http://elynsgroup.com Copyright: © 2017 Greenberger C, et al. Open Access Case Report J Pall Car Nur Journal of Palliative Care and Nursing Page 1 of 3 End-of-Life in Israel: A Case Report Chaya Greenberger 1* and Anat Romem 2 1 Faculty of Life and Health Sciences, Jerusalem College of Technology, 92/2 MitzpeNevo Street Maale Adumim, Israel 2 Department of Nursing, Jerusalem College of Technology, 7 Bet Hadefus Street, Jerusalem Introduction Our palliative care team, working within the framework of an oncology ward in a major Israeli hospital, recently cared for a 73-year-old married male with advanced stage liver cancer. A retired engineer and father of two grown children, professionals, he and his family are Jewish by faith and members of the Conservative/ Masorati (Israeli branch) movement, one of the three main streams of Judaism. Members of this movement, as opposed to that of Jewish Orthodoxy, perceive Judaism as an evolving religion; canonized texts may be reinterpreted in order to adapt practice to different life contexts [1,2]. In the context of end-of-life, for example, mainstream Jewish Orthodoxy would prohibit withdrawal of mechanical ventilation if it resulted in an individual’s immediate demise (which is tantamount to hastening death and prohibited according to medieval codes of law). A significant number of conservative rabbinical authorities with a broad following, would permit it since the individual is being kept alive by technological means and its withdrawal is merely removing the impediment to death [3–5]. The aim of this discourse is to present the approach our team took to treating and nourishing this patient in the specific context of his faith, illness state, personal wishes, the concerns of his family, and the Israel Dying Patient Act, 2005 [6,7]. The latter stipulates the legalities of care at end-of-life (i.e., the point at which the estimated life span is six months) by which all the country’s health facilities must abide. The Act was drafted by a committee of 59 experts representing all sectors of Israeli society in terms of culture, religion, and profession. It reflects the vector of consensus regarding issues of care for the dying without the dissenting opinions. For the most part, the law is in line with the mainstream Jewish Orthodox position [8,9]. The Case Our patient presented at the emergency department of the medical center with abdominal pain (exacerbated after meals), profound weakness, constipation, and a ten-pound weight loss incurred over the past month. The CT scan that he had undergone one and a half weeks prior to his arrival revealed multiple suspicious nodules in the liver. His wife reported that up until the last two weeks her husband was still going to work. He then experienced a sudden deterioration; stopped eating due to poor appetite and the discomfort it caused, became bed bound, and was unable to perform any activities of daily living. Home- care nurses administered intravenous fluids (500 cc/day) in order to maintain hydration. After admission to the Oncology ward, our patient underwent a biopsy which confirmed the diagnosis and poor prognosis. As is often the case with liver cancer, the disease process was discovered in our patient at a very late stage. The liver is a central multi-tasked vital body organ; its failure, in this case, was due to the presence of substantial malignant tumor tissue which was incompatible with life [10–12]. A port-a-cath was inserted for the administration of chemotherapy scheduled for the following week. While hospitalized, the patient ate only small morsels of food and his wife requested that a feeding tube be inserted. Poor appetite, nausea, and sense of fullness are classic symptoms of this cancer. The patient was evaluated by a psychiatrist and found competent to make his own decisions; he initially agreed to small doses of chemotherapy and minimal oral feeding. Within a few days, however, he deteriorated and at that point refused both treatment and any form of nourishment, including tube feeding. Our patient was then transferred to a hospice where he died six days later. Retrospective evaluation of this case, as it was reported in the medical records and recalled by the care team, uncovers several lacunae. Before addressing these and their import to the analysis of the case, its legal and ethical context as reflected in the Dying Patient Act, 2005 will be presented. The Israel Dying Patient Act, 2005 The Act opens with two essential premises: 1) individuals at end-of-life want to continue to live, and 2) individuals at end-of- life are competent to make their own decisions. These premises have practical import. With respect to the first, it implies that care must be taken to neutralize overt or covert pressure, either from the care provider or family sources, which might lead the individual to decline treatment for the prolongation of life. This premise not only directly protects the sanctity of life but also indirectly protects the individual’s freedom to exercise his/her autonomy. The second premise directly protects autonomy; it is waived only if an appropriate health professional attests to the individual’s lack of competence to make a specific end-of-life decision. The first premise is waived if the individual makes it clear that he/she does not want to continue to live or has explicated this wish in an advanced directive. In such a case, and in the presence of physical or psychological suffering, the Act permits withholding, and in most cases, withdrawing life-prolonging treatment (e.g. surgical procedures, dialysis, chemotherapy); mechanical ventilation need not to be initiated [6,7,13]. For the sake of comparison, it is important to point out the relevant Recommendation of the Council of Europe No. 1418/1999 on the “Protection of the human rights and dignity of the terminally ill and the dying,” which were reiterated in the Recommendations of 2009: “…in the event where no previous expression of the patient’s will is available the right to life shall not be breached. To ensure their right to life shall not be breached, a catalogue must be prepared of therapeutic procedures that must be provided under any circumstances and that must not be neglected” [14]. Although Israel is not a member of this council, its Act stipulates as mandatory (to ensure that their right to life shall not be breached), the ministering of basic care, which includes nutrition and hydration, oral or enteral during the end-of-life period (six months, as delineated by the law). These are perceived Received Date: September 13, 2016, Accepted Date: February 20, 2017, Published Date: February 28, 2017. *Corresponding author: Chaya Greenberger, Faculty of Life and Health Sciences, Jerusalem College of Technology, 92/2 Mitzpe Nevo Street Maale Adumim, Israel 98411, Tel: 972-528-119-420; Fax: 972-253-552-70; E-mail: greenber@jct.ac.il