The Health Ministry has finally changed bureaucratic regulations that induced the health funds to insist terminal patients unable to eat on their own undergo surgery to insert a gastric feeding tube into the stomach instead of just a nasogastric tube, easily threaded from a nostril into the stomach. Ministry Director-General Prof. Avi Yisraeli said in a decision in effect since January 1 that "historical reasons" - rather than purely medical ones - had caused different payment criteria. These depended on whether the patient (usually elderly) had a much-less-invasive nasogastric tube (zonda) for feeding or a percutaneous endoscopic gastrostomy (PEG) tube, requiring a surgical incision to connect the tube to the stomach. The issue was raised in 2007 by Prof. Mark Clarfield, chief of geriatrics at Soroka University Medical Center in Beersheba, in a Hebrew book called Le'echol Oh Lahdol: Hazana Besof Hahayim ("Feed or Cease: Artificial Nutrition in End-of-Life Care"). Edited by Prof. Yaron Niv of the Rabin Medical Center-Beilinson Campus in Petah Tikva, the 150-page volume was reviewed in October that year by The Jerusalem Post, which highlighted the conflicts of interest involved in unnecessary gastrostomy. Clarfield noted in his chapter that the decision on what type of feeding was used - which seems simple and results from unique anatomical considerations in each patient - "involves a whole political system." For historical reasons, he contended, "various types of feeding are found on the two sides of a line that separates responsibility of the Health Ministry (codes or 'kodim,' in Hebrew) and the health funds. "Since treatment of most patients requiring geriatric nursing care is not in the basket of health services, families must subsidize care in institutions. When feeding is by nasogastric tube, that makes them complex nursing cases for which the health funds are responsible, and since the insurers have a say in how patients are treated, a conflict of interest results and non-medical considerations interfere with care," Clarfield maintained. But now, the way such patients are fed will not determine who pays for their hospitalization, said Yisraeli. Both those with a nasogastric tube and a PEG have come under the ministry's funding responsibility (with participation by families). Niv, who edited the book, told the Post that he was very pleased by the ministry's policy change. "Now the decision for PEG or nasogastric tube will be based on medical and ethical arguments and not on financial and administrative causes," he said. "PEG - not an innocent, non-invasive action - is a surgical procedure that can cause complications and even death. A nasogastric tube insertion is easy and can be done by a nurse. There is no significant difference between these two procedures ... and PEG is no better than nasogastric tube for improvement of the clinical and nutritional status," Niv stressed. "Thus, the Health Ministry's decision is really a milestone in clinical sanity and better for the person at the end of life," he said. Gastrostomy, Clarfield wrote in the volume, was permitted in a patient defined as si'udi (requiring nursing care), which was funded from the ministry budget. However, the use of a nasogastric tube boosted a patient immediately to the category of si'udi murcav (complex nursing), even when there was no change in his medical condition. According to the National Health Insurance Law, responsibility for treatment of a complex nursing patient rested with the health funds via the basket of health services. This division of authority, he declared, interfered with treatment of patients. "As a result, the health funds had the incentive to ensure that the nasogastric tube was removed and replaced by a gastrostomy even when there were no medical grounds for doing so," the geriatrician said. In addition, the ministry, which owns government hospitals, was put in the position of deciding to use a nasogastric tube merely so the health funds would have to pay for the patient's care, Clarfield wrote. And geriatric nursing departments sometimes preferred to use gastrostomy so as "not to lose" patients to departments of complex nursing. In late 2007, there were some 18,000 geriatric nursing beds in the country. Of these, 6,800 were privately funded and about 11,200 subsidized by a limited ministry budget. A bed is allocated when the ministry has enough budget for it and when a patient or his immediate family can prove that the costs of care in an institution are too high and their income too low to cover all expenses. An additional 1,000 beds are for complex nursing patients and funded by the health funds. Since treatment of most patients requiring geriatric nursing care is not in the basket of health services, their families must subsidize care in institutions. Clarfield, who formerly was the ministry official in charge of geriatrics, wrote that until now, when a Health Ministry team arrived for inspection in a certain geriatric nursing institution, the medical team was liable to "prepare" patients by removing their feeding tubes so the inspectors would not demand that they be transferred to a complex nursing department. Immediately upon departure of the ministry team, the patients were reintubated. Under the new regulations, this will cease.