Today in Israel, as in most of the world, hospice and palliative care are readily available for most, if not quite all, patients who require them. As a form of specialist treatment, the two were conceived together back in the 1960s, and initially developed hand in hand. They are now recognized worldwide as distinct branches of medical therapeutics. Institutions dedicated to providing loving care for terminally ill patients have long existed in the western world, but the modern hospice movement, with palliative care as an integral aspect of it, were the brainchild of a most remarkable woman, Cicely Saunders. Later showered with honors from around the world, she was made a Dame – equivalent to a knighthood – by the Queen in 1979, and was awarded the exclusive Order of Merit a decade later. The origins of today's hospice movement and palliative care have a deep Jewish connection. At a major conference held in London in 1980, Dame Cicely described how she came to found the world's first modern hospice – St Christopher's. Appointed in 1947 as a social worker by St Thomas', the famous teaching hospital in the center of London, in the first ward she entered she met David Tasma, a Jewish refugee from Warsaw. “I knew then the truth that he was dying,” she said, “which he did not. So I followed him up and I waited, and when he was admitted to another hospital it was in fact I who finally told him. The foundation of St Christopher's is how we coped with that truth together. “He needed skills which were not then available, but still more he needed a sense of belonging and somehow to find meaning. And as he remembered his grandfather, the rabbi, he made peace with the God of his fathers. When he died he left a £500 founding gift, “to be a window in your home.” It took her a full 20 years to enlarge that initial £500 to a sum sufficient to construct, equip, staff and open St Christopher's, but open it did in 1967. In memory of David Tasma, Dame Cicely, a committed Christian, insisted on calling that 1980 conference its bar mitzvah – taking place as it did just 13 years after the opening of her hospice. Here I must admit that I played a small part in that conference, and in the subsequent nurturing of palliative care here in Israel. In 1980, I was a civil servant in the UK's Department of Health. Dame Cicely approached the government for assistance in organizing her bar mitzvah conference, and it fell to me to help plan details, arrange for a health minister to chair the event, and finally to edit and manage the publication of the proceedings under the title “Hospice: the living idea.” Years later, when I had moved on to one of Britain's leading cancer charities, now known as Macmillan Cancer Support, I helped arrange for a group of Israeli nurses to go over to the UK and participate in a palliative care training program at the world-famous Royal Marsden Hospital. The idea of this project had been readily endorsed by my own boss at Macmillan, and I remember coming over to Israel to discuss it with Israel's then-health minister, Haim Ramon, and the enthusiasm with which he authorized it. Hospice care is intended for patients suffering from a terminal illness when curative treatment is no longer possible. It is an holistic approach to dealing with the physical, emotional and spiritual needs of the patient through a combination of medical, nursing and psychosocial care. By alleviating pain and other distressing symptoms, it is designed to provide the terminally ill patient with as fulfilling a quality of life as possible, and eventually a peaceful death without either accelerating or postponing it. These principles underlie palliative care as well, but nowadays palliative casts its net wider than the terminally ill, aiming to manage symptoms and enhance comfort and quality of life for patients at any stage of life. It is normally introduced when the disease is considered beyond treatment, but it can be delivered alongside aggressive therapies and even, in some cases, together with therapies aimed at cure. Israel's first hospice, located within Sheba Medical Center, was opened in 1983. Today there are seven which offer both in-patient and home hospice care services, and palliative care nursing is well established. All the same, recent research by Prof. Dena Schulman-Green shows that there is much room for improvement. For the past few years Schulman-Green has been working in Israel to strengthen the development of palliative care. “I want everyone in Israel and everywhere to have access to quality palliative care when they need it,” she says, “so that's the ultimate vision. But that means that patients and families need to know what it is and to ask for it. And clinicians need to know to offer it and how to provide it.” Schulman-Green has spent her career seeking to improve the lives of patients with serious, chronic illnesses. The holistic approach of palliative care integrates all aspects of care through a multidisciplinary team that works as an extra layer of support, in partnership with the patient's other providers and family. Ideally, palliative care is integrated early in the course of a serious, life-limiting illness. Schulman-Green supports the inclusion of regular palliative care training into the nurse education curriculum, and the full integration of palliative care into Israel's health care system. Recent developments have assisted the expansion of palliative care in Israel. The Dying Patient Law in 2005 led to a directive policy statement in 2009, and in the same year palliative clinical nurse specialists were recognized. This was followed by the introduction of periodical inspection by the Health Ministry and the National Plan in 2016. The National Plan is the result of work carried out in 2015, following a request from then-director general of the Health Ministry Moshe Bar Siman-Tov. The program was written by a steering committee and six working teams, which included representatives from “Tamicha,” the Israel Association of Palliative Care, an organization devoted to assisting professionals providing palliative care in hospices and generally. They offer support, training sessions and conferences, and campaign for palliative care to be fully included in the health baskets of the medical insurance companies. The worldwide struggle for palliative care to be recognized as a medical specialty has been long, and Israel has had to fight as hard as any country. The 29-year battle was led by Dr. Michaela Berkowitz, the chair of Israel's Palliative Medical Society and head of the palliative care department at Sheba. The long endeavor was crowned with success in May 2012, when palliative medicine became a recognized subspecialty in Israel. Even so, a further battle is being waged to ensure that appropriate training modules are included in both nurse and medical training curriculums. Israeli nurse education is ahead – it incorporates a palliative care module in many post-basic courses. Medical education has some way to go. A limited university level palliative care education program is available for 130 physicians, and various palliative care studies for medical students are offered at four faculties of medicine, but the holistic principles underlying palliative medicine and care need to be integrated into the education provided in Israel to all medical students as a matter of course. This is already the case in Britain, although not yet fully in the US. It is not widely known that in 1996 a Middle East Cancer Consortium (MECC) was established through an official agreement of the ministries of health of Cyprus, Egypt, Israel, Jordan, and the Palestinian Authority. Turkey officially joined the Consortium in 2004. The MECC has established academic-based medical programs that bring together scientists, academicians and clinical professionals from its member countries, joined by medical personnel from many others. Since its inception, one of MECC's major activities has been the Palliative Care Project, dedicated to promoting the availability of quality palliative care resources to patients and their families throughout the Middle East. MECC's motto is: “Respect all people, collaborate in fighting human suffering, and help build a bridge for better understanding among all.” Saunders was a fervent opponent of euthanasia because she argued, from long and deep personal experience, that effective pain control is possible, that distressing symptoms can be effectively relieved, and that terminally ill patients can die peacefully and in dignity. People gravitated towards euthanasia, she believed, because knowledge of what palliative care could achieve for those suffering terminal illnesses was not well enough known, nor widely enough available. Towards the end of her life she herself developed breast cancer. She died in 2005 at the age of 87 in her beloved St. Christopher's Hospice.
