INTRODUCTION
The Israel Cancer Association (ICA) was established in 1952, and has been a prime mover behind the fight against cancer diseases in Israel ever since, taking action on all fronts. The ICA's objective is to reduce cancer mortality and morbidity in Israel and to improve the lives of patients who are at different stages of the disease. These goals are achieved by promoting research, prevention and early detection, upgrading treatment and rehabilitation of cancer patients, and promoting patient rights and developing palliative care (PC).
These services are provided to the general population and to cancer patients pursuant to clear professional criteria defined by the advisory committees. ICA-supported projects are meticulously reviewed, and public donations are invested only after giving careful consideration and exercising professional judgment, concerning the issue at hand, while upholding national interests.
Akin to any other field that the ICA endeavors to promote, in PC the resources are allocated towards assisting patients and their families, constructing buildings, promoting research, purchasing equipment and training the members of the interdisciplinary team.
CLINICAL INFRASTRUCTURE
Survey of Hospice Services in Israel
Inpatient Hospice Services
There are currently two main inpatient hospices in Israel: the Cancer Hospice at Sheba Medical Center, Freedman Pavilion, Tel Hashomer, and the hospice at Hadassah Mt. Scopus Medical Center, the Ina and Jack Kay Center for Supportive Care (Bentur, Resnizky & Shnoor, Reference Bentur, Resnizky and Shnoor2004). In 1983, a 25-bed inpatient unit Tel Hashomer Hospice at Sheba Medical Center was established (in collaboration with Ministry of Health and “Clalit” Health Services—CHS) under the direct administration of the ICA, until 2003.
The Inpatient Hospice of Hadassah Mt. Scopus Medical Center, established in 1986, is located in a cottage within a garden overlooking the Judean desert, as far as the Dead Sea, and has 14 beds. A nurse manages the Inpatient Hospice of Hadassah Mt. Scopus Medical Center, as well as the Home Care Hospice. The ICA has been funding the positions of nurses and a social worker since 1989, both for the inpatient hospice and home care hospice.
In addition to these two inpatient hospices, there are several institutions that offer PC, which are also affiliated with the long-term care division of the health care system in Israel, such as the Hospice Department at Nof Hadar Geriatric Hospital in Haifa. For many years, the ICA has been funding the positions of the Head Nurse and social worker at this institution. Further examples are: St. Louis French Hospital in Jerusalem and the Italian Hospital in Haifa. In “Elie Wiesel House” for children in Sheba Medical Center, ICA assisted in its establishment and funded a nursing post for two years.
There are hospitals that offer hospital based palliative care in the general wards, and specifically, within the oncology department and PC outpatient clinics at the Oncology Institutes. There are also Pain Clinics in at least six medical centers throughout Israel (Waller, Bercovitch & Adonsky, Reference Waller, Bercovitch and Adunski1998). In many of those centers, ICA offers long-term financial assistance for nursing, social work, and dietitian positions. From 1998–1999, The Israeli Palliative Medical Society, ICA, and “Janssen-Cilag” setup a 24 hour palliative telephone “hot line” operated by volunteer physicians who are members of the Israeli Palliative Medical Society. “Clalit” Health Services has recently initiated a new national nursing and palliative care telephone consultation service (hotline). This is the third consecutive year in which the ICA is funding the position of the nurse who coordinates this service (Berkovich & Golan, Reference Berkovich and Golan2009).
Home Palliative Care
PC services in the community setting have been growing steadily in recent years, further underscored following the issue of the Health Ministry Director-General Circular of 2009 (Waller, Reference Waller, Saunders and Kastenbaum1997, 11). The ICA affiliated home palliative care (HPC), which is still run by the Association, was established in 1989 for about 30 patients or more at a time. This is a 24 hour service, available all year round. The service is operated by a highly skilled interdisciplinary team comprised of nurses, physicians, social workers with important assistance of a medical secretary.
Additionally, there are other PC services within the community setting that are affiliated with the health care funds or independent associations dispersed across Israel. The ICA funded or continues to fund nursing posts in each one of the services mentioned above, and in some it also funds social work positions.
Contemporaneously, volunteer community based hospice services were developed: the HPC in Tivon, established in 1984, and which continues to operate, and the HPC in Arad, which operates in collaboration with the local ICA Branch (Bentur, Resnizky & Shnoor, Reference Bentur, Resnizky and Shnoor2004). There are two for-profit HPCs in Israel as well.
Special Services
Bedouin Mobile Unit
The “Bedouin Mobile Unit” is essentially a 24 hour service offered to the Bedouin population residing in villages and throughout the Negev, some of them in temporary structures or in tents. The mobile unit is a service provided by the CHS in collaboration with the ICA and other agencies, which assisted in purchasing the mobile vehicle and for many years has funded nursing and social work positions (Singer, Rotem & Alsana, Reference Singer, Rotem and Alsana2009).
Team Members
The ICA has been funding nursing, social work, and dietician positions in the community and at medical centers for many years, from the north to the south, among both Jewish and Arab personnel who are interested in operating PC services. In most cases, the ICA funds these positions for about five years. The institution itself, which employs the incumbent, undertakes to hire the employee and fund the position upon the completion of the ICA funding period (some of the positions earmarked for PC are funded for a period extending beyond five years). All the positions of the ICA HPC interdisciplinary team are funded by the Association.
Palliative Care Activities and Special Projects Conducted by the ICA
Broad-based supportive activity is conducted by the ICA across Israel at support centers and in some of the ICA's 70 branches. The activities are geared toward patients and their families from all sectors and cultures (Jews, Arabs, Bedouins, Druze, Circassians, etc.), and are coordinated and supervised by ICA regional social workers.
Support Centers
The activities are held at the support centers and at ICA branches and are offered free of charge. There are some support centers directly operated by ICA (in Givatayim, Haifa, and Jerusalem) and others run with ICA assistance (Beer Sheba, Afula). In these centers, the patients and families enjoy support (within support groups), therapeutic workshops, art workshops, body-mind activity, excursions, lectures, reading clubs, and more.
Regional Social Workers
The regional social workers provide professional training within the community and in organized support groups. A very important telephone support service is part of an effort to make it easier for patients and families to cope during the different stages of the disease. Last but not least, the social workers instruct, guide, and accompany ICA's numerous volunteers.
Monetary Grant
The ICA provides a one-time monetary grant to assist in enhancing the lives of thousands of patients a year, who subsist on a below average income.
“Give Kids the World” Vacation in Orlando, Florida
Every year, the Miri Shitrit Foundation, under the auspices of the ICA, sends children with advanced stage cancer and their families on a week-long vacation at the "Give Kids the World" Village in Orlando, Florida.
Family Vacation
Each year, a vacation retreat is held for 120 families who have a child with cancer. The true mosaic of Israeli families (Jews and Arabs, religious and secular, new immigrants and native Israelis) enjoy a stay at the Water and the Motor Park, as well as an artistic program featuring Israel's top performing artists.
Informational Activity
Publishing Booklets and Information Pamphlets
The ICA offers booklets and information pamphlets in different languages on all aspects relating to cancer, included PC.
Tele-Information Service
To promote public knowledge, ICA offers a “tele-information service” hotline in Hebrew, Arabic, and Russian. Additionally, ICA's cancer resource and information center provides assistance in seeking further knowledge through access to international databases and professional publications. This is Israel's leading source of information in the fight against cancer.
Barriers to the Development of a Palliative Clinical Infrastructure and Ways of Coping with these Obstacles
PC services are not explicitly included in the health care package as of yet, due to a lack of precise legal criteria defining the PC service within the health care system (B. Lev, Personal Communication, 2009). As a result, we have a rather low population per palliative bed ratio (as compared to the United Kingdom (Leach, Reference Leach, Doyle, Hanks and Cherny2004). The recent Director General of the Ministry of Health circular of July 2009 is aimed at improving this situation (The Director-General's Circular, 2009).
EDUCATIONAL INFRASTRUCTURE
The ICA is constantly aware of the need to broaden professional knowledge and enhance expertise among health professionals.
Palliative Education for Physicians
Since 1996 and up to this very day, ICA assists in the palliative care education effort, offering its premises, logistics, and some of the lecturers. The above activity has provided university level PC education to about 130 physicians. At present, various PC studies for medical students and continuing education programs are offered at four faculties of medicine.
Palliative Education for Nurses
Undergraduate Education
Palliative nursing education is an integral part of the curriculum of nursing schools. The minimal mandatory time allocation is 15 hours.
Post Basic PC Nursing Education
In the official post graduate oncology nursing educational program there is a 42 hour module also in addition to 3–4 days in an inpatient hospice or HPC.
In Service Education
Hospitals, long-term care facilities, and community health providers became more aware of the rising need for more skilled and trained palliative care staff, so either they recommend an entire INPACT (Israeli National PC Training) course adapted to their specific needs or they develop one of their own. The ICA HPC has served since the 1989 and continues to serve as a national training center for PC for cancer patients, providing training to professional staff from all over Israel as well as to Faculty of Medicine students at Tel Aviv University, and nursing students taking advanced courses in oncology. The ICA HPC also serves as a clinical arena for palliative care study.
INPACT—Israel National PC Training
INPACT is a significant course geared toward an interdisciplinary team, which succeeds in providing a common denominator and an initial phase of therapeutic discourse, during 6 eight hour sessions. Some of the lecturers in this course are ICA employees. Some of the courses were held at the ICA offices. The ICA is counted among the supporters of this program, which provided health care in Israel with more than 630 certified palliative professionals (reported by the secretariat of “SIAL” Research Center in December 2009). Following the nursing authority circular (2009), issued in March 2011, a one-year palliative course (300 hours) for nurses will be inaugurated to train palliative care clinical nurse specialists.
Programs Offered by the ICA
Psycho-Oncology
The ICA organizes seminars in psycho-oncology for novice and experienced oncology nurses and social workers. This initiative has been offered on an annual basis for over 12 years and about 150 nurses, 170 novice social workers, and 150 senior social workers completed this seminar and received a certificate approved by the Ministry of Education. A shorter psycho-oncology workshop was offered to three groups of radiotherapy technicians.
Physiotherapy
About 150 physiotherapists have completed a special theoretical and clinical course on combined decongestive physiotherapy, for the treatment of Lymphedema. This course has been offered for six years.
Speech and Swallowing
A speech and swallowing continuing education course is offered several times a year to small groups of speech pathologists by the speech and language pathologist of the ICA. When the need arises she offers consultation and training sessions in their workplace.
The ICA Contribution to Meetings, Congresses, and Multimedia Information about PC
The ICA assists in training teams by awarding travel scholarships to participate in continuing education courses and conferences in Israel and abroad; The ICA organizes dozens of seminars and conferences, including workshops geared toward PC nurses working at hospitals, in the community and at various healthcare funds, and it also finances the purchase of professional literature, including Israeli and international PC journals and computerized databanks for oncology institutes, in addition to initiating the dissemination of professional material, etc. The ICA often raises and explains issues related to PC in all media channels, such as pain relief drugs, including opioids, the role of medical cannabis in PC and coping with pain in general.
Symptom Management
Since 1995 the ICA and the Israeli Oncology Nursing Society have collaborated in the planning and implementation of educational activities dedicated to updating and improving the management of symptoms.
For example, study days on cancer related fatigue, chemotherapy induced nausea and vomiting, pain management, nutrition, bone health, body image distress and several courses on sexuality of the cancer patient.
LEGAL INFRASTRUCTURE
The ICA was among the organization that inspired legislation of the vital, cardinal laws concerning PC: (1) Opioid Administration Law in Israel (1979), amended in 1997 provided relatively liberal legislation that facilitated the opioid treatment of cancer pain (Cherny & Sapir, Reference Cherny and Sapir1997). (2) The Terminally-Ill Patient Law (2005), which guarantees high quality, available PC and prohibits euthanasia, and assisted suicide. (3) A Nursing Authority Circular (May, 2009), introducing the PC clinical nurse specialist. (4) Health Ministry Director-General Circular instructs hospitals and healthcare funds to establish a network of hospice services in Israel (July 2009).
The ICA stands on guard and ascertains that in every relevant forum, including the Knesset (Israeli Parliament), that the clinical palliative infrastructure is not altered to serve other purposes within the health care system. For instance, the ICA was actively involved in the Labor, Welfare, and Health Committee of the Knesset on November 2, 2009 on the following subject: changing the designation of the oncology hospice at Sheba Medical Center, Tel Hashomer (Knesset Protocol, November 2009).
THE ORGANIZATIONAL STRUCTURE
The Israeli Palliative Association — “Support” (Tmicha) was established in February 1993 (Waller, Berkovitch, & Adunski, Reference Waller, Bercovitch and Adunski1998). The Israeli Palliative Medical Society was established in June 1997 (Waller, Berkovitch & Adunski, Reference Waller, Bercovitch and Adunski1998). The ICA supported and fully sponsored the “Support” Association and its journal (published 1994–2006) and maintains a warm, supportive and close relationship with the Israeli Palliative Medical Society.
Additional organizations in Israel that are related in one way or another to PC are: The Israel Pain Association, The Israeli Society of Clinical Oncology, The Israeli Geriatrics Society, and The Israel Association of Family Physicians. There are also nursing associations, such as the Israeli Oncology Nursing Association and The Pain Management Nursing Forum, psycho-social organizations, such as the Israeli Association of Psycho-oncology and the Israel Ostomy Association. Most of these organizations conduct activities to promote this issue in close collaboration with the ICA. A national lobby group of hospital and community PC Nurses was established in the 1980s and it resumed its activity in December 2009. This lobby group is coordinated and run by the ICA Head Nurse.
THE CURRENT DEVELOPMENT AND STATUS OF PC IN ISRAEL ACCORDING TO IOELC (INTERNATIONAL OBSERVATORY OF END OF LIFE CARE)
One of the aims of the PC network in all countries is to achieve optimal integration within the national health care system. It should be noted that in spite of Israel's relatively modest resources, and to a great extent thanks to ICA's critical support, from the outset, to this very day, PC in the State of Israel has for the most part succeeded in achieving this goal. This accomplishment is evidenced by that fact that Israel ranks among the leading 15% (out of 234 countries in the world) in respect of the development of PC (Wright et al., Reference Wright, Wood and Lynch2008). The parameters included in the calculation were: awareness, availability (including Opioids), clinical infrastructure, academic infrastructure, and others.
SUMMARY
This article gave an overview of the contribution of the ICA to the development of PC until 2011, with regard to four infrastructures: clinical, legal, organizational and educational. This survey underlined the critical involvement and contribution of the ICA as a non-profit volunteer organization in the forecast, set up, implementation and upgrade of PC in Israel.
Indeed the high level of integration of PC in the Israeli health care system, is recognized by IOELC, evidenced by Israel's high ranking among the 35 leading countries in the world (of 234 states) in palliative care.
The ICA assumed the role of pioneer in formulating and establishing a national plan for the development of PC in Israel. The ICA plays and will continue to play a crucial role in the arduous battle to implement the ambitious plans of further development of PC in Israel with the aim of ensuring more patient and family-focused medicine.
