There has been a long history of hospice care in this region dating back to the Middle Ages with the Christian and Jewish tradition of hospices along the crusader and pilgrims’ paths providing care for the needy, sick and dying. One or two of these ancient institutions are still remembered in old names and buildings in Jerusalem.¹⁰⁷ In the late 1970s a group of concerned nurses, led by Aliza Yaffe and her other colleagues based at the Israel Cancer Association (ICA), started to develop postgraduate specialist oncology nurse training which was established in 1978, and included a component of palliative care and symptom management. As more nurses took up specialist nurse training there were greater opportunities for patients at the end of life to be cared for at home by specialist nurses; first as part of the family physician system and later as part of community health teams, where currently over 500 trained oncology nurses with palliative care skills continue to play a vital role in providing care at the end of life. Aliza Yaffe, head nurse at ICA, describes the first ICA initiative to develop the community based palliative care nursing service:

‘It started in1978, more or less at that time a few nurses of the American Oncology Nursing Society came here and presented a seminar on pain management. It was a good place to start thinking about some other things, not only the care of the patients in the hospital, but also to see what you can do to take care of persons in the community. And after we were finished that course - it was not a very long one, 80 hours that first postgraduate education - I came to the Manager and I said, ‘I think that we need to develop oncology nursing services in the community. The patient is staying in the hospital for a short time, and when he goes home then somebody has to go on taking care of him. The hospital experience is very short, and most of the time he will spending at his own home.’ It started with two nurses in Tel Aviv and Ramat Gan; their job was to get information from the hospital about who was going to be discharged and go and visit him at home and make an assessment of his needs, and try to take care of those needs. The theoretical model said that we are going to do that from prevention, early detection ’til bereavement, but it very soon became obvious that that couldn’t be done, because the patient was suffering a lot of symptoms, mostly pain. The nurses were working half-time, [they] had to go and see what the patients needed and to learn the needs of the nurses that are taking care of him. So it was a lot and then we said, well we will postpone the prevention, early detection for a little later, and we will try and do as good as possible symptom management. Very few [nurses] had access to a physician that would come with her to see the patient and help him. There were community nurses but they had no specific cancer nursing education: no palliative care, no cancer nursing. They came and they were very nice and they were very good at the heart but not so good at the other things.’¹⁰⁸

By the early 1980s, this concern by the Israel Cancer Association to develop the skills and knowledge of nurses in end of life care for patients at home, and the needs of patients to have access to skilled care, facilitated the emergence of the modern hospice movement in Israel, which has overseen the development of freestanding hospice units and specialist home care services throughout the country (Table 5).

Table 5: Chronology of the establishment of palliative care services in Israel

Since the 1990s, in spite of ongoing financial and political challenges, significant and steady development has continued in hospice and palliative care services, policy, professional education and public awareness.

The current situation from the perspective of positive and negative aspects of palliative care service development is summarised by Nathan Cherny, oncologist and director of the Cancer Pain and Palliative Medicine Service, Sha’are Zedek Medical Centre, Jerusalem:

‘The things that are strong are now our very wide network of palliative care home care services, which are being provided in multiple different frameworks, many of them by the HMOs who are the payers, which go under different titles of home admission and oncology home admission or sometimes home hospice care.  There are also several free standing hospice services which don’t belong to any HMO but which the various HMOs can buy services from.  And there are different patterns of service delivery in different parts of the country.  Most of the country, and this is talking about Israel as distinct from Palestinian territory has an increasing availability of some sort of home care.  The quality of care is various and the training of manpower is very variable, and if one can make a generalisation, the nursing element of the teams generally has some modicum of training in palliative care.  The physician part of the team is very variable; from people who have got diplomas in advanced training in palliative care to people who really have no training, but who hopefully have some degree of supervision.

I think that the last 10 years has seen a dramatic change in terms of the awareness of analgesics and the number of people involved in this endeavour is very large. Just at a local meeting of palliative care they get somewhere between 400 and 600 people. For a little country that’s a very impressive number, it would be an impressive number in a big country.  That’s the positive side.

The negatives; the downside is that the level of funding is very small and thus the amount of service you can obviously bring into peoples houses is very limited. With very sick people, where you’re going to be dependent largely upon family care givers with really a relatively small amount of professional support, there are limitations as to how successful home care can be and how far it can go.  The number of services available outside of the home: there is a small number of free standing hospices, and to date there is only one inpatient palliative care unit in a general hospital which is the unit here. Overwhelmingly the rest of the hospitals in the country not only don’t have dedicated palliative care beds but the palliative care services within the hospitals are generally limited to maybe a part time nurse. There is no widespread recognition that this is an important service to bring in to hospitals.

A commission was called by the Ministry of Health to get advice about improving palliative care services and a palliative working paper has been presented to them, and one of the things that’s been emphasised in that is the importance of developing palliative care inside general hospitals.  Certainly given that most of the cancer services are in general hospitals we need to make sure that these are amply supported with adequate manpower.’¹⁰⁹

Aliza Yaffe details more of the current challenges:

‘When we look at the little map of Israel, if you will look at the whole area, we have so many different services and our problem is how people communicate with each other. If we do not have an inpatient hospice in Beersheba then we need one because not everybody can take care of a person in his own home all the time. You need a possibility, even for respite, even for a few days; let the family rest a little bit, to have a place where the patient knows the people that will be taking care of him and ... and even if they want to open one more door and they’re going to build something in his home to make it more comfortable. That’s one of the things that I am sorry that happening, that we are not really linked. The problem of inpatient hospices is that patients are not referred, not because they don’t need to be, but because the health care system is reluctant to pay the price that the hospital management is taking for the service. That’s very complicated and we should do more.

The new service that we have developed is in the hospital palliative care, it should be a team but it’s really [often just] a hospital palliative care nurse not a team. Some places it is a team and some places it’s only one nurse. This is something that we started about five years ago. One of the nurses, the head nurse of the hospice, developed it in Haifa in Meyer Hospital. The nurse is giving the service to the oncology department and patients that are suffering the symptoms who are getting the treatment. She makes a whole assessment, and refers to the specific physician. Dr Waller is doing that in Tel Hashomer; he goes to the oncology department once a week and has a clinic there. The nurse [refers] the patients that need his expertise, especially if they have a number of symptoms that one medicine for makes it worse and things like that. Usually they are referred to their oncology nurse in the community if they are not [already an] inpatient. But if they are in the hospital then the staff are given [information] about what to continue, what to stop, and how to change treatment.’¹¹⁰

Individual service development since the opening of the first freestanding hospice is described below:

Tel Hashomer Hospice
In 1982 Dr Marian Rabinovitch, who was chair of geriatrics at Chaim Sheba Medical Centre in Tel Aviv, and other colleagues in the Israel Cancer Association, decided to address the end of life needs of their patients. Dr Rabinovitch explored hospice care in other countries, first in Germany and then England, where he visited St Christopher’s Hospice and was inspired by the work and teaching of Dr Cicely Saunders. Returning to Israel he set up a multi-professional team with the support of head nurse Dvora Goren, and in 1983 they opened the first freestanding inpatient 25 bed hospice, ‘Tel Hashomer’, in the grounds of Chaim Sheba Medical Centre. The care provided was based on the British hospice model pioneered by Dr Saunders.

At Tel Hashomer, Dr Rabinovitch was joined by other physicians, most of who worked on placements from the geriatric department at Chaim Sheba. Physician Alexander Waller, who became Medical Director in 1989, took on Dr Rabinowitz’s work and with other colleagues developed the multi-professional team (physicians, nurses, physiotherapist, social workers, and clinical psychologist). The team was joined in 1991 by hospice physician Michaela Bercowitz; since 1998 she has taken on the post of Research and Information Co-ordinator.¹¹¹ Tel Hashomer pioneered the hospice movement and was influential in supporting the development of other services, co-ordinating the establishment of professional training and education, and encouraging research. In 1989 the hospice set up a home care service for patients living within a 25 mile radius of Tel Hashomer. This service is now well-established and the nursing team can care for up to 25 patients at any one time.¹¹²

Home Hospice of Kiryat Tivon
In 1984, the following year after Tel Hashomer opened, a small home hospice was established in the small town of Kiryat Tivon in northern Israel. As the founder, sociologist and gerontologist Dr Ilene Ora Cibulski explains:

‘I had the privilege of joining a wonderful group of people who were the first group who tried to create palliative home care, at the same time in Tel Hashomer, I heard Dr Rabinovitz who was a geriatrician, he was actually the first [doctor in palliative care], talking about doing [palliative care] in a hospital setting. I said 90 per cent of the people, are 90 per cent of the time at home, the future solutions have to be in the community, and I had the privilege of having a physician, Dr Miriam Boaz, who was the head of the outpatient clinic at Afula Hospital, and Professor Schaeffer Scharf who was the head of the rheumatology clinic in Haifa, Ramban Hospital, and Ruth Givon who became our head nurse, she was a public health nurse and she had developed community programmes for infants who came out of the Holocaust. All of us together felt that we had to do something about what was happening … and we began immediately as an interdisciplinary team.’
For example, Professor Scharf, he would go to visit a patient, he would let the local physician know, this was a physician who never visited a patient, especially when [the patient] became homebound, [physicians] never went to visit. The only people who did home visits at the time were nurses, physicians just didn’t do it. … We started a training course, and within a year we had about 12 volunteers, plus another 12 who were professionals and they were wonderful.’¹¹³

Ina and Jack Kaye Hospice, Hadassah, Mt Scopus, Jerusalem
In 1986, the second inpatient hospice in Israel based at Hadassah, Mt Scopus, supported by a combination of funds from independent benefactors and the HMO, was opened by physician Dr Reuvan Fink, social worker Roni Gertel; and paediatric oncology nurse Ruth Gassner, who describes the early years:

‘The hospice was opened in ’86. I came one year before to think what we need, what we want, how to develop, how to start ... the only place that we knew in Israel was Tel Hashomer, they opened in ’83, so we went to Tel Hashomer, we visited to get some ideas. And in ’86 we started the hospice with only one patient at the beginning. Before that I was in paediatrics; a head nurse in a paediatric department.

In ’85 they decided to open, there was a big donation from the States coming from a Jewish family that donated a lot of funds and this went to re-open the renovation because the house was deserted [since the previous occupant, the Hadassah hospital director, had been killed during military action in 1967]. I started to recruit some staff, and I did it on my own intuition. I didn’t know what I want; I just knew that I wanted good people. Most of the staff working here in the hospice [now] are people that started with me in ’86.’

In 1989, supported by donations from independent benefactors (the Crown Fund) the hospice opened a home care service, as Ruth Gassner explains:

‘Dr Fink saw the need, he was very aware of the need of some of the patients that came here, who said that they want to go back home, and if they had support at home they wouldn’t come to the hospice. It came from the patients. And he had a dream and he talked about that, I must say home care is not my part, but he insisted and he raised the money for home care with Professor Penchas who was the General Director of Hadassah.’¹¹⁴

 Helen Englesberg, one of the first nurses in the hospice who later joined the home care service and Judy Yoran, the home care social worker note that the home care was set up to offer a 24 hour on-call service for patients and their families. Helen Englesberg explains:
 
They can call ... each family has a specific nurse that’s their nurse, but the other nurses will come to them, be there on a day when the nurse is not there, and then they’re also on-call at night and on the weekend. So any time of the day and night they can call to get an answer [like] you know, should we give more pain medication?’

The hospice worked to create a place of empathy and trust, with staff keen to explore different therapeutic approaches to improve support for patients and their families. Social worker Malka Yehezkel describes some of the very successful initiatives tried over the years for adults and for bereaved children, some of whom later as adults, report great benefits:

‘We try all kind of things during the years, like group work here: we had an art therapist working with us and we tried to do groups with the families here, and it didn’t succeed very much. It was an open group, you know, a group every week it was different persons come, the family that were here, but I felt that families prefer the one-to-one. Sometimes we do it, not formally, but... the family sit there so I join them and we sit together, so it’s like a group. … But group work after the death of the patient, maybe I would like to do more groups, support groups?’ Before a few years we did a course of group work in Tel Aviv, Ruthie [Gassner] and me, a nurse and a social worker, and the group was of one nurse and one social worker from hospices and this kind of unit at home care, and we opened a group here for small children, not so small, 9 to 12, of patients, children of patients, a support group after the death of the parent. And it was a small group but a very good, very good experience for us.’¹¹⁵

Nancy Caroline Hospice of the Upper Galilee (HUG), Rosh Pina
Founder of HUG, physician Professor Nancy Caroline became interested in palliative care in the course of her pioneering work training emergency paramedics. In the late 1980s she went to Tel Hashomer Hospice to train in palliative medicine with Alexander Waller, and to gain practical experience. She left Tel Hashomer in the early 1990s to establish her own home hospice which opened as the Hospice of the Upper Galilee (HUG) in 1994. She died in 2002. The multi-professional team has been led by medical director Dr Jim Shalom since 2001, with the emphasis on offering a range of therapeutic skills to cancer patients and their families, The team includes physician and homeopath Dr Eyal Goldberger, Dr Marianna Zrobliov, Dr Ehud Barav, specialist oncology and palliative care nurse Yael Bleich, nurses Mazal Nitoker, Liora Aloni and Meira Gerlick, and social worker and family therapist Yaniv Ben-Shoshan. The team also calls on volunteer psychologist Niva, art therapist, Leila and music thanatologist Adira. Some key aspects of the ethos that have, and continue to be, developed in this hospice are explained by Jim Shalom:

‘As a policy, almost always house calls are made by two staff members. Usually it’s a doctor and a nurse, but it can be the nurse and the social worker, occasionally there’ll be even three. This was something that Nancy set up from the beginning. It’s logistically complicated because we’re often coming from different geographic directions. There are two separate reasons for this policy, one in order to improve patient care, and the second to provide support for the staff itself. When you have a very complex case that has different technical and emotional components and you’re alone you tend deal with the technical aspects. You will be better equipped to go into the more painful, less quickly available solutions if there’s another person there. In that respect a visit of two facilitates comprehensive and intimate care. A visit by two staff members, especially if it is a difficult visit is easier on the staff and helps prevent burn out, rather than a single staff member going to the visit alone. So this policy both works to the benefit of the family, and I think it also works to the benefit of the staff.  It also usually necessitates less frequent visits. Furthermore, I suspect often when it’s a physician and a nurse there’s an element of psychological balance, a parenting model, where one person can deal with the more, the drier, technical, fatherly-type stuff, and somebody can sort of be more of the hugger.
…. I think another thing that has become important, something that was very important for Nancy, and I think we’ve tried to maintain to maintain right from the beginning, is aggressive symptom control. We’re striving - we’re not quite there - to be able to evaluate in our charts too so that one can take a symptom, score it and then see what happens over time.’

The hospice also aims to provide reliable and varied sources of information by which to support patients through treatment and at the end of life, and in 2005 started creating a small library, as part of this process, explained in more detail by Jim Shalom:

‘What happens all over the world, and also here in Israel, is that when people are dying with cancer, they try, they are looking everywhere for hope. So besides taking the orthodox treatment of chemotherapy or radiation, they go to all kind of healers, serious and charlatans and they spend a lot of money for these things and travelling very big distances for this. So Nancy’s dream, which we share, is that we should be also a centre for information of this, not just treating the dying patient, which is the main field of the hospice, but also supporting, giving advice in all the fields related to palliative care. So we have many dreams also of having a place, a centre, not just going to out there in the field but having a place that will be a centre for these kind of services. We are far away from that possibility but that’s the general direction. At present in order to help patients who are looking for support, we are in the process of setting up a small library to give books on the field that could help someone deal with this stage of life.’¹¹⁶

Negev Palliative Care Services
The service was established in 1991 by Professor Pesach Shvartzman, a family medicine specialist, originally as a home care service for adults in the city of Beersheba. In 1994, Dr Yoram Singer, also a family medicine specialist, joined the service and developed an extensive home based service and a hospital consultation service for adults. He describes the development of the service:

‘The home hospice team was started by two physicians and a nurse - and they built it according to the British model and one of the things about the British model is that, in order to get home palliative care, you have to sign a consent form by which you really do sign the fact (a) that you realise the fact that you have a life-limited disease and (b) that you are not going to get any kind of active treatment. Now nobody in this culture in the Middle East anywhere was willing to sign that kind of consent form, so there were about three patients, all of whom were American or British people, and that’s how the thing worked. And after a year and a half the staff resigned and Pesach [Shvartzman], who was just come to Beer Sheba, asked me to take over this and I said to him, ‘No way,’ you know, I was just setting up this very difficult initiative, trying to set up a teaching clinic against all odds and it was enough for me to do that, and I said to him, ‘I’m sorry, there’s a limit,’ and he said, ‘No, it’s good for you and it’ll be nice and interesting and we’ll do it together,’ really tried to convince me but I said no, no, no way. And so they took somebody else and it was a complete failure, it really almost disintegrated then. Pesach came to me again, he said, ‘Listen, we’ve tried it and it doesn’t work. Why don’t you give it a try? Try it for three months, if you don’t like it we’ll find somebody,’ and after two weeks I was completely sucked in and that was that, and since then we’ve been really doing it together.

The service has really grown quite a bit now. It began against all odds because it’s not part of the basket of services and there’s no initiative, no reason why to develop this kind of service because it doesn’t even save money because of the way the health system works. It means finding posts which is something that’s very difficult to get. So we were really having a very, very difficult struggle. We started off and now we have is a service consisting of three home care units and one mobile unit. The home care unit, one is in Beersheba, which is the main one and it’s the biggest one, and we have 24 patients ongoing at all times.
We have the meetings at the [community health] centre where Pesach works.
[The service] is a joint initiative of the University, the Division of Health in the Community in the Faculty of Health Sciences, and the HMO and actually we get a little bit of funding from the Israel Cancer Association as well. Part of our post, well one half of our nursing posts and a half of our doctor posts are financed through this.’

The hospice has developed working criteria, and has an ethos of maintaining personal contact with the patient as Yoram Singer explains:

‘One criteria for working in our service is either you must have a position in the service or you must be a resident - we don’t have any doctors who are not part of the service doing calls, because the physician or anybody who does any kind of call duty must be at that Thursday afternoon meeting to get input, and we don’t want somebody to sort of go to the patient and start saying, ‘Well, there’s nothing for me to do, go to the hospital.’ That’s not what we’re about. We have our patients, we have this personal contact which is absolutely essential; otherwise it won’t work.’¹¹⁷

Cancer Pain and Palliative Medicine Service, Sha’are Zedek Medical Centre, Jerusalem
In 1994, the Sha’are Zedek Medical Centre called on oncologists Dr Nathan Cherny and Professor Rafael Catane to set up a service for cancer patients, to include a programme of integrated oncology and palliative care. Nathan Cherny takes up the history:

‘Professor [Rafael] Catane was the first Chair of Palliative Care and he is now Chair of Oncology at the Sheba Medical Centre [in Tel Aviv]. Initially the service was an out patient consultative service and over the years the programme has grown. Two of us are both oncologists and palliative care physicians, one of them is Dr Ora Rosengarten, who also co-ordinates the Jerusalem Home Hospital (the home care programme for the largest of the HMOs in Jerusalem). In terms of the palliative care team since 1995 we‘ve had a palliative care nurse, she was initially funded by a philanthropic grant, and since 1997 she’s been on staff and we’ve had funding.  We also have a research and education co-ordinator whose name is Rama Sapir, her background is that she’s a clinical pharmacologist and together she’s been a key player in research and in terms of developing educational publications in Hebrew but also translated into Russian and now Arabic; the management of pain, the management of symptoms, the management of post operative pain which have been very widely disseminated.’

An important aspect of the service has been the dedication of the team to address the need for the relief of suffering in patients at the end of life. The team works to improve pain relief and symptom control; conducting ongoing research and thereby constantly refining good practice, and also by developing psychosocial support. The initiation of spiritual counselling is part of the overall ethos of the service. Nathan Cherny explains:

‘When I started in Israel, although there was a rabbi in the hospital, there was no tradition of chaplaincy organised spiritual care and this was clearly missing from the programme.  We had a limited, a couple of volunteer chaplains who’d come and gone but not very successfully.  Partly because of cultural issues, and there was some degree of scepticism as to whether Israeli patients had a lot of spirituality.  In 2002 Jonathon Rudnick approached me, he was a young rabbinic student who was interested in chaplaincy, and I said we were interested in taking him on but only after he got formal training.  And he went to the States and did the thing called Pastoral Care Programme and came back and started working on a voluntary basis; initially once a week. We introduced the service with a degree of scepticism on the part of some of my colleagues but from the outset it’s been an enormous success.  Partly because of his specific skills, not only interpersonal skills and religious skills but he is also multi lingual speaking Hebrew, English and Russian, remembering that there are a million Russian immigrants in Israel.  What we saw through that experience was that there was a huge need a huge yearning for it and that we found we were able to spiritually engage patients across the entire sociological spectrum, from the ultra orthodox to modern orthodox, through secular, Christian, Moslem in a very productive and rich way, and it’s really been one of the turning points in the development of the programme. There is good co-operation between his work, the social worker and the psychologist without competition over patients.  There are different issues being addressed and good communication between the services.  Based on that initial experience on a volunteer basis we applied for funding from the New York Jewish Federation, and they gave us a grant to make Jonathon’s position a full time position and to start an internship programme and this is what Jonathon has described to you.  And besides the clinical programme here he’s put in a lot of his energies teaching about the concept across the country, and in the next stage of our programme is to get funding to take on interns who will see it into other institutions.  Not only to train interns but you need to train staff and to socialise them into the concept of this aspect of care, which we strongly believe is an important part of care.’¹¹⁸

Rabbi Jonathan Rudnick describes the ways in which the spiritual counselling supports, not just the patient but also supports the staff:

‘We’re trying to learn about how [this kind of approach] happens here, in order to try to help that happen in other hospitals, and part of it is clearly how the staff related to it.  The whole other issue, in terms of the staff benefiting from this for themselves, for the spiritual care that the staff need, is a bit more difficult conceptually but I think that in general not just in spiritual care many people kind of feel like the whole issue of self care, like everyone says, “yeah, we need to take care of ourselves but lots of us don’t do it so well.” But seeing this as something that is an important resource and something they can help in terms of the care for patients and families; the whole staff went along with this.  And slowly and slowly [staff] started referring patients, in a sense of it being very slow and organic which is one of the important issues that Nathan emphasises in terms of changing and developing the culture in the hospital setting in Israel where this is seen as OK, positive and something that the staff will want to support because it helps them as well.’¹¹⁹

Milton and Lois Shiffman Home Hospice in the Valleys
The hospice is one of the few services owned by HMO Kupat Holim Clalit. Founded in 1999 by nurse Mali Szlaifer, the hospice took over the work of the (now closed) Afula Hospital Home Care, on the retirement of the medical director Isaac Kersz. Mali Szlaifer explains the aims and ways the service has developed since 1999:

‘For terminal patients I really felt that we can not do too much, and the needs were very large. The problem was that nobody was really in charge of that and the community send them to the hospital because they already paid for it, and they don’t know how to manage their symptoms and things like this. The hospital sent them back home and the people were very miserable - really. … Sometimes they give them something, or here or there, but didn’t help a lot, and then they sent them back to the hospital and the hospital sent them back home. The vision of our hospice when we were establishing, is to provide excellence - not good but excellent palliative care for patients and family, and also to be one of the leaders in palliative care in Israel, and to ensure that high-quality standard of palliative care services will be accessible to all patients suffering from progressive diseases - see that I’m not using the word ‘cancer’ ...in our hospice we will see other diseases, … but we see very few referrals [ for other illnesses]. In the beginning, the American partners (the Jewish Federation of Detroit) agreed to pay for three years. We are in the sixth year, so they decided that they will give for another three years but smaller amounts of money, and maybe I’ll have to close some of those regions.

Staff satisfaction [is important], because one of my concerns at the beginning was that nobody works for the hospice a full-time job, everybody works very part-time, so I was afraid that, OK, this is not important and so on. But what happened over time [although they said] ‘it’s very bad time’ but they ‘see this as the quality work’, as the nurses say: this is where they can magnify their profession. Because the district is very spread, one of the options was that I would take a nurse, for example, and she would be travelling most of the time because she must go from here to there to there to there - so I decided to take nurses or physicians who live in the region, a very small region, but that they can cover this region in 10/15 minutes of driving, and for example a nurse can have between one and four patients. [She is on call] 24 hours a day, all year. If she is not able to go to the patient, in every region there are two nurses, and then she will refer the patients for the other nurse, and sometimes today what happens is, if the nurse goes on vacation the doctor is on call for the patient because they build a very strong relationship in their team.

In Israel, as I told you, in the beginning the Jewish Federation of Detroit gave us money to make a partnership, but in the Arab city they have no partnership, and I felt very bad because I felt like it’s some kind of discrimination, and I ask them that it doesn’t look good that we only give treatment for Jewish people. And they think about it and in Detroit they also have a very large Arab community and they want to improve the relationship between the Arabs and Jews so this also met some agenda of theirs. They give me the money to open the hospice in the Arab city of Nazareth, and then I was in United States with an Arab social worker but she was working for the hospice of us here, and we made some projects together with the community of Israel and United States. OK?  So this is what I was writing about, you see, that sometimes when you are talking about mutual issues that are important for both communities and you are not talking about peace but those things that improve peace and understanding because, you see, we are people the same.

So the goals were to provide high-quality culturally and religiously tolerant palliative care and train professionals from the various religious groups emphasising the ethnic diversity of patients. And patients and families stated in this satisfaction questionnaire that the spiritual and cultural differences were appreciated and respected, you see that and this unique project demonstrated the feasibility of multi-religious collaboration in palliative care is a potential to promote understanding and peace.’¹²⁰

Jerusalem Home Hospital
Founded in 1991 as an HMO run service, the Home Hospital was established to provide ‘hospital’ type care at home for patients with a range of acute and chronic illnesses, including palliative care at the end of life. The service is unusual because from the start palliative care has been offered to patients with a range of illness, not just cancer, and also the service provides palliative care for children at home. The medical director Dr Jeremy Jacobs explains:

‘We’ve got, we have about 25 – 30 patients, full-time ventilated patients at home … with tracheostomies, and home ventilators the size of a shoe box. They’re at home, most of them are in home hospital; the minority manage to do without us.’

The service was also encouraged by work with heart failure patients at the end of life to ensure an effective home care service that would benefit both the health service and patients by preventing recurring hospital admission, Jeremy Jacobs continues:

‘We discharged a lot of patients at one stage and we found that the heart failure patients went back to the hospital very significantly, so that we persuaded our bosses to reallocate funding in order to open up the service again. We have started a pilot service that’s focused on heart failure patients. Whereas in the past we have always waited for patients to be referred to home hospital, with the heart failure patients who are home bound/bed bound with recurrent readmissions to hospital we are actively seeking out patients to admit to home hospital. We’re going to take them in and give them the service for as long they, as long as they remain at the level of heart failure. We’ll keep them for a long period of time, with a nurse practitioner going in and a doctor going in, and see if that really keeps them out of hospital or not.’

The service continues to emphasise the importance of palliative care provision and employs a part time palliative care consultant Dr Ora Rosengarten and a specialist palliative care oncology nurse Yonat Lamed. The Home Hospital, as a concept and in practice, has proved both efficient and well-regarded and the nature of the team and the way they work have changed since the hospice was established as Ora Rosengarten explains:

‘Some 20 physicians work today in the Home Hospitalization service and provide the best possible care to the patients. Most of the physicians have been working with us for a long period, they have acquired good experience in palliative care, and they do their best to respond to patients’ needs 24 hours a day. Along with the nurses, we provide all services for end of life care – as much as can be done in the Hospital setting, allowing the patient to enjoy the home without compromising the quality of care. The work done by the team of the home hospitalisation is very difficult and only those really devoted persist in this work.’

An important part of the service has been to develop the supportive role of nurses for families in the home care setting. As Yonat Lemed, specialist nurse explains:

‘A big part of the nursing work actually is supervising nurses, and the nurses themselves, to guide the family, it’s a big part of our role. If they get infusions they are taught how to change the bags, sometimes even with the sores the families are taught how to treat and change the bandages and everything; pain medication, of course. And we have to prepare the family what’s going to be, I mean, if we know already what is the deterioration of the patient, we have to start to prepare the woman, the wife, what she can expect to see, and what are convulsions and what are etc, and not just using those high words. Then it’s like we prepare her for what she will meet, will see, and then what to do if there’s something else, what will happen. This is really a big part of our role to do, the nurses.’¹²¹

By 2002 the Jerusalem Home Hospitalhad built its capacity to provide care for 450 patients at any one time. However, funding is always precarious, and the service was severely tested in 2002 when over two months, due to unexpected funding cuts by the health insurer, the service was forced to reduce the number of patients to 150, prioritising cancer patients needing palliative care. A consequent sharp increase in hospital admissions prompted the insurer to acknowledge the cost effectiveness of home care and to restore some of their funding. By 2005 the service had managed to increase capacity back up to 300 patients.

Bereavement services
Formal bereavement counselling is being developed in some services: the Ina and Jack Kay Hospice; and from 2005 at Tel Hashomer.¹²² In 2005 Negev Palliative Care Services started to develop bereavement counselling through Ma’agan House, Beersheva. However, most services offer some element of bereavement counselling that builds on well-established informal support already provided by the service prior to a patient’s death. Bereavement support may, as for instance at HUG, include one or more members of the whole team, or in other services tend to be taken up mainly by social workers or psycho-oncologists. Malka Yehezkel, the inpatient social worker at the Ina and Jack Kaye Hospice, Hadassah describes how she supports the family in the first stages of bereavement:

‘After the death of the patient I sometimes go: first I go to the visit of the ‘shiva’; the Jewish have the ‘shiva’ [7 day mourning period immediately following the burial] ¹²³, the Moslem have 3 days, so I go to visit at this stage ...I open the door to continue this follow-up if they want. Sometimes they are ready to come back here [at the hospice] and meet me regularly. At the beginning when the patient is here it’s not a regular meeting, every day I go up, I see them here or we meet. Afterwards, with the follow-up, it’s regular meetings, like in a clinic, it’s very different, that part. And I’m ready to go to their home if they feel it’s too difficult to come to the hospice again.’¹²⁴

Other services will usually try to offer some bereavement support but may depend on volunteers being available. For example in Kiryat Tivon as Ora Cibulski explains immediately following the patient’s death:

We do very little. [But] we always go to the 7-day mourning period [Shiva]. We’re always there immediately after the patient dies. We call up or make contact [for] 30 days - 30 days is usually, it’s a sort of type of mourning period [‘Sheloshim’] - and then whoever was in direct contact with the particular family calls about once a month until six months. Sometimes there are visits - it very much depends upon the particular volunteer.¹²⁵

Paediatric services
Palliative care services for children have developed slowly since the 1990s. For a few years there was one dedicated, though small, inpatient unit at Chaim Sheba – The Marion and Elie Wiesel Children's Pavilion, but a change in staff in the 2000s has meant that this unit has a greater emphasis on curative care. There are two home care hospice services able to care for children (Jerusalem Home Hospital and HUG).  However, as paediatric oncology nurse Ruth Gassner notes:

‘In oncology paediatrics, mainly when children die they stay in the hospital. From my experience I don’t believe that you can open an inpatient hospice for children, I don’t think that. Not even one parent would give up treating here, I mean treating, giving chemotherapy, etc to the children, I don’t think so. Usually they give it until the end. Very rare that they take the child home and he dies at home. It’s not so often.’¹²⁶

Professor Pesach Shvartzman, who has helped to develop the paediatric palliative care consultation service at the Soroka Medical Centre, Beersheva agrees and continues:

‘Children are another issue, you know. [For] children, what we lack, what we don’t have is inpatient care, and we are doing our best to get a contribution to have an inpatient department. Now our children, you know, we have some children at our palliative care unit, usually children culturally - and it might be a Jewish culture - although we have many of the children who are Bedouins, usually children die in the hospital. It’s very difficult for parents to go home and let the child die because it might be obvious that the old people die, it’s not obvious that children have to die, so I can tell you that there are not many families in whom we could take the child out and take care of him at home. … We have about 4 or 5 children dying each year and of course, just having ... I usually work with the social workers of the paediatric oncology department, so there is not ... what I did I just first of all trained the department themselves to do something by themselves and just give them the support and usually I used the resources of the paediatric oncology department because, you know, just to have a few people - five children a year - it’s problematic when you talk about cost-effectiveness.’¹²⁷

Because families rarely request home hospice care for children, since the late 1990s in response to these very different needs of dying children and their families, paediatric services have tended to develop hospital based services rather than home or specific hospice services. For instance, there are currently hospital consultation teams and hospital based support groups for families within paediatric oncology units at several large medical centres.

Drop-in centre
The only drop-in centre in Israel was established in the early 2000s, Ma’agan House, in Beersheba, run by Negev Palliative Care Services as a charitable venture funded by an independent, overseas, benefactor. Dr Yoram Singer explains:

‘Ma’agan House is a community house whose function is to support cancer patients and their families. It’s like a club, where they have all kinds of activities for cancer patients and their families. There are, there are also group therapy sessions, and there’s an art therapist and a music therapist who come. They have lectures on all kinds of, not medical issues but sort of bringing together cancer patients - not only terminal cancer but cancer patients and their families under one roof.’¹²⁸

The centre is organised by a social worker with a group of trained volunteers able to offer a range of supportive and creative therapies.

Changes in service provision
Since the late 1990s, financial and staffing difficulties have resulted in closure of some home hospice services such as the Haifa Home Care Hospice in 2003, the reduction in provision of services as at the Jerusalem Home Hospital in 2002, and the shift of emphasis from palliative care to more curative based paediatric care at the Marion and Elie Wiesel Childrens’ Pavilion when dedicated palliative care staff moved to other locations.¹²⁹

There are, however, new services are under development, for example, a home hospice will open in January 2006, Al-Taj for Health and Heritage Association near Nazareth.¹³⁰ Likewise various new services have been set up in the last 2 to 3 years within existing organisations, for example, the mobile desert unit started in May 2004 at the Negev Palliative Care Services; the inpatient unit and the spiritual counselling service at the Cancer Pain and Palliative Care Unit at Sha’are Zedek, the development of palliative care services at the new Davidoff Oncology Unit which now incorporates the Beilinson Unit at the Rabin Medical Centre and the current expansion of services at the Hospice of Upper Galilee.

Since the 1980s, with the support of the Israel Cancer Association (ICA) and the Israel Association for Palliative Care (IAPC), dedicated services have been developed in many areas of the country; including an extensive community nursing service and regular training programmes.