Sisters of St Joseph. The 44 bed hospital is dedicated to the care of all patients with ‘advanced disease’, regardless of their faith or belief.³² They have an 18 bed inpatient palliative care facility. Patients may be referred by physicians or oncologists from other hospitals.³³

Al-Taj for Health and Heritage Association

This charitable association is being established as a volunteer run home hospice service in north Israel. The service is operating with the founder, Kassim Baddarni, who is registered nurse, able to undertake home visits to around 20 cancer patients. A needs assessment for the organisation is completed. A multi-disciplinary team of 2 full time and 10 part time volunteer health professionals and lay support staff are enrolled for an official start in January 2006.³⁴

Additional hospital based services

The Italian Hospital, Haifa provides palliative care for patients at the end of life.³⁵ The 95 bed hospital, founded in 1905 by Italian doctors and staffed by a religious order of nursing sisters, developed an oncology unit in the 1950s; this is now supervised by the Rambam Hospital, a large regional medical centre in Haifa.³⁶ The unit offers palliative care (including palliative radiotherapy with a treatment capacity of up to 500 patients a week) and psychosocial support.³⁷

A Reiki healer is currently working as a volunteer in the Rambam Hospital oncology unit, offering Reiki healing to all cancer patients at the unit who request it, at whatever stage in their illness.³⁸

Paediatric Support

At the time of this report (2005) there are no government recognised or formal specialist palliative care services available for children in Israel.³⁹
There are, however, a number of informal and general services offering consultation, advice and psychosocial support for children at the end of life. Palliative consultation and support is offered by paediatric oncologists at:

• Chaim Sheba Medical Centre, Tel Aviv
• Edmond and Lily Safra Children's Hospital
• The Marion and Elie Wiesel Children's Pavilion (although specialist palliative care is no longer the emphasis in this unit, support is provided for children at the end of life)
• Rambam Medical Centre, Haifa
• Meyer Children's Hospital (This hospital (based at Rambam Medical Centre) has no formal palliative care service, however medical oncologists Dr Sergey Postovsky and Professor Miriam Ben Haroush, are dedicated to providing paediatric palliative care whenever needed.
• Negev Palliative Care Services (Ben-Gurion University of the Negev – Faculty of Health Sciences) offer paediatric palliative care consultation at the
• Children’s Hospital, Soroka Medical Centre, Beersheva

The homecare multi-professional team at:

• Jerusalem Home Hospital will care for children and young people at the end of life

Members of the Psycho-Oncology Society working at:

• Schneider Children's Medical Centre, Rabin Medical Centre, Petah Tikva, Tel Aviv offers palliative support for children and also provides bereavement support for parents.⁴⁰

Community Health Centres

There is a network of around 80 community centres that offer a home medical and nursing care service for patients with a range of sub-acute and chronic conditions, including those at the end of life.⁴¹ These community based services vary in different locations; the extent and expertise of the palliative care offered depends on whether medical and or nursing staff have had specialist training.⁴² Within the available cancer services throughout Israel, there are around 500 oncology nurses with specialist oncology postgraduate training, which includes training in palliative care and symptom management. These nurses are working in hospital oncology units or community settings. Currently, around 30 oncology nurses have completed further training in palliative care and some are now working within hospices (hospital or home based).⁴³

Oncology Units

Several oncology units provide psychosocial support for patients. A particularly comprehensive service has been developed by psycho-oncologists at the Beilinson Unit, part of the Davidoff Centre, opened in 2005, at the Rabin Medical Centre, Petah Tikva near Tel Aviv. This support is offered not only for inpatients at the end of life but also for patients attending the unit throughout treatment – regardless of outcome.⁴⁴