Dying of ‘Old Age’ in Israel

Abstract

This article examines the current state of end-of-life care in internal medicine wards in Israel, through an analysis of medical practice and the existing legal framework. The authors demonstrate the processes that lead chronically ill, elderly patients to perceive death as an unexpected phenomenon that is to be avoided at all costs. This perception stems, among other things, from the lack of public debate on questions relating to the end of life and the dominant cultural expectation that physicians provide curative interventions. This results in a dearth of palliative care for the elderly along with a growing number of medical interventions that are of questionable value. The authors propose an alternative approach that highlights individual well-being and that demonstrates the potential areas of intervention by which death can be transformed into an expected and acceptable occurrence for the old and infirm. This approach allows patients to avoid unnecessary interventions and to reduce the burden of responsibility on family members and physicians, who are currently being called on to make end-of-life choices under exigent circumstances. We present these dilemmas by focusing on typical cases of incompetent elderly patients when there is no clear documentation of their wishes regarding treatment, and when their families do not have a coherent perception of what they may have wanted or of the care that would be most appropriate for them. We conclude with a call to action that highlights the need for greater awareness—through public discourse and private discussions—of end-of-life medical choices before the onset of ill-health and incompetence.

Notes

1. This data is from the electronic medical records of the Tel Aviv Sourasky Medical Center, a tertiary hospital in Tel Aviv, for 2008.

2. Ibid.

3. See, for example, Vladimir Kaplan et al., “Pneumonia: Still the Old Man's Friend?” Archives of Internal Medicine 163.3 (2003): 317–23. Furthermore, this work focused on patients aged over 65 years and did not differentiate between competent and incompetent patients. It is reasonable to assume that the mortality rates of incompetent patients are higher, as this group consists of older patients with serious comorbidities.

4. Jen-Hau Chen et al., “Occurrence and Treatment of Suspected Pneumonia in Long-Term Care Residents Dying with Advanced Dementia,” Journal of the American Geriatric Society 54.2 (2006): 290–95.

5. Bliss Michael, William Osler: A Life in Medicine (Toronto: University of Toronto Press; 1999), 290.

6. Amongst the many articles describing non-beneficence, see, for example, Diane E. Meier et al., “High Short-Term Mortality in Hospitalized Patients with Advanced Dementia: Lack of Benefit of Tube Feeding,” Archives of Internal Medicine 161 (2001): 594–99; David Casarett, Jennifer Kapo, and Arthur Caplan, “Appropriate Use of Artificial Nutrition and Hydration—Fundamental Principles and Recommendations,” New England Journal of Medicine 353 (2005): 2607–12, and Muriel R. Gillick and Angelo E. Volandes, “The Standard of Caring: Why Do We Still Use Feeding Tubes in Patients with Advanced Dementia?” Journal of American Medical Directors Association 9 (2008): 364–67. For two opposing Israeli perspectives on the topic, see Yitshal Berner, “Non-Benefit of Active Nutritional Support in Advanced Dementia,” Israeli Medical Association Journal 8 (2006): 505–6, and Dvorah S. Shapiro and Reuven Friedmann, “To Feed or Not to Feed the Terminal Demented Patient—Is There any Question?” Israeli Medical Association Journal 8 (2006): 507–8.

7. Bechor Zvi Aminoff, “The New Israeli Law ‘The Dying Patient’ and Relief of Suffering Units,” American Journal of Hospice & Palliative Medicine 24.1 (2007): 54–58. The author developed a suffering scale that included scores for “not calm, screams, pain, decubitus ulcers, malnutrition, eating disorders, invasive action, unstable medical condition, suffering according to medical opinion, and suffering according to family” (55).

8. The Dying Patient Law, Sefer Hukkim (in Hebrew) (2005), 330.

9. For a thorough analysis of the Dying Patient Law, see Carmel Shalev, “End-of-Life Care in Israel: The Dying Patient Law,” Israel Law Review 42.2 (2009): 279–305.

10. For a review of the problematic aspects of the concept of medical futility, see Howard Brody, “Medical Futility—A Useful Concept?” in Medical Futility and the Evaluation of Life-Sustaining Interventions, ed. Marjorie Zucker and Howard Zucker (Cambridge: Cambridge University Press, 1997), 1–14.

11. In this, we follow the notion of medical futility elaborated in J. Lawrence Schneiderman and Nancy S. Jecker, Wrong Medicine (Baltimore, MD: Johns Hopkins University Press, 1995), 11–12.

12. Casarett, Kapo, and Caplan, “Appropriate Use of Artificial Nutrition and Hydration—Fundamental Principles and Recommendations”; Susan L. Mitchell, “A 93-Year-Old Man with Advanced Dementia and Eating Problems,” Journal of the American Medical Association 298.21 (2007): 2527–36.

13. David Rothman, Beginnings Count: The Technological Imperative in American Health Care (New York: Oxford University Press, 1997), 117–25.

14. Paul T. Menzel, Strong Medicine: The Ethical Rationing of Health Care (Oxford: Oxford University Press, 1990), 190–99.

15. J. David Bleich, Bioethical Dilemmas: A Jewish Perspective (New Jersey: Ktav Publishing House, 1998).

16. Merav Sarig, “Israeli Cancer Patients Resume Hunger Strike,” British Medical Journal 333.7567 (2006): 517.

17. It should be noted that Israel's 1995 National Health Insurance Law is unusually generous in obliging health funds to provide substantial coverage for life saving interventions abroad, if they are not available in the country (section 11). The case was brought to public attention on www.ynet.co.il (8 November 2009), available at http://www.ynet.co.il/Ext/Comp/ArticleLayout/CdaArticlePrintPreview/1,2506,L-3800643,00.html (accessed 24.4.2010).

18. Revital Gross and Raviv Maizel, “Legislative Measures to Deter Violent Patients,” Health Policy Monitor, November 2008, available at http://www.hpm.org/survey/is/a12/5 (accessed 24 April 2010).

19. Carmel Shalev and David Chinitz, “Joe Public v. The General Public—The Role of the Courts in Israeli Health Care Policy,” Journal of Law, Medicine & Ethics 33.4 (2005): 650–59; Carmel Shalev and David Chinitz, “In Search of Universality, Equity, Comprehensiveness and Competition—Health Reform and Managed Competition in Israel,” Dalhousie Law Journal 20 (1998): 553.

20. Dan Even, “Who Votes for Death?” (in Hebrew), Ma’arivNRG, 28 December 2008; available at http://www.nrg.co.il/online/55/ART1/831/400.html (accessed 24 April 2010).

21. Current research indicates that individuals who have prepared legally valid documents regarding their wishes for end-of-life care were significantly less likely to receive invasive care at the end of life which had little demonstrated benefit, and were less likely to die in a hospital. Furthermore, those who had prepared advanced directives received care that was strongly associated with their stated preferences. Maria J. Silveira, Scott Y. Kim, and Kenneth M. Langa, “Advance Directives and Outcomes of Surrogate Decision Making before Death,” New England Journal of Medicine 362.13 (2010): 1211–18.

22. In a recent article evaluating dementia as a terminal illness, the authors demonstrated that patient families who were informed about the severity of the patient's medical condition and were aware of the short prognosis expected were less likely to opt for interventions in the final months of the patient's life. See Susan L. Mitchell et al., “The Clinical Course of Advanced Dementia,” New England Journal of Medicine 361 (2009): 1529–38.

23. Sherwin B. Nuland, How We Die—Reflections on Life's Final Chapter (New York: Vintage, 1995).

24. Information regarding palliative care training in Israel is available on the Israeli Association of Palliative Care website, www.palliative.org.il (accessed 24 April 2010).

25. For example, the field of palliative care and pain alleviation is not mentioned at all in the detailed syllabus of the residency in Internal Medicine, available on the Israeli Medical Association website, http://ima.org.il/trainees/web/category.asp?catid=659 (accessed 24 April 2010).

26. The curriculum of an internal medicine resident in Israel is available at the Israeli Medical Association website http://ima.org.il/trainees/web/category.asp?catid=47 (accessed 24 April 2010).

27. Laura Loertscher et al., “Cardiopulmonary Resuscitation and Do-Not-Resuscitate Orders: A Guide for Clinicians,” The American Journal of Medicine 123.1 (2010): 4.

28. Some commentators criticize the distinction as unethical and inconsistent with previous case law. Vardit Ravitsky, “Timers on Ventilators,” British Medical Journal 330 (2005): 415–17. The definition of “cyclical” treatment in the Law (section 3) reveals that the framers of the Law foresaw the development of a technology that would install timers on ventilating machines, so that the supply of oxygen would cease automatically after a predetermined period of time. This technological solution has been described as “the displacement of ethics by trickery” in Y. Michael Barilan, “Revisiting the Problem of Jewish Bioethics: The Case of Terminal Care,” Kennedy Institute of Ethics Journal 13.2 (2003): 155. See also, Silke Schicktanz, Avia Raz, and Carmel Shalev, “The Cultural Context of End-of-Life Ethics: A Comparison of Germany and Israel,” Cambridge Quarterly of Healthcare Ethics 19 (2010): 1–14, 10–11, 12.

29. Ministry of Health, Director-General Directive 6/03 on “Guidelines for Using a Proxy under the Patient Rights Law” (2 April 2003).

30. Hans Jonas, “The Right to Die,” in Bioethics, ed. T. A. Shannon (New Jersey: Paulist Press, 1981), 196.

31. Jonas, “The Right to Die,” 208.

32. Steven H. Miles, Robert Koepp, and Eileen P. Weber, “Advance End-of-Life Treatment Planning: A Research Review,” Archives of Internal Medicine 156 (1996): 1062–68.

33. James A. Tulsky et al., “Opening the Black Box: How Do Physicians Communicate about Advance Directives?” Annals of Internal Medicine 129 (1998): 441–49.

34. Douglas K. Martin, Elaine C. Thiel, and Peter A. Singer, “A New Model of Advance Care Planning: Observations from People with HIV,” Archives of Internal Medicine 159 (1999): 86–92; Peter A. Singer et al., “Reconceptualizing Advance Care Planning from the Patient's Perspective,” Archives of Internal Medicine 158 (1998): 879–84.

35. Douglas. K. Martin, Linda L. Emanuel, and Peter Singer, “Planning for the End of Life,” The Lancet 356 (2000): 1672–76.

36. Greg A. Sachs, “Increasing the Prevalence of Advance Care Planning, Hastings Center Report 24.6 (1994): S13–17; Singer et al., “Reconceptualizing Advance Care Planning from the Patient's Perspective,” n. 22.

37. Carmel Shalev, “Reclaiming the Patient's Voice and Spirit in Dying: A Perspective from Israel,” Bioethics 24.3 (2010): 134–44, 142–43.

38. This data is available at the official Israeli Ministry of Health website, http://www.health.gov.il/transplant/about_adi.htm (accessed 24 April 2010).