End of Life Care Policy

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

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Abstract

A policy paper defining recommendations in order to integrate palliative care into health care services was written by a committee appointed by the Ministry of Health. The objective of the paper is to assure universal access to end of life care to every person in need. This policy is expected to improve appropriateness of care for the terminally ill, equity in receiving care, and quality of life for these patients and their families. Palliative care is also expected to save costs.

Purpose of health policy or idea

Objectives: To assure access to end of life care to every person in need, by integrating palliative services into the mandatory benefits package, which is provided by the health plans.

Characteristics: The director-general of the Ministry of Health began a process of defining organizational guidelines for integrating palliative care into the services provided in inpatient and community settings. In order to do so, he appointed a professional committee that defined these guidelines. The committee submitted a policy paper; next month, discussions within the ministry will begin in order to gradually implement the recommendations, which address both conceptual and organizational issues. The policy paper states that comprehensive palliative care (i.e. physical, emotional, social, and spiritual care) should be provided to all terminally ill patients and their families. Patients can choose where palliative care would be given (i.e. at home, or in a hospital or nursing home). Care should be provided 24 hours a day, with appropriate geographical accessibility. Patients and their families should be involved in decision-making regarding their care (e.g., the extent of pain control medication administered, which may affect alertness). Every terminal patient should undergo a comprehensive evaluation as a basis for defining his needs; his treatment should be defined after discussing his preferences with him and his family.

Palliative care should be delivered on two levels: the primary level of palliative care should be delivered by internists, geriatric oncologists, etc., at the hospital or in a nursing home, and by the family physician and other community clinic staff in the community. The secondary level of palliative care should be provided directly by palliative care specialists, who would also be responsible for consulting and training the teams that provide the primary level of care.  

The target populations defined by the committee include terminal cancer patients with a prognosis of no longer than 6 months (as defined by 2 physicians); patients with progressive congestive heart failure; COPD; renal failure; AIDS; dementia; degenerative neurological diseases (e.g. ALS); patients in coma.

Incentives: If palliative care is included in the mandatory benefits package (as suggested in this policy paper), the health plans would be obligated by law to provide it.

This policy would affect terminally ill patients and their families, as well as primary care providers and specialists in palliative care.

Main points

Main objectives

To assure access to end of life care to every person in need, by integrating palliative services into the mandatory benefits package provided by the health plans.

Type of incentives

If palliative care is included in the mandatory benefits package (as suggested in this policy paper), the health plans would be obligated by law to provide it.

Groups affected

Terminally ill patients: these services will greatly improve the quality of life and quality of dying, Providing psychological and emotional support to informal caregivers will decrease burden, improve their quality of life, and ability to provide care, Primary care providers will receive the professional support, consultation, and information they need thus improving quality of care.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Innovation: Moderate. Palliative services have been provided in Israel for more than two decades. However the scope of these services has been very limited, and dependent on the initiative of local professionals who have a personal belief in the philosophy of hospice care. The innovation lies in the large scope of services recommended, and in universal eligibility for them.

Controversy:  Moderate. Although most stakeholders understand the importance of hospice care and support the idea, there is concern regarding the source of funding. The health plans are not willing to supply these services without additional funds, and the Ministry of Finance is reluctant to increase the health care budget.

Systemic impact: Large. The scope of services is expected to significantly increase. Moreover, this service will be included in the continuum of care for severe patients. It  may  also change the composition of hospital and nursing home beds (by reducing the number of acute and sub-acute beds). It is also expected to affect professional specialization and training.

Public visibility: Small. The work of the committee and its recommendations have not received media coverage, and have not yet been subject to public debate in various forums.

Political and economic background

Unrelated to national health policy statements or programmes.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The idea to nominate a committee to examine the need for and organization of palliative services, and the supply of hospice care in Israel, arose for several reasons. First, several national advisory committees (the geriatric committee, the committee for oncology and hematology care, the committee for community health care, and the committee for pediatric care) applied to the Ministry of Health for assistance meeting the unmet needs of their patients at the end stage of illness. While oncologists, geriatricians, and others care for patients during the early stages of disease, they lack the tools to care for them once they have reached the end stage of their illness, when their needs have changed. Second, studies conducted abroad, and a recent study conducted in Israel (Bentur et al., 2005) have indicated that substantial societal, health care system, and provider barriers prevent terminal patients from obtaining optimal end of life care, as defined by modern hospice principles. Societal attitudes toward terminal patients and death, and the "medicalization" of end of life care, impede optimal palliative care. System barriers include cost containment efforts, fragmented coverage of end of life care, increased reliance on informal caregivers and families, and a lack of coordination of care. Provider barriers include problems with provider-patient communication, delayed referral to hospice care, limited ability to recognize and treat common symptoms of advanced terminal diseases, and lack of training in palliative care (SUPPORT, 1995; Christakis and Iwashyna, 2000; Higginson and Edmonds, 1999).  

During the last decades of the twentieth century, palliative, end of life care has become the "state of the art", recommended care for terminally ill patients. Hospice services have grown in Western Europe (mostly in the UK) and the US. Since 1982, inpatient and outpatient hospice services have been included in the benefits package of Medicare for patients with a prognosis of 6 months or less. Moreover, during the past two decades, the model of end of life care has changed from one that traditionally split the curative and palliative phase of care, to one that combines these types of care. According to this model, patients are entitled to receive palliative care from the onset of their illness, with the amount of palliative care increasing as the illness worsens. This model also includes bereavement services for the family.

Another factor that induced the Ministry of Health to appoint a committee to examine the issue in Israel was the aging of the Israeli population, and the increase in the rate and total number of chronically ill.  Health services in Israel are not prepared to provide an adequate response to the growing number of people who suffer from progressive diseases, which cause a deterioration in health and functioning over a long period of time. Moreover, most of the chronically ill reside in their homes, further complicating provision of services to them. This important, complex issue has received a great deal of media coverage in recent years, bringing it to the attention of the minister of health and other politicians, as well as to that of the general public.

Recently, the Knesset preliminarily approved (during the first of three votes) the "Dying Patients Law". This law permits passive euthanasia - that is, lack of provision of care to a patient whose days are numbered.  Its passage would exempt physicians from criminal liability for failure to administer care to a dying patient.  This law was tabled on the recommendation of a public commission chaired by Rabbi, Professor of Internal Medicine, Avraham Steinberg (hence it was known as the "Rabbi Steinberg Law"). The Steinberg Commission first presented its report to the minister of health in 2002. The rationale behind the law explains that, in recent years, "progress, and scientific and medical knowledge and technology, which facilitate the artificial extension of the lives of the terminally ill, such as was never before possible", have added to the complexity and urgency of addressing this issue. This difficult issue has increasingly been brought before the courts, which have turned to the legislature to formulate an appropriate response. The government therefore recommends setting in law the rules for the treatment of terminally ill patients, and respect for a patient's wish not to receive care. The rationale behind the law claims that it will "balance the sanctity of life, the importance of quality of life, the prevention of pain and suffering, and the autonomy of the individual". This too contributed to placing the issue on the public agenda.

As a result of all of the above factors, in August 2004, the new director-general of the Ministry of Health nominated the committee to examine the need for and the organization of palliative services and the supply of hospice care in Israel. The main purpose of the committee was to develop a long-term program to promote palliative care in Israel, including infrastructure, training, and the like. Its recommendations will be the basis for this program, and hence include both the principles on which palliative  services shoudlbe founded, and specific policy measures for implementation (e.g., the number of hospice beds per population).

Professor Schvartzman was nominated to chair the committee. He is heads the Family Medicine Department of the Medical School at the Ben-Gurion University, is a consultant to the Beer Sheva home hospice unit, and heads the Negev district's pain management clinic in the Negev. Prof. Shvartzman is a leader in this field, and recently obtained board certification in palliative care in the US. Also serving on the committee are senior specialists in palliative care (physicians, nurses and social workers), senior researchers in health policy, senior directors of the health plans, representatives of the Israel Medical Association, and representatives of NGOs such as the Israel Cancer Association and Tmicha (the umbrella organization of palliative professionals in Israel). Almost all  members of the committee are dedicated to the concept of palliative care for an extended time; some of them have a "bee in their bonnet" about the issue. Their personal interest and charisma are a  driving force behind promoting the committee's recommendations.  In addition, the committee nominated a "monitoring committee" to ensure that the ministry begin implementing the recommendations.

Small scale examples: As of this writing, there are no examples of comprehensive palliative services in Israel. However, limited palliative care is provided in inpatient and outpatient settings. There are only 3 inpatient hospices (78 beds) in three central cities. A few hospitals also supply palliative services through a team (physician and/or nurse) that acts as consultants to hospital departments. However, these teams usually treat physical symptoms only, primarily pain, without providing psychological or spiritual assistance. Some oncology departments also provide palliative care, primarily pain control. Palliative care services in the community are not included in the benefit package mandated by the NHI law, such that the health plans are not obligated to provide these services. As a result, home hospice services the community are limited:only 7 such units are currently providing palliative services. Four of them are operated by Clalit Health Services, two are operated by inpatient hospice units, and one operates as an independent NGO. All of them are dependent on donations, in addition to selling their services. Together,  these services assist about 2,000 terminally ill patients annually - less than 10% of the dying people who could benefit from such services. 

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Wissenschaft

• Andere

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

Position regarding the recommendations:

Ministry of Health: It convened a special meeting to discuss the committee's recommendations and the implications of their implementation. It is not yet known whether the ministry supports the recommendations, although it understands the importance of improving the quality of care of the terminally ill. The ministry also believes that hospice services are cost effective for the system as a whole, since studies abroad and in Israel have demonstrated that home hospice care reduces hospitalization and number of hospital days.

Ministry of Finance: It supports these services, mainly because of their potential contribution to saving costs in the system.

The health plans: They acknowledge of the importance of this issue, as they very often need to provide services at home to terminally ill patients. However, they are concerned about whether these services will receive adequate budgets (since hospice services are provided by multidisciplinary staff, and therefore are very expensive). To date, these services have not been included in the benefits package; the health plans are concerned that the committee's recommendations imply providing extra services without additional reimbursement. From their standpoint, a savings in hospital days is not a real savings, as their payments to hospitals are governed by various global arrangements.

Specialists in oncology, internal medicine, and gerontology: Some of these practitioners do not support the committee's recommendations, since they believe they already provide appropriate care to the terminally ill. Some of them believe that the primary need of the terminally ill  is to control pain; they remain unaware of any additional psychological and spiritual needs of the patients and their families.

Specialists in palliative care: They support the recommendations because of their professional background; they believe in providing quality of life at the end of life rather than extending life at any cost.

NGOs (the Israel Cancer Association and Tmicha): They support the reccomendations, which complement their mission of providing quality of life at the end of life.

Actors and positions

Regierung
Ministry of Health	sehr unterstützend		stark dagegen
Ministry of Finance	sehr unterstützend		stark dagegen
Leistungserbringer
Health Plans	sehr unterstützend		stark dagegen
Oncologists, Gerontologists, Internal medicine specialists	sehr unterstützend		stark dagegen
Specialists in palliative care	sehr unterstützend		stark dagegen
Wissenschaft
Academia	sehr unterstützend		stark dagegen
Andere
Israel Cancer Association	sehr unterstützend		stark dagegen
Tmicha NGO	sehr unterstützend		stark dagegen

Actors and influence

Regierung
Ministry of Health	sehr groß		kein
Ministry of Finance	sehr groß		kein
Leistungserbringer
Health Plans	sehr groß		kein
Oncologists, Gerontologists, Internal medicine specialists	sehr groß		kein
Specialists in palliative care	sehr groß		kein
Wissenschaft
Academia	sehr groß		kein
Andere
Israel Cancer Association	sehr groß		kein
Tmicha NGO	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

The committee submitted its final report and recommendations to the director- general of the Ministry of Health and the deputy director of the ministry in January 2005. They convened a special meeting at the beginning of April 2005 to discuss the implementation of these recommendations. The meeting was attended by senior ministry officials,  the members of the committee, and the members of the relevant national advisory councils.

The recommendations include short-and long-term steps for implementation. In the short term (during the first year), a palliative consultant team should be established in every hospital and health plan home medical care unit.

In the long term, the number of palliative beds should be increased from 78 to 300 beds 50 beds per million population. This may be accomplished changing the purpose of existing beds.  In addition, there should be a substantial increase in the number of specialized personnel in the field of palliative care (physicians, nurses, and social workers). Finally, training in palliative care should be increased in Israel, both for primary care providers and specialists.

At the April meeting, the Director-General and Deputy Director-General of the Ministry of Health expressed a strong commitment to these recommendations. Members of the advisory committees supported the recommendations unanimously. The Ministry will publish a policy paper announcing that palliative services will be developed gradually. In practical terms, it was decided that the committee would continue its role in gradually implementing the recommendations.

Its first step will be to define the structure of two different types of service unit, including the cost of operation. This will be presented to the health plans, with which possible implementation will be discussed. In addition, the Ministry of Health is willing to lead a process of training and accreditation in the specialty of palliative care for both physicians and nurses.

Concurrently, a national training program in palliative care is being established by Ben Gurion University and ESHEL - The Association for the Planning and Development of Services for the Aged in Israel, with funding from the New York Jewish Federation. Although independent of the committee's recommendations or the government's involvement, this process will facilitate implementation of those recommendations.

A training course for about 40 professionals has recently ended. Participants included physicians, nurses, and social workers who currently work in palliative care, and who have agreed to train others in this field. The course was founded on the principle of "training the trainers". In 2005, three courses will be held, in which the graduates of this first course will train an additional 120 primary care professionals.

In 2006, another 10 courses are planned, which will train an additional 300 professionals.

Implementation of the committee's recommendations is dependent on finding the needed funds. Although funds could be saved by changing the purpose of existing beds and professionals, some additional funds would nevertheless be needed to reach the target number of beds and professionals (especially in the community). We would note that a recent Myers-JDC-Brookdale Institute study has shown that home hospice services are much cheaper during the last two months of life than is caring for the same patients in the regular medical services. The main savings was in hospitalization (Bentur, 2005).  Similar findings have been reported by other studies conducted in Israel (Schvartzman, 2005) and abroad (Emanuel, 1996, Smith 2003, Hughes et al. 1997).

Monitoring and evaluation

The committee has recommended that a sub-committee (comprising members of the main committee) monitor the gradual implementation of its recommendations. This sub-committee will indicate whether or not the recommendations are being implemented according to plan.

At present, however, no other formal evaluation of the process or outcomes of this policy is yet planned.

Review mechanisms

Halbzeitevaluation

Expected outcome

If the recommendations included in the policy paper are in fact implemented, we expect that comprehensive palliative care (i.e. physical, emotional, social, and spiritual care) will indeed be offered to all terminally ill patients and their families.

Costs: Providing palliative care at the end of life, rather than through regular medical services, as it is  provided today, is expected to save costs for the health system, as has been found in studies in Israel and abroad. Today, only 10% or less of those who need this care, receive it.

Access to care would be improved, since the policy ensures service to all parts of the country, and to all citizens, through inclusion of these services in the national health insurance benefits package.

Quality: Quality will improve, since the services provided will reflect the "state of the art" understanding of care for terminally ill patients, currently considered the most appropriate care for people in this condition. Palliative care has been found to improve the quality of life for both patients and their families; thus, adding these services to the national health insurance benefits package, will improve quality of care.

Equity: If comprehensive palliative services are developed, equity will increase, since access to services will improve throughout the country, and the percentage of people in need who benefit from these services will increase. In addition, if the services are added to the national health insurance benefits package, as recommended, they will be universal.

Undesirable effects: The committee recommended palliative care during the last 6 months of life. However, it is known from the literature (Morrison and Meier, 2004; Miller et al., 2004) that physicians succeed in correctly estimating the expected length of life for only about one-third of all terminally ill patients. Although in some cases they refer the patients to palliative care too late, in other cases the patient receiving palliative care survives for more than 6 months. Thus, patients may receive palliative care for longer periods. No evidence exists regarding the relative cost of providing these services versus regular medical services. Furthermore, it is well known that patients who are far from death do use many other medical services (e.g. chemotherapy) in addition to palliative care.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Costs: Moderate. Providing palliative care at the end of life rather than through regular medical services, as is the case today, is expected to save costs for the health system, as has been found in studies in Israel and abroad. Today only 10% or less of those who need this care, receive it.

Quality: Large. Quality is expected to  improve, since these services represent  the "state of the art" understanding of care for terminally ill patients, and are considered the most appropriate care for people in this condition. Palliative care improves the quality of life for both patients and their families at this stage.

Equity: Large. If comprehensive palliative services are developed, equity will increase, since access to the services will improve throughout the country, and the percentage of people in need who benefit from these services will increase. In addition, if the services are added to the national health insurance benefits package, as recommended, they will be universal.

References

Sources of Information

Bentur, Netta, Shirli Resnitzky, and Yitshak Shnoor.  Palliative Care in the Israeli Health Care System. Jerusalem: Myers-JDC-Brookdale Institute, 2005. (Hebrew).

Christakis, N.A., and T.J. Iwashyna. Impact of individual and market factors on the timing of initiation of hospice terminal care. Medical Care 38:528-541, 2000.

Emanuel, E.J. Cost savings at the end of life. What do the data show? Journal of the American Medical Association 275:1907-1914, 1996.

Higginson, I.J. and P. Edmonds. Services, cost and appropriate outcomes in end of life care. Annals of Oncology 10:135-136, 1999.

Hughes, S.L., A. Ulasevich,  F. M. Weaver, W. Henderson, L. Manheim, J.D. Kubal, and F. Bonarigo. Impact of home care on hospital days: A meta analysis. Health Services Research 32: 415-432, 1997.

Miller, S.C., B. Kinzburnner, P. Pettit, and J.R. Williams. How does the timing of hospice referral influence hospice care in the last days of life? Journal of the American Gerontological Society 51:798-806, 2003.

Morrison, R.S., and D.E. Meier. Palliative care. New England Journal of Medicine 350:2582-2590, 2004.

Shvartzman et al. Evaluation of Cancer Patients' Last Year of Life (Utilization, Symptom Control, and Quality of Life). (unpublished data, 2005).

Smith, T. Adding hospice and palliative care services to the cancer center menu. Journal of Palliative Medicine 6:641-644, 2003.

The SUPPORT principal investigators. Controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risk of treatment (SUPPORT). Journal of the American Medical Association 274:1591-1598, 1995.

Author/s and/or contributors to this survey

Netta Bentur and Revital Gross

Empfohlene Zitierweise für diesen Online-Artikel:

Netta Bentur and Revital Gross. "End of Life Care Policy". Health Policy Monitor, April 2005. Available at http://www.hpm.org/survey/is/a5/2