End of life care policy

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

One year after the legislation of the Dying Patient Act, the Director General of the Ministry of Health published a circular listing the procedures, processes and activities for implementing the Act. This is important because the law is exceedingly complex. The Israeli medical establishment is aware of the issue of the dying patient and many physicians would wish to improve the quality of care for them. Nonetheless, they are concerned about the barriers facing them since the enactment of the law

Recent developments

In March 2008, the Director General of the Ministry of Health (MOH) published a circular with instructions for the implementation of the 2005 Dying Patient Act. This circular was necessary in order to list the procedures for practical application of the law. Because the law is very complicated, there is a need for instructions, definitions and the development of user-friendly forms.

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

Innovation :  Not only is the law itself innovative in Israel, the development and formulation of instructions from the MOH within a relatively short period (about a year) of time after the legislation is also a novelty. This emphasizes the importance given to this law and its implementation.

Controversy:  Although most stakeholders understand its importance and support the idea, many are concerned about the difficulties they will face in implementation, such as coping with a discussion about death, or admitting that they can offer nothing more than palliative treatment. Moreover, some believe in the power to cure and do not give up until they have made prolonged and extensive efforts. In addition, in the Jewish religious community, particularly the ultra-Orthodox, there is a demand to preserve life at any cost, even the suffering of the patient and his family. There are strong ethical and cultural taboos in Israel about confronting death

Systemic Impact:  Because of the many obstacles, only some of which could be listed here, it will take a long ime until we see significant change.  

Public  visibility: The recommendations have received very little media coverage until now.

Transferability : The comprehensive and detailed recommendations that had been developed by the Israeli MOH can be implemented in other countries with adaptations in accordance with their health system structure and culture.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government

• Providers

• Patients, Consumers

Stakeholder positions

Ministry of Health - initiated the circular in order to facilitate implementation of the "Dying Patient Act" and therefore of course strongly supports it.

Hospital directors - are required to appoint a committee within the hospital to implement the law, but many of them may not be interested and will not make a special effort to implement it. This because many believe that they have more urgent and important tasks, and they do not perceive end-of-life situations as very important.

Providers - oncologists, gerontologists internal medicine specialists support the instructions in theMOH circular  since they no longer feel like "criminals" in the eyes of the law and, with the law behind them, they do not need to hide what they are doing. When a patient had decided on DNR many of them do not want to use a "technological imperative" to employ medical interventions simply because they are available.

Palliative organizations are very supportive since there is evidence that physicians and patients do not adequately discuss patients' preferences for end-of-life medical care. However, they  believe that the public has an interest in making decisions about the use of medical technology near the end of life and many fear that in the terminal stages of their lives, they will receive more medical care and less pain relief than they want.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
Hospital Directors	very supportive		strongly opposed
oncologists, gerontologists internal medicine specialists	very supportive		strongly opposed
Patients, Consumers
NGO Palliative organizations	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

Not relevant

Actors and influence

Government
Ministry of Health	very strong		none
Providers
Hospital Directors	very strong		none
oncologists, gerontologists internal medicine specialists	very strong		none
Patients, Consumers
NGO Palliative organizations	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

In March 2008, the MOH published a circular with instructions for implementing the 2006 Dying Patient Act. This was necessary in order to list the procedures for the practical application of this law, which is exceedingly complex and requires instruction, detailed definitions and the development of user-friendly forms.

However, successful implementation is dependent on the cooperation of Hospital Directors who need to set up a committee that will develop practical procedures in order to implement the directives.

The senior physicians at the hospitals have also a critical role in suggesting to their patients to write advanced directives, and thus they affect the implementation of the law. Without their leadership and responsibility for the process, other physicians will not feel responsible for it, will not discuss the patient's wills and will not suggest to the patients and their families to make decisions about their own life.  

Monitoring and evaluation

At this early stage, the policy does not  include an element of monitoring or evaluation.

Expected outcome

The circular aims to cope with barriers to implementation of the law by simplifying and explicating it.

A practical expectation might be that a) More citizens, of all ages will write advance directives and living wills. b) Hospital Directors will cooperate with the directions, and take  responsibility for the implementation of the procedures that had been developed in their hospitals. C) More physicians will adequately discuss patients' preferences for end-of-life medical care c) more advance directives documents will be adaquatly honored by the medical staff  d) the care for critically ill individuals with chronic diseases will be improved fundamentaly.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

Quality of health care services: Quality is expected to improve since this law respects a person's right to make decisions regarding his or her life and quality of life. It will also improve the quality of life of patients' family members, who sometimes struggle to maintain the patient's dignity at the end of life.

Equity:  Equity is also expected to improve, because all patients are now entitled to make decisions regarding their own lives, while in the past, only people who knew how to speak up for themselves, most of them educated or well connected, could participate in making decisions about their own life, take legal action or fight for their opinions.

Cost efficiency:  Implementation of the law has no cost implications.

References

Sources of Information

• Ministry of Health Director General Directive no. 7/08, March 2008
• Bentur N. The attitudes of physicians toward the new "Dying Patient Act" enacted in Israel. Accepted to the "American Journal of hospice and palliative medicine", 2008      
• Steinberg A, Sprung CL. The Dying Patient Act, 2005: Israeli innovative legislation, IMAJ 2007;  9: 550-552.

Reform formerly reported in

End of Life Care Policy Process Stages: Policy Paper

Author/s and/or contributors to this survey

Dr Netta Bentur

Senior Researcher, Myers-JDC-Brookdale Institute

Suggested citation for this online article

Dr Netta Bentur. "End of life care policy". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/is/a11/2