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Development of Palliative Care in Israel and the Rising Status of the Clinical Nurse Specialist

Livneh, Jessica PhD, RN

Journal of Pediatric Hematology/Oncology: October 2011 - Volume 33 - Issue - p S157–S158
doi: 10.1097/MPH.0b013e318230e22f

It was in 2009 that the Ministry of Health in Israel issued unique recognition for registered nurses. Palliative Care has been recognized as a specialty for nurses, working already in different clinical specialties. By obtaining the qualification of a Clinical Nurse Specialist in Palliative Care, nurses obtained the de jure status of what they have been doing for years de facto.

Cancer Center—The Sheba Medical Center, Oncology Out-Patient Clinic, Tel Hashomer, Israel

The author declares no conflict of interest.

Reprints: Jessica Livneh, PhD, RN, Cancer Center—The Sheba Medical Center, Oncology Out-Patient Clinic, Tel Hashomer, Israel 52621 (e-mail:

Received August 2, 2011

Accepted August 2, 2011

On May 14th 2009, Prof. Avi Israeli, the Chief Executive Officer of the Ministry of Health, signed an injunction recognizing palliative care as a specialty for nurses.1 This action brought an end to the long struggle led by Dr Shoshana Riba, Head Nurse and Chief Nursing Officer to create a new professional status for nurses in Israel.

The success of the nursing division to get approval for this important decision was largely due to the fact that for 2 decades nurses were already working as clinical specialists treating dying cancer patients.

In 1983, The Israeli Cancer Association opened the first hospice in Israel at the Sheba Medical Centre. This event marked the beginning of the development of palliative care services both in hospitals and the community enabling professional support and care for patients and families who chose either to be admitted to a specialty facility or to remain at home with their families. The development of these services was accompanied by intensive professional activity.

The development of these services would not have been possible without the nurses who played a pivotal role, taking an active part in patient's daily care, including pain control, while alleviating the patient's anxiety and accompanying patients and their families through the different stages at the end of life.

Initially this was the first acknowledgment from the medical field for the important role of the palliative nurse. Palliative care nurses were devoted to the terminal patient and his immediate needs. This often meant using both learnt and intuitive skills to find alternative, sometimes unconventional ways to help the patients and their families. Often nurses had to overcome conservative and rigid attitudes shared by healthcare professionals and laymen.

The nurses who chose to work in these units showed compassion and competence in their demanding and challenging roles. They proved that with courage, faith, determination, and perseverance even the healthcare system can be revolutionized.

And revolution was indeed occurring, creating fundamental changes in Israeli society.

The debate about how dying patients should be treated was discussed by the entire spectrum of society, from the general public to the press as well as by professionals and public figures.

Finally a detailed and comprehensive law regulating the treatment of the dying patient was enacted on December 6th, 2006, by the Knesset (Israeli Parliament). The legislation was the product of intensive professional and public debates and discussions. On February 20th, 2000, a national committee was appointed by the Ministry of Health to enact a law regulating all matters concerning the dying patient. The committee comprised 59 individuals, all specialists and high ranking professionals in their fields, representing the entire range of relevant views. This multidisciplinary committee was divided into 4 subcommittees:

  • Medical/Scientific, which included physicians, nurses, social workers, and sociologists
  • Philosophical/Ethical, including a philosopher, medical ethicist, and clergy from several religions
  • Legal, including judges, lawyers, professors of law, and the legal advisors of the relevant ministries
  • In addition, a subcommittee representing Jewish law, including rabbis and physicians who were well versed in matters of medicine and Jewish Law was also formed

These subcommittees were successful in reaching a wide consensus on almost all issues related to the dying patient, despite the inherent complexity of the subject, and despite the deep differences in opinion between members of the committee.2

Parallel to all these activities, Dr Shoshana Riba, Head Nurse, and Chief Nursing Officer led the process to approve palliative care as a clinical specialty for nurses. Such an approval was one of the conditions needed to create a new professional status for nurses in Israel—the clinical nurse specialist.

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The American Nurses Association defines the clinical nurse specialist (CNS)3:

As clinical experts who practice within a specialty area, treating and managing the health concerns of patients and populations. The CNSs practice autonomously and integrate knowledge of disease and medical treatments into assessment, diagnosis, and treatment of patients' illnesses. The CNSs provide leadership of multidisciplinary groups in designing and implementing innovative alternative solutions that address system problems and/or patient care issues. In many jurisdictions, CNSs as direct care providers, perform comprehensive health assessments, develop differential diagnoses, and may have prescriptive authority. Prescriptive authority allows them to provide pharmacologic and nonpharmacologic treatments and order diagnostic and laboratory tests in addressing and managing specialty health problems of patients and populations. CNSs serve as patient advocates, consultants, and researchers in various settings.

This process took many years and was accompanied by intensive professional and public debate. Furthermore, there was much opposition to the definition of the nurse as a CNS and many attempts to limit their medical activities. The majority of the opposition came from medical professionals. Despite the opposition, 2 decades of professional excellence, devotion, and courage of palliative care nurses was finally acknowledged when palliative care nursing was the first area of expertise in which nurses in Israel could achieve the status of CNS. Today, the process of recognizing nurses from other areas of expertise, such as diabetes, is on its way.

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Despite all these advances in the acknowledgment of the CNS, there are many cancer patients who do not receive adequate palliative care.

There are several reasons for this, including understaffed hospice home units and inadequate number of beds in Oncology and Hospice wards.4

In an effort to implement palliative care more widely in the Israeli Health Care System, and despite the limitations mentioned above, on July 12th, 2009, the general administration of the Ministry of Health published a circular requiring the development of palliative care services in general hospitals, community services, and nursing homes. The institutions have to make all the arrangement for the provision of palliative care services within 4 years of the issue of this circular and to report to the Ministry of Health (State of Israel Ministry of Health, Circular of the General Administration No. 30/09).5,6

Although the CNS concept was approved by the Ministry of Health, it has still not been fully incorporated. Currently the recognition of CNS is given only to nurses who meet the definition of a “Parent of the Profession” nurse, which refers to those whose professional work in palliative care was acknowledged before the approval of the injunction recognizing palliative care as a specialty for nurses (State of Israel Ministry of Health, Circular of the Nursing Division No. 79). Two Israeli universities are currently developing programs for training the future generations of CNS and these courses are due to open next year.

To date, all CNSs in Israel have received their training abroad or on special training programs such as the Macmillan Project, which took place between 1993 and 1995 and was held under the auspices of the Nursing Division of the Israeli Ministry of Health and England's Macmillan Cancer Relief. In this particular project, Israeli nurses were sent to England to be trained in palliative care. One of the groups of nurses sent comprised nursing educators who were trained how to incorporate topics such as death and dying into the nursing education given here in nursing schools.

Nurses also attended seminars, courses, and “continuing education” programs organized by professional organizations but most of the training was done by the “apprentice” method.

Recognition of palliative care as an area for clinical specialty is required to develop formal academic programs that are supervised, and include licensing examinations at the end. Such programs are essential to assure the proper training required to administer good palliative care.

The injunction, which recognizes palliative care as a specialty for nurses acknowledges the important role nurses played in the development of palliative care in Israel. But even more important, in this era when technology frequently distances the patient from the caregiver, this injunction ensures a specialty, which provides genuine human contact. As a nurse I feel that this is essence of our profession.

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1. State of Israel. Injunction to declare Palliative Care as Specialty, 2009. (Medinat Israel. Rashumot. Kovez Hatakanot 6778, May 14th 2009) Zav Briut Ha'am (Kviat mumhiut betipul Tomech) Ha'tashsat, 2009)
2. Steinberg A, Sprung CL. The dying patient act, 2005: Israeli Innovative Legislation. Medical Ethics. 2007;9:550–552
3. American association of Colleges of Nursing. AACN Statement of Support for Clinical Nurse Specialist. Approved March 13, 2006
4. Bentur N. Resnizky S. Shnoor Y. Palliative care and Hospice Services in Israel. Meyers-JDC-Brookdaele Institute, August 2005
5. State of Israel. Ministry of Health. Circular of the General Administration. No. 30/09 Issue: Operation of Palliative Care Services (Hospice) in the community, general hospitals and nursing institution. July 12th, 2009. (Medinat Israel. Misrad Habriut. Hozer Hamenahel Haklali. Mis. 30/09. Benose: Hafalat Sherut Palliative (Hospice) Bakehilah, Bebet-Holim Klali Ubemossad siudi 12/9/2009)
6. State of Israel. Ministry of Health. Circular of the Nursing Division No. 79 Issue: Nurse Specialist in Palliative care. May 18th 2009

palliative care; Israel; clinical nurse specialist

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