National Cancer Institut

Palliative care in the reg on rep

resented

Middle East 

Cancer Consortium

by the

CYPRUS

EGYPT

ISRAEL

JORDAN

TURKEY

PALESTINIAN AUTHORITY

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health

i

Amanda Bingley & David Clark

Palliative Care Developments 

in the Region Represented by 

the Middle East Cancer Consortium:

A Review and Comparative Analysis

National Cancer Institute MECC Palliative Care Monograph 

We would like to thank the Middle East Cancer Consortium 

(MECC) and the Office of International Affairs, National 

Cancer Institute (NCI), Bethesda, MD, USA, for supporting 

the publication of this review and providing funds for the 

preceding reports. In particular, we are indebted to Dr. Joe 

Harford, Office of International Affairs, NCI, and Professor 

Michael Silbermann, MD, Executive Director of MECC, for 

their ongoing encouragement and enthusiasm for this work. 

This review would not have been possible without the cooperation and goodwill of all those people in the MECC 

region--health care professionals, academics, administrators 

and volunteers--who kindly agreed to be interviewed, 

dedicated time and resources to our field visits, commented 

on earlier reports, and continue to support our endeavor. We 

are especially grateful to the following people within each 

individual country and authority, who either facilitated key 

aspects of data collection or coordinated interviews with 

many palliative care professionals during our field work:

Dr. Sophia Pantekhi at the Arodaphousa Hospice, 

Cyprus Anti-Cancer Society and Jane Kakas at 

PA.SY.KAF (Cyprus);

Professor Nagwa Elkateb at the National Cancer 

Institute, Cairo (Egypt);

Dr. Nathan Cherny at Cancer Pain and Palliative 

Care Services, Sha’are Zedek Medical Centre, Jerusalem; Dr. Amitai Oberman and Mali Szlaifer at the 

Home Hospice in the Valleys, Nazareth; Dr. Yoram 

Singer at Negev Palliative Care Services, Beersheba; 

Dr. Michaela Bercovitch and Dr. Alexander Waller at 

Tel Hashomer Hospice, Tel Aviv (Israel); 

Ahmad Al-Khateib and Professor Amal Bandak at 

King Hussein Cancer Centre, Amman; Dr. Bassam 

Hijawi at the Ministry of Health, Amman; and Rana 

Hammad at Al Malath Hospice, Amman (Jordan); 

Carol El-Jabari at the Patient’s Friends Society, East 

Jerusalem; Dr. Khamis Najjar at European Gaza 

Hospital; Dr. Abdel Razzaq Salhab at Beit Jala Hospital (Palestinian Authority);

Professor Serdar Erdine at Istanbul University Faculty of Medicine; Professor Ozgur Ozyilkan at Baskent 

University Faculty of Medicine, Ankara; Professor 

Yasemin Oguz at Ankara University (Turkey).

We are also hugely indebted to our colleagues at the 

International Observatory on End of Life Care, Lancaster 

University, for their technical help, general guidance and 

unique perspective on the global mapping of palliative care 

developments – in particular Michael Wright, Anthony 

Greenwood, Tom Lynch, Lynne Hargreaves, and Justin Wood.

All errors of commission or omission are, of course, our own.

CITATION

Suggested citation for this monograph:

Bingley A, Clark D. Palliative care in the region represented 

by the Middle East Cancer Consortium: a review and 

comparative analysis. 

Citation for a chapter should also include the chapter title. 

All material in this report is in the public domain and may 

be reproduced or copied without permission: citation as to 

source, however, is appreciated.

FRONT COVER PICTURES

Cyprus: 7th century Byzantine castle in Pathos, ruined by 

earthquake in 1222

Egypt: Menkaure’s Pyramid on Giza Plateau

Jordan: Petra, an impressive façade carved into the rock 

more than 2000 years ago

Israel: Jaffa Port, a seaport at least 3200 years old

Turkey: Celsus Library in Ephesus, completed in AD 135

Palestinian Authority: Hisham Palace, Jericho (West Bank)

Acknowledgments

National Cancer Institute v MECC Palliative Care Monograph 

Acknowledgments iii

Preface vii

Executive Summary ix

Chapter 1. Introduction 1

Chapter 2. A Comparative Analysis of Palliative Care Provision in the MECC Region 3

Chapter 3. The MECC Region in Context: 

Socio-Demography, Health Care Systems, Epidemiology, and Public Health 15

Chapter 4. Palliative Care in Cyprus 27

Chapter 5. Palliative Care in Egypt 37

Chapter 6. Palliative Care in Israel 41

Chapter 7. Palliative Care in Jordan 83

Chapter 8. Palliative Care in the Palestinian Authority 97

Chapter 9. Palliative Care in Turkey 105

Appendix 1. Example of the IOELC questionnaire sent to participants 

for MECC country report project 2005 115

Appendix 2. IOELC interview template as used for MECC country report project 2005 117

Appendix 3. Comparison of the political economies of Cyprus, Egypt, Israel, Jordan,

Palestinian Authority, and Turkey 119

Table of Contents

National Cancer Institute vii MECC Palliative Care Monograph 

Arguably, the three most important features of cancer in 

low- and medium-resource settings are “late presentation, late presentation, and late presentation.” The fact 

that cancer often presents at an advanced stage means 

that curative therapeutic approaches are less effective and 

that the need for palliative care is all the more pressing. 

The Middle East Cancer Consortium (www.mecc.cancer.

gov) was established in 1996, and its first regional project involved cancer registries that documented not only 

the incidence of various cancers but also the stage of the 

disease at diagnosis. MECC’s second regional project 

revolves around a response to this information aimed at 

building capacity for palliative care in the region. To do 

so effectively, it is necessary to establish a baseline of 

information on palliative care services in the jurisdictions 

covered by MECC and to examine barriers to delivery 

of palliative care that might exist. Toward this end the 

U.S. National Cancer Institute (NCI), a major sponsor of 

MECC, commissioned the International Observatory on 

End of Life Care (based at Lancaster University, UK) to 

conduct the study described in this monograph. 

The results of this survey clearly indicate the necessity 

to expand and improve palliative care services for patients suffering from physical as well as psychosocial 

and spiritual distress as a result of a cancer diagnosis. 

While many palliative care services in the region focus 

on cancer, it is evident that these services can also aid patients with other life-threatening diseases as well. MECC 

has already begun to address the issue of palliative care 

by organizing several regional training and educational 

activities aimed at capacity-building. Moreover, MECC 

seeks to build a consensus among its members to establish 

standards for palliative care services in the region. This 

sort of consensus building has been previously utilized 

within MECC to develop standards for cancer registry 

(www.mecc.cancer.gov/standards.html) that have enabled 

comparisons of cancer incidence rates in the region as 

detailed in a previous monograph published by the NCI 

(1). Despite the difficulties of working in the Middle East, 

MECC has shown that well-meaning individuals can put 

aside political differences and work collectively for the 

good of all the people in the region.

We applaud the work done by the International Observatory on End of Life Care, and we are confident that it will 

prove to be a valuable resource for planning and implementing activities in the Middle East aimed to improve 

palliative care.

Michael Silbermann, M.D., Executive Director, MECC

Joe B. Harford, Ph.D., Director, Office of International 

Affairs, NCI

REFERENCE

1. Freedman LS, Edwards BK, Ries LAG, Young JL (eds.) Cancer 

Incidence in Four Member Countries (Cyprus, Egypt, Israel, and 

Jordan) of the Middle East Cancer Consortium (MECC) Compared 

with US SEER. National Cancer Institute, 2006. NIH Pub. No. 

06-5873. Bethesda, MD.

Preface

National Cancer Institute ix MECC Palliative Care Monograph 

Palliative care developments in the region represented 

by the Middle East Cancer Consortium provides the first 

comprehensive review and comparative analysis of palliative care in MECC members Cyprus, Egypt, Israel, 

Jordan, Palestinian Authority, and Turkey. The monograph 

describes palliative care services both across the region 

and within individual MECC members in terms of the 

numbers of patients, coverage, estimated workforce, patient capacity, services per million population, and type 

and range of services. Specific palliative care service data 

were collected throughout the year 2005.

The review includes comparative population data and epidemiology. It describes the different health care systems, 

the funding of general and palliative care services, the 

availability of opioids, opioid-related legislation, as well 

as relevant education and training programs. It outlines 

the common barriers to palliative care service development 

in the MECC region and lists future plans and goals as 

identified by key health professionals. All figures relating to socio-demographic and epidemiological data are 

accurate as of January 2007.

Major findings across the region

represented by MECC members in

2005

A total of 69 palliative care services were identified in 

the region represented by MECC: Cyprus, Egypt, Israel, 

Jordan, Palestinian Authority, and Turkey, covering a 

population of 162.9 million. 

The primary causes of death across the MECC region are 

cardio-vascular and heart diseases. Cancer is the second 

commonest cause of disease-related death. Lung cancer 

is the commonest in men, breast cancer the commonest 

in women. Colorectal cancer is the second commonest in 

both men and women. The highest percentage of cancer 

deaths per population is found in Israel.

Palliative care provision is estimated at 2.34 services per 

million people. An average 95% of all palliative care in 

the region is specifically set up for cancer patients. At a 

local level, while some MECC members provide care for 

cancer patients only, in others there is limited provision for 

patients with other illnesses such as AIDS, heart failure, 

and neurological conditions. There is very limited pediatric 

palliative care in Israel and Jordan. No dedicated pediatric 

services exist elsewhere in the MECC region.

Patient capacity for palliative care is estimated at around 

168 inpatient beds in either freestanding hospice units or 

specialist hospital units and around 653 home care patients 

at any one time. These figures are subject to fluctuation, 

depending on funding, health care systems, state of development, and workforce capacity. Israel provides additional home care capacity via an extensive community 

medicine system. 

The estimated palliative care workforce is 434 health professionals. Trained volunteers are active in many services, 

particularly in not-for-profit home care services. Exact 

numbers of volunteers are unknown. 

Hospice and palliative care service coverage across the 

region and at a local level is markedly uneven. Cyprus and 

Israel have the most comprehensive coverage of dedicated 

palliative care for patients with cancer across significant 

numbers of their urban and rural populations; in Jordan 

and Egypt coverage is restricted to those people resident 

in or able to travel to capital cities with either limited 

charitable provision or support in specialist cancer centers; 

in Turkey and the Palestinian Authority, there is limited 

coverage in a few hospitals in major cities for patients 

treated in their specialist pain or oncology units; these 

patients are fortunate to have palliative care trained health 

professionals. 

Funding for palliative care services varies greatly across 

the region and locally. Israel has the most comprehensive 

funding: a mix of charitable, government, and insurance 

Executive Summary

MECC Palliative Care Review 2006
National Cancer Institute x MECC Palliative Care Monograph 

health care systems. Jordan has a similar mix of funding 

sources. Cyprus relies almost entirely on charitable funding, with government providing small annual subsidies. 

Egypt has one small charitable funded service; otherwise, 

as in Turkey and the Palestinian Authority, no dedicated 

funding sources exist beyond health care systems provided 

by government, limited private medical insurance, and one 

or two non-government organizations.

Opioids are available throughout the region. All member 

governments have passed legislation for the prescription 

of any appropriate strength of generic or proprietary medication. Quantities permitted per prescription vary from 3 

days up to 10 days supply. In Israel physicians may, in 

exceptional circumstances, prescribe 30 days supply. Opioid 

phobia leading to inadequate pain and symptom management is a continuing issue throughout the region, despite 

the introduction of training programs in Israel, Cyprus, and 

Jordan to educate health professionals, including pharmacists. Turkey has an ongoing publicity program to educate 

government, health professionals, and the public. 

Opioid consumption is highest in Israel and Cyprus, countries with the most developed specialist palliative care services; consumption is relatively low in Egypt, Jordan, and 

Turkey. The Palestinian Authority has limited and erratic 

access to a small range of opioid medications. Commonest 

opioid medications used in palliative care are reported to 

include codeine, pethidine, and generic morphine preparations. Since 2000 the International Narcotic Control Board 

records a trend for less prescribing of cheaper generic morphine and instead an increase in the use of more expensive 

proprietary opioids such as fentanyl, particularly in the 

form of transdermal patches.

Access to education and training in palliative care varies 

considerably across the MECC region. Interested health 

professionals take funding opportunities where possible to 

access specialist postgraduate programs or short seminars 

in other countries, particularly the US and UK. International conferences and seminars, including those organized 

by MECC, have proved supportive. Core training units in 

palliative care are available for nurses in Cyprus, Israel 

and Jordan, and for medical students in Israel. 

Barriers to palliative care service development are reported 

as: a lack of core education and training, limited resources 

with very little secure funding, and inadequate government 

legislation to include palliative care in the general health 

care system. 

Future plans include: service providers negotiating with 

governments to improve funding and support the expansion 

of inpatient and home care hospice services throughout the 

health care system as well as the introduction of palliative 

care as a medical specialty, part of core medical and nursing curricula education, and for all health professionals 

to have access to postgraduate training in palliative care. 

Health professionals across the region would also like to 

see palliative care extend to a greater range of illnesses at 

the end of life. 
National Cancer Institute 1 MECC Palliative Care Monograph 

In this monograph we present a summary, comparative 

analysis and review of palliative care provision in the 

geographic region of the Middle East. The review includes a set of complete reports, compiled in 2005, on 

palliative care services in: Cyprus, Egypt, Israel, Jordan, 

the Palestinian Authority and Turkey. 

The reports presented here are the result of a commission 

originating from the meeting of the Ministerial Steering 

Committee of the Middle East Cancer Consortium (MECC) 

held in May 2003 in Geneva. Several representatives expressed their desire to Tommy Thompson, then Secretary 

of the U.S. Department of Health and Human Services, 

for an increased emphasis on palliative care in the context 

of cancer treatment. As a result of this meeting, Secretary Thompson asked the National Cancer Institute (NCI), 

Bethesda, Maryland, USA, to take the lead in planning a 

workshop on palliative care to be held in the region. The 

purpose of the workshop was to raise awareness of the 

need for palliative care programs and to provide access 

to international experts in this field. The workshop took 

place in Larnaca, Cyprus, 2-3 February 2004 for representatives in palliative care from the members of MECC: 

Cyprus, Egypt, Israel, Jordan, the Palestinian Authority, 

and Turkey.

A pilot questionnaire survey of current hospice and palliative care service provision in the region represented 

by MECC was conducted prior to this meeting during 

December 2003–January 2004 by the International Observatory on End of Life Care (IOELC). The survey was 

commissioned by Dr. Joe Harford, Director of the Office 

of International Affairs of the NCI. 

Following the 2004 pilot survey IOELC was commissioned and funded by NCI to write full “country reports” 

on hospice and palliative care service provision for all the 

current members of MECC: Cyprus, Egypt, Israel, Jordan, 

the Palestinian Authority and Turkey. The IOELC “global 

analysis program” aims to map palliative care development, history and current services, country by country, 

around the world using a common template, which enables 

a comparative analysis. Country reports provide a resource 

for current and future policy, education and training, and 

service development. All these reports are compiled using a multi-method approach incorporating quantitative 

and qualitative analysis, including statistical information, 

questionnaires (see Appendix 1), ethnographic interviews 

and narrative accounts, referenced peer-reviewed and grey 

literature and photographs. Interviews are conducted 

wherever possible in each country with key health care 

professionals and others involved in service provision 

(see Appendix 2).

Methods of data collection

The MECC project involved data collection at all the 

levels outlined above. Meticulous attention was paid to 

validation and cross-referencing of all information. Building on the pilot study conducted in 2004, we were able to 

contact a total of 59 individuals in the region covered by 

MECC, who were interviewed individually or in group 

settings (including nine telephone interviews). A further 

nine individuals provided detailed information by email 

and questionnaires. Interviewees included key palliative 

care physicians, oncologists, surgeons, specialist nurses, 

nurses, social workers, psychologists, administrators, spiritual counselors, occupational therapists and volunteers. 

We visited a total of 14 palliative care units and hospices 

providing single or multiple services in Cyprus, Israel, 

Jordan and the Palestinian Authority. The range of services 

visited included home care, a mobile unit, inpatient hospice, inpatient hospital-based units, and oncology-based 

support services.

This work was completed in December 2005 with all reports 

accessible on the IOELC website (www.eolc-observatory.

net). Since posting, there has been a very significant number 

of “hits” on these reports, together with some extremely 

favorable comments received from individual colleagues 

in the region. A second MECC palliative care training 

meeting took place in Larnaca, Cyprus, 15-17 November 

2005 when participants had access to the presentation of 

findings from the IOELC report.

Chapter 1

Introduction:

Background, Aims, & Methods
Chapter 1 Introduction

National Cancer Institute 2 MECC Palliative Care Monograph 

This monograph contains a comprehensive synthesis of the 

project’s findings furthering the dissemination of MECC 

reports completed in December 2005. The production and 

publication of country reports has already been found to 

have provided an invaluable resource in raising awareness of palliative care issues in the areas represented by 

MECC. This publication aims to provide a baseline of 

information suitable for use in education and training, 

and to facilitate policy and service development.

Structure and contents of the

review

Following this introduction and background to the project, 

Chapter 2 provides a comprehensive and comparative 

analysis of palliative care provision across the region 

represented by MECC. Using additional tables to support our narrative approach we give an overview of the 

quantity, coverage, range and types of service provision 

currently operating, patterns of service development, levels 

of responsiveness of health service providers to palliative 

care needs and the perceived gaps in service provision. We 

compare four key issues of health policy and legislation 

that are considered to be crucial elements in the successful 

development of palliative care provision in the region: 

opioid availability, education and training of health care 

professionals and volunteers, financing of services, and 

different modes of access to palliative care. 

The final part of Chapter 2 focuses on service development from the perspectives of local activists and service 

providers. The discussion includes how different service 

providers address specific issues around multicultural 

needs, pediatric palliative care, and care for patients with 

diseases other than cancer. We provide a brief overview of 

the levels of published literature in the region from hospice, 

palliative care and related sources, including the “grey” 

literature (newsletters, reports, technical documents), and 

information from web-based sources. Chapter 2 concludes 

by identifying some key issues and recommendations 

identified by researchers and key palliative care professionals in the region. We note major indicators to success 

as well as describing the most significant obstacles and 

challenges. Reported future plans are outlined that aim to 

improve existing services or encourage the development 

of new services.

Chapter 3 places the region represented by MECC in 

context giving a sociodemographic overview including 

population patterns, epidemiology, public health and health 

care systems. Where possible we use 2004-2006 estimates 

with further updates accurate as of January 2007, from 

available data returns by national public health registries 

and international organizations. Appendix 3 gives a brief 

general outline of the region’s political and economic 

situation using various referenced sources providing information up to date at the time of writing.

The remaining chapters (4 to 9) present the six individual 

reports, compiled in 2005, on palliative care service provision in Cyprus, Egypt, Israel, Jordan, the Palestinian 

Authority and Turkey. Each report uses data collected 

from site visits, including narrative accounts and “oral 

histories” from interviews with key professionals, specific 

population, health care and epidemiological data, and documentary analysis. The reports cover all known individual 

palliative care and hospice services operational in 2005, 

and the range and type of provision offered. We include 

the history of services, locally and nationally, together 

with any specific plans for future development. 

In this context ”Middle East” denotes the geographic 

region and does not necessarily represent any particular 

political or economic grouping.

REFERENCES

1. The Middle East Cancer Consortium (MECC) was established in 

1996 with the aim of setting up population-based cancer registries for member countries in order to monitor cancer incidence, 

mortality and epidemiology, promote preventative health policy 

and encourage research and educational links (Silbermann and 

Young, 2005; Silbermann, 2001; Freedman et al., 2001). 

2. The members of MECC as of July 2005 are Cyprus, Egypt, Israel, 

Jordan, the Palestinian Authority and Turkey. Turkey joined MECC 

in June 2004. Since 2004 MECC has started an education and 

training program in palliative care with the aim of supporting the 

development and improvement of services and links nationally 

and internationally. http://mecc.cancer.gov/registry.html.

3. Clark D, Wright M, Bingley AF. A questionnaire survey on behalf 

of the National Cancer Institute in preparation for the workshop 

on Palliative Care in the Middle East: Larnaca, Cyprus: 2 -3 

February, 2004, Unpublished report: International Observatory 

on End of Life Care, Lancaster University, UK.
National Cancer Institute 3 MECC Palliative Care Monograph 

This chapter offers a comparative analysis of the development of some key aspects of hospice and palliative care 

provision in the MECC region. We examine the palliative 

care service provision across the region, including the 

range and type of current services and patterns of service 

development, levels of responsiveness of health service 

providers to palliative care needs, and the perceived gaps 

in service provision. We compare four aspects of health 

policy and legislation that are considered crucial elements 

in the successful development of palliative care provision: 

opioid availability, education and training of health care 

professionals and volunteers, financing of services, and 

modes of access to palliative care. We explore how different service providers address specific issues relating to 

multicultural needs, pediatric palliative care, older people 

at the end of life, and care for patients with diseases other 

than cancer. 

The chapter includes a short overview of the range of 

published literature in the region from hospice, palliative 

care and related sources, including the “grey” literature 

(e.g., newsletters, reports, and technical documents) and 

information from internet-based sources. We conclude by 

highlighting some key issues and recommendations identified by researchers and key palliative care professionals 

in the region. We note examples of success as well as the 

most significant obstacles and challenges. Reported future 

plans are outlined that aim to improve existing services 

or encourage the development of new services. 

Palliative care service provision

In 2005, we identified a total of 69 services across the 

region that are defined as dedicated to providing supportive 

Chapter 2

A Comparative Analysis of Palliative Care 

Provision in the MECC Region

Table 2.1. Adult and pediatric supportive and palliative care provision in MECC (2005)

Adult services Pediatric services

Freestanding unitHospital unit Hospital-based consultationHome careDay care Outpatient clinicDrop-in centerMobile unitNGO support*Pediatric unitPediatric hospital supportPediatric home careTotal

Cyprus 1 - - 2 2 2 - - 3 - - - 10

Egypt 2 1 - 1 - 1 - - - - - - 5

Israel 3 4 2 7 2 2 1 1 2 1 5 1 31

Jordan - 1 2 2 - 1 - - - - 1 1 8

Palestinian Authority - - - - - 5 - - 1 - 2 - 8

Turkey - - 7 - - - - - - - - - 7

Total 6 6 11 12 4 11 1 1 6 1 8 2 69

*NGO support indicates the presence of organizations which fund or voluntarily provide supportive or palliative care services (this may be the stated sole purpose of the 

NGO (e.g. Cyprus Anti-Cancer Society) or additional to other more general services in health or social care support offered by the organization (e.g. Patients Friends 

Society in the Palestinian Authority).
Chapter 2 A Comparative Analysis

National Cancer Institute 4 MECC Palliative Care Monograph 

care or palliative care (Table 2.1). Details of these services 

appear in Chapters 4-9. 

Where a service is in the process of development from 

(largely) physical care--pain and symptom management-

-to a broader form of holistic care that approximates the 

World Health Organization (WHO) definition of palliative care, we have included it in our analysis (1). For 

example, we include services where, although there is no 

specialist provision, health care professionals undertake 

palliative care training, raise professional awareness of 

needs and practices, and, in some cases, are starting to 

actively develop training opportunities in existing oncology clinic, hospital units, or nongovernment organizations 

(NGOs).

In describing the current state of hospice and palliative 

care service provision, we apply a typology that defines 

different stages of development. Four categories are used: 

“no services identified,” “capacity building,” “localized 

provision,” and “approaching integration.” These are fully 

defined in Table 2.2 (2).

The map in Figure 2.1 shows the four categories applied 

across the MECC region according to the status, range, 

and type of provision identified in each country and area. 

The Palestinian Authority and Turkey are described as 

in the initial stage of palliative care development, where 

there is no specialist service provision, although there 

are interested health care professionals in the process of 

“capacity building,” raising awareness, and, as far as possible, introducing palliative care practice into their work. 

Jordan and Egypt are identified as providing localized 

provision, where individual local services and organizations are established or in development, and some training 

is available for professionals, but other key aspects are 

still in the process of debate or development, such as a 

national strategy for provision, opioid policy, and education. Cyprus and Israel are approaching integration because 

they have organizations with well-established services, 

in some cases integral to existing health care providers, 

national policies on opioid availability, education, and 

training (undergraduate and postgraduate education in 

Israel, and training at professional levels in both Israel 

and Cyprus), and there is clear evidence of clinical and 

academic research activity.

Table 2.2. Typology of stages of palliative care development

“No 

services 

identified”

“Capacity building” “Localized provision” “Approaching integration”

•	 Initial awareness of palliative care 

needs

•	 Expressions of interest registered 

with key organizations (e.g., MECC, 

WHO, EAPC)a

•	 International links established with 

other hospice-palliative b care service 

providers 

•	 Conference participation

•	 Visits to hospice-palliative care 

organizations

•	 Education and training (visiting 

teams/ overseas training)

•	 Preparation of development strategy; 

lobbying of policymakers/ health 

ministries for palliative care to be part 

of a National Cancer Control Plan 

(NCCP) c

•	 Initial capacity buildingd activities 

•	 Local campaigning and publicity 

Services set up – (i.e. home 

care, or freestanding hospices); 

funding source established

•	 Government legislation in 

progress (NCCP to include 

palliative care) 

•	 Opioids available

•	 Training within hospice 

organization plus external 

courses

•	 Developing academic links

•	 Developing research activity

•	 Capacity building and localized 

activities 

•	 Regular campaigning and publicity 

countrywide

•	 Range of providers and service types

•	 Broad awareness of palliative care 

needs 

•	 Some integration with mainstream 

health providers

•	 Opioid, NCCP and palliative care 

health policy/legislation agreed and/ 

or in statute book 

•	 Established education centers 

•	 Academic links and development of 

core curricula for undergraduate and 

postgraduate health professional 

training 

•	 Research activity – national/

international publications

Source: Wright and Clark (2006); Wright et al. (2006) 

a See Appendix 1 for abbreviations 

b Hospice-palliative is common usage for our publications; see Wright et al. (2006) and reports on IOELC website

c NCCPs are part of a package of legislation to ensure government health care provides for cancer prevention and treatment programs – palliative care health professionals lobby their 

governments to include at most basic provision (at least acknowledgement of need) for palliative care as part of the NCCP – this is part of palliative care development strategy that is 

encouraged by WHO, EAPC and other supportive international organizations. 

d Capacity building does not have a hyphen in the original IOELC tables
Chapter 2 A Comparative Analysis

National Cancer Institute 5 MECC Palliative Care Monograph 

Palliative care coverage in the

MECC region

There is enormous variation in palliative care provision 

and patterns of development in the region represented by 

MECC (Figure 2.2). Currently, home care services are the 

most common type of service provision, but there is no 

home care in Egypt, the Palestinian Authority, or Turkey. 

In many cases, home care services are initially set up 

by volunteers; in almost all situations, these are trained 

nurses, social workers, and physicians working in their 

own time. Later, the services are taken on and supported 

by an NGO or existing health care provider. For example, 

one home care service in Israel was originally established 

by a group of untrained volunteers who responded to 

the needs of people in their community dying of cancer. 

The volunteers organized a group of trained professionals and supportive volunteers, who are trained in basic 

psychosocial and personal support skills. 

In Cyprus, two charities provide all the specialist services 

in the Greek Cypriot south, and one provides some limited support in the Turkish Cypriot north of the island. In 

Israel, one major NGO provides funding toward several 

palliative and supportive end-of-life care services, for 

educational and research activity, clinical development 

and public health education programs. In the Palestinian 

Authority, one NGO will offer psycho-social support for 

women with breast cancer at the end of life, and also 

provides a range of supportive services for breast cancer 

Figure 2.1. Map of MECC region showing different levels 

of service development according to typology defined as 

“capacity building” (blue: Palestinian Authority, Turkey), “localized provision” (green: Egypt, Jordan), and “approaching 

integration” (yellow: Cyprus, Israel)

8

2

1

1

1

5

4

11

11

11

12

0 2 4 6 8 10 12

Number of reported services

Pediatric hospital based

Pediatric home care

Pediatric unit

Primary/community

Mobile unit

NGO support*

Day care

Outpatient clinics

Hospital-based

Inpatient units

Home care

Figure 2.2. Range of different types of supportive and palliative care in the MECC region (2005)

*NGO support includes charities entirely dedicated to palliative care and also organizations 

that offer specific support at the end of life as part of other humanitarian work. 

Illustration 2.1 A freestanding hospice, the Ina and Jack Kaye 

Hospice at Hadassah Mount Scopus, Jerusalem provides 

inpatient and home care services [photograph: Amanda Bingley, May 

2005]
Chapter 2 A Comparative Analysis

National Cancer Institute 6 MECC Palliative Care Monograph 

survivors, and other health-related services. Of the 11 

hospice inpatient units in the region, 7 are freestanding 

(1 unit in Cyprus, 2 in Egypt, and 4 in Israel). 

There are four specialist units with beds for palliative 

care patients based within hospital oncology wards in 

Israel and Jordan. These kinds of specialist units are 

distinct from hospital-based consultation offered at the 

end of life. In such situations, professionals who are 

aware of the principles of palliative medicine or who 

have completed some specialist training are providing 

pain and symptom management. However, they are often 

constrained from developing full palliative care services 

because of limited or no resources, a lack of trained staff, 

and perhaps little or no support from colleagues. In 2005, 

this kind of hospital-based consultation was the only 

palliative care service available in Turkey, although a 

few dedicated oncologists are working to develop more 

comprehensive services in several major hospitals. In 

the Palestinian Authority and Egypt, this kind of service 

continues to be the main type provided.

There is a major lack of pediatric palliative care support 

across the region, with only a single small four-bed unit 

dedicated to palliative care for children found in Israel 

and two home care services that will care for children if 

requested, in Israel. Similarly in Jordan one home care 

service will care for children on request, although in both 

Israel and Jordan the services are primarily for adults. 

There are hospital-based consultation and support services in major pediatric cancer units in Jordan and the 

Palestinian Authority. In Israel, there are some specialist 

palliative care consultation services in major pediatric 

hospital units, and currently the only services that are 

fully developed and offering a range of psycho-social 

support including bereavement services are in Israel. In 

part, as the quote below illustrates, this reflects the different approaches to, and needs of, children with lifelimiting illness, where both professionals and family will 

continue to pursue active treatment right up to the end of 

life and there is often anxiety at the prospect of hospice 

care, which is seen as “giving up” hope (3).

“In a country like Israel, very little palliative care is 

done for children: they fight until the very end in terms 

of active treatment. And they feel a lot of confidence in 

the hospitals. We had two that we took care of (of course 

it’s very traumatic for the staff too), but basically their 

main umbilical cord remains the hospital. In other words, 

even when their child is dying, if there’s any chance that 

some new type of treatment will [work]...they can see 

the oncologist again and have one more treatment. We 

don’t get into the stage that they say no more treatment.” 

Home hospice team physicians in discussion – Israel, 

May 2005 (4). 

In Cyprus there are similar difficulties in pediatric services in terms of access to appropriate pain relief and 

the fact that opioids for children are generally given as 

IV infusions in hospital. As the quote below suggests 

this may ultimately result in limited choice for a family 

around the preferred place of care for their child at the 

end of life:

“[In Cyprus]...with the pediatric oncologist, I always 

send him copies of anything that comes through, especially related to opioids or pain in children. They do use 

morphine with children. But children don’t really die at 

home, they tend to be admitted to the ward and given IV 

fluids with morphine. At least they are using morphine 

now for the children, which is a move forward.” Clinical 

nurse specialist – Cyprus 2005 (5). 

Another area of service provision that is a concern for 

professionals across MECC is the severe lack of palliative 

care services for patients with cardiovascular disease, 

despite the overwhelming numbers of deaths from these 

causes. Only two countries (Israel and Jordan) have hospice and palliative care provision (one service in Jordan 

and two in Israel) for patients with diseases other than 

cancer, despite the proven benefits of palliative care, for 

example, in patients with heart failure (6). The lack of 

services to support end-of-life care in people with noncancer-related disease is in stark contrast to the response 

Illustration 2.2 The Cairo Evangelical Medical Hospice in 

Egypt is one of 2 privately funded services with a small 

inpatient unit and outpatient service for people with cancer at 

the end of life [photograph kind permission of Dr. Naguib Elnikhaily, March 

2005]
Chapter 2 A Comparative Analysis

National Cancer Institute 7 MECC Palliative Care Monograph 

in some African countries to the overwhelming palliative 

care needs of very high numbers of people dying from 

AIDS (7). An estimated 95% of hospice and palliative 

care in Israel and Jordan is dedicated to cancer patients 

(8). In Cyprus, Egypt, and Turkey, virtually all of current 

hospice and palliative care provision is for cancer patients, 

although Cyprus does have a ward in one hospital for 

AIDS patients (9).

Palliative care capacity in the

MECC region

The 69 palliative care services identified in this review 

cover a total MECC population of 162.9 million people. 

There is an estimated 2.36 services per million population. 

There are insufficient data available to assess the exact 

palliative care capacity across MECC, but Table 2.3 provides estimates of inpatient beds available in specialist 

palliative care units, in freestanding units, and in specialist hospital-based units (figures for capacity in general 

hospital facilities are not known), and some indication of 

home care service capacity. In addition to an estimated 

168 beds in freestanding or specialist hospital units, there 

is an estimated 653-patient home care patient capacity 

at any one time. These figures can fluctuate considerably over a year. In Israel, where there is a community 

medicine system, an estimated 80 specialist nurses work 

with around 500 oncology nurses, caring for patients in 

the home. Jordan is in the process of developing a community medical service.

Table 2.3. Palliative and supportive care capacity* in the 

MECC region reported estimates 2005

Beds in 

freestanding or 

inpatient units

Home hospice 

capacity 

(maximum)

Cyprus 18 (+ 40 

hospital-based)

121 per month

Egypt 9 -

Israel 93 498 

(at any one time)

Jordan 8 34 

(at any one time)

Palestinian Authority - -

Turkey - -

Total capacity 168 653

*

Freestanding units are purpose built hospices. Capacity means total bed numbers in 

the hospice. Inpatient unit capacity means bed numbers in an inpatient hospital-based 

unit – i.e. beds may be within an oncology unit - it is not unusual for bed numbers to 

vary – for example a hospital might be forced in an emergency to use a palliative care 

bed for an oncology patient or a patient from a different unit – hence the estimates. 

Home hospice capacity means the numbers of patients that can be cared for at any 

one time – this will depending on staffing levels – the figures for all these designations 

were stated as estimates within a fairly stable range – for example a home hospice 

will be staffed according to the level of funding available and often also depends on 

how many hours the director and or team feel they can manage to work, if they are 

voluntary workers or part funded. Thus, they may be set up to care for between 20 

– 25 patients at any one time. Estimates are based on the maximum numbers given 

by directors for their hospice.

Table 2.4. Palliative care workforce capacity in the MECC 

region: reported estimates in 2005

Role in palliative care Estimated workforce 

employed full- or parttime

Administrative staff/director 34

Physician/medical director 92

Nurse 230

Social worker 33

Psychologist 17

Physiotherapist 8

Occupational therapist 4

Music therapist/art therapist/

yoga therapist/massage therapist/

dietician

2 / 3 / 

1/3/ 3

Spiritual counselor 4

Total 434

Illustration 2.3 Music thanatologist Adira (right) with Shosha 

[photograph kind permission of the team at the Nancy Caroline Hospice of the 

Upper Galilee, Israel]
Chapter 2 A Comparative Analysis

National Cancer Institute 8 MECC Palliative Care Monograph 

Palliative care workforce

capacity

An estimated 434 health care professionals were actively 

employed in specialist palliative care in the 69 identified 

services in the MECC region in 2005. Table 2.4 details 

their roles and numbers. 

Nurses represent the largest number of professionals in palliative care services throughout the MECC region. Many 

services--for example in Cyprus, Israel, and Jordan--have 

been set up and run by nurses, with part-time, voluntary 

support from primary care physicians or oncologists. 

Often services survived in this way for many years before 

additional funds supported an expansion of services into 

teams including full- or part-time social workers and 

administrators, and later, psychologists. Relatively fewer 

physiotherapists and occupational therapists participate, 

and they are more often found in better resourced, wellestablished services (although several services reported 

having external access to physiotherapy or occupational 

therapy support on request). The smallest numbers of the 

workforce are those professionals offering specialized 

therapeutics such as music and art therapy, yoga or massage therapy, dietetic advice, and spiritual counseling. 

These specialist professionals are only found in around 

four services in the MECC region; in some cases they 

are only temporarily in post. One or two services had a 

particular emphasis on providing this kind of support. 

In many services, however, the emphasis tends to be on 

Figure 2.3. INCB recorded average standard defined 

daily doses (S-DDD) of morphine per million inhabitants, 

compared over the years 2002-2005, in Cyprus, Egypt, 

Israel, Jordan, and Turkey

0

50

100

150

200

250

300

Cyprus Egypt Israel Jordan Turkey

Morphine S-DDD/million pop

Morphine 2000-2002 Morphine 2002-2004 Morphine 2003-2005

Source: International Narcotics Control Board Narcotic Drugs: 

Estimated World Requirements for 2005. Statistics for 2004. New York: United 

Nations, 2005.

Estimated World Requirements for 2007. Statistics for 2005. New York: 

United Nations, 2006.

providing nursing and medical support, either by choice 

because of the health care providers’ focus, or because 

poor resources or less specialist training limit the extent 

and range of provision. 

Opioids are reported to be available in all MECC countries across the region. Cyprus, Egypt, Israel, Jordan, 

and Turkey report annually on opioid preparation and 

consumption, as sovereign states and members of the 

International Narcotics Control Board (INCB). Quantities are measured in kilograms or grams per year and are 

also defined by the INCB as the “average consumption 

of narcotic drugs, in defined daily doses for statistical 

purposes per million inhabitants per day” or “average 

standard defined daily doses (SDDD).” The Palestinian 

Authority is not an acceded party to the conventions of 

the INCB, which therefore has no published figures for 

the consumption of narcotic drugs in the West Bank and 

Gaza Strip. A limited range of opioids is available for 

use in oncology units in these areas, although choice and 

availability of drugs and availability of the different drug 

dosages cannot be guaranteed (see Chapter 8) (10). 

The range of available drugs varies in different countries, but all MECC members report access and usage of 

common generic opioids used in palliative care: codeine, 

pethidine, and generic morphine preparations. Health care 

professionals across the region note a general trend in all 

pain management, including palliative care, towards an 

increased use of more expensive proprietary opioids, in 

particular the fentanyl formulation prescribed as Durogesic 

(most frequently in the form of transdermal patches). In 

Israel and Turkey there is a reported reduction in prescriptions of generic morphine (see Figure 2.3 for comparative 

changes in morphine use from 2000-2005).

In Cyprus, Egypt, and Jordan a marginal increase in morphine use partly reflects a greater overall use of opioids 

in pain management as well as encouragement to access 

the cheaper generic opioids. For example in Jordan, since 

2004, a local pharmaceutical company has been licensed 

to produce the cheaper, generic morphine sulphate for 

use within the country and for export around the region. 

However, despite this situation, as Figure 2.4 illustrates, 

from 2000 to 2005 the INCB reports a relatively marked 

annual increase in fentanyl use in all countries.

In Israel, physicians also note an increased use of other 

opioid derivatives such as hydrocodone and the synthetic opioid oxycodone. This pattern of increased use 

of proprietary opioids and derivatives is thought to arise 

from two key factors. The first is opioid phobia, when 

the physician, patient, and patient’s relatives are anxious 

about prescriptions of morphine but less concerned when 
Chapter 2 A Comparative Analysis

National Cancer Institute 9 MECC Palliative Care Monograph 

the prescription name does not indicate the opioid nature 

of the medication. The second factor is that pharmaceutical companies favor marketing profitable proprietary 

medications. Cheap generic morphine salts, although 

effective, are considerably less profitable.

MECC members Cyprus, Egypt, Israel, Turkey and the 

Palestinian Authority all have some form of government 

legislation for opioid availablity and prescribing powers 

for physicians. Jordan currently has temporary regulations to permit opioid prescribing. Quantities permitted 

per prescription across the region range from sufficient 

medication (of any appropriate strength) for a three-day 

up to a 10-day supply. In Israel, the maximum, and 

exception, at any one time is a 30-day supply. As part 

of opioid awareness and education, Israel, Cyprus, and 

Jordan routinely include pharmacists in their training 

courses. The increase in training opportunities in Israel 

and Cyprus has resulted in markedly less antagonism 

and phobia from health care professionals and, consequently, their patients. Widespread opioid phobia, however, remains a considerable barrier to adequate opioid 

prescribing in Turkey, and is a continuing problem in 

Jordan, despite new training programs since 2004.

Lack of training, particularly at the primary and community care level, still leads to inadequate or inappropriate 

prescribing even in countries “approaching integration” 

with their palliative care services. The following quote 

Figure 2.4. INCB recorded average standard defined daily 

doses (S-DDD) of fentanyl per million inhabitants, compared over the years 2002-2005, in Cyprus, Egypt, Israel, 

Jordan, and Turkey.

Source: International Narcotics Control Board Narcotic Drugs: 

Estimated World Requirements for 2005. Statistics for 2004. New York: United 

Nations, 2005. 

Estimated World Requirements for 2007. Statistics for 2005. New York: United 

Nations, 2006.

0

200

400

600

800

1000

1200

1400

Cyprus Egypt Israel Jordan Turkey

Fentanyl S-DDD/million pop

Fentanyl 2000-2002 Fentanyl 2002-2004 Fentanyl 2003-2005

illustrates the continuing lack of adequate pain management and symptom relief in general health services:

“We encounter problems with two types of physicians ... 

and I’m generalizing ... One type is physicians who just 

back away from any involvement with cancer patients, 

including referring them to us. For a long time, and probably still in areas that are under-serviced, people just 

don’t get treated properly. They don’t get treated by the 

hospital and they don’t get treated by the family physicians properly. ... The other category is the sort of proud 

family physician; he knows his stuff and thinks that he 

can handle it, when today really palliative care is different than it was 15 years ago. It’s far more complex ... the 

drug regimens are more complex and the orientation is far 

more sophisticated than it was before.” Senior palliative 

care physician (Israel, 2005) (11).

However, this situation is also reported as having steadily 

improved from the early 1990s, largely as a result of 

concerted campaigning by pioneers of palliative care to 

change government policy and legislation around opioid 

availability (12). In Turkey, however, Oguz et al. (2003) 

as cited below, emphasize the ongoing problem in general 

hospitals, where there is little or no awareness of palliative care needs: 

“Narcotics are often available to meet the needs of dying 

patients with chronic pain, [but] many private pharmacies 

shun the bureaucracy and the potential liability that goes 

with dispensing ‘green’ prescriptions (for addictive or 

abusable [sic] drugs) and ‘red’ prescriptions (for narcotics). The difficulty in finding a health care professional 

to come to the home to dispense, administer, monitor, or 

instruct in the proper use of opiates encumbers or entirely 

obstructs home care with narcotics. Undertreated pain and 

the lack of a means to secure access to opiates lead people 

to seek overloaded hospital based clinics or avoidable and 

costly inpatient treatment. Hospitals and their staff are not 

organized or trained to provide palliative care.” 

Of seven university hospitals and nine state hospitals in 

the three largest cities Oguz et al. observed that:

“...no hospital had a policy on end of life care, pain management or DNR (do not resuscitate) orders. Dying patients are often placed in what health care professionals 

informally call ‘agonal rooms.’ These are often in less 

noticed areas of the hospitals... The dying person is often 

alone in an institution from which he or she or relatives 

sought help” (13). 

The pattern of inadequate pain and symptom management 

due to lack of specialist training and awareness is echoed 
Chapter 2 A Comparative Analysis

National Cancer Institute 10 MECC Palliative Care Monograph 

by hospice and palliative care professionals throughout 

the region.

Education and training

Education and training in palliative care is available internationally at the postgraduate and fellowship levels 

for all health care professionals in the MECC region who 

have the means to travel or who are supported through 

NGO or other charitable funding. Table 2.5 outlines the 

available courses and types of training in Cyprus, Egypt, 

Israel, Jordan, the Palestinian Authority and Turkey. 

Israel, with the most extensive palliative care services, 

is the only MECC country that has some core training 

units in palliative care for medical students and has also 

developed a national specialist postgraduate qualification in palliative care. Cyprus, Israel, and Jordan provide 

single units on palliative care during core nursing training. 

Egypt has some palliative care training in development 

for core nursing education. 

Table 2.5. Overview of education and training in the MECC region, 2005

Core education National specialist 

education and training

International 

education/ 

links

Research

activity

Physicians Nurses Diploma/MSc/ 

CME/ 

Specialist 

courses

Short 

units/ 

seminar

Fellowships/ 

diplomas/MSc/ 

Spec. courses

Journals/

conference

Cyprus Short 

placement a

Yes Yes Yes

Egypt Unit in 

development

Yes

Israel Yes: unit in 

5th yr b

Yes Yes Yes Yes Yes

Jordan Short 

placement

Yes Yes

Palestinian Authority Yes

Turkey Yes Yes Yes

Total c 1/6 4/6 1/6 4/6 6/6 3/6

a Short placements: nurses spend a short time from a few days, to weeks or perhaps up to 3 months in a hospice as part of their final year or as an optional unit.

b Unit of study in 5th year. 

c

 The totals describe the number of countries with education and training out of the total MECC members: this provides a quick comparative measure of the level of education in the 

region. 

Illustration 2.4 MECC delegates at the first palliative 

care seminar, Larnaca, Cyprus, February 2-3, 2004. 

[photograph: David Clark]
Chapter 2 A Comparative Analysis

National Cancer Institute 11 MECC Palliative Care Monograph 

International opportunities in palliative care education 

are a vital part of raising awareness and providing access 

to training courses for all MECC members. In the case of 

physicians in the Palestinian Authority and Egypt, such 

opportunities represent the only viable training option. 

The MECC palliative care seminars (the first two of which 

ran in February 2004 and November 2005) have proved 

to be an important point of contact and networking for 

members. In particular, they provide a supportive and 

collegial environment for professionals who have little 

chance to develop palliative care skills within their own 

institutions.

Volunteer support services exist in Cyprus and Israel, 

and to a limited extent in Jordan and the Palestinian 

Authority. In all situations where volunteers are involved 

in a service, some basic training and needs awareness 

are provided, and this often extends, where possible, to 

training of family members. 

Ethical issues

Issues of disclosure about a patient’s prognosis are reported 

to be a major problem throughout the MECC region. 

Professionals in Israel and Cyprus, both countries with 

the most active and extensive palliative care services, 

note a great improvement in the willingness of health 

care professionals to be open: a change that has reportedly come about as cancer survival rates improve. Most 

palliative care professionals are sensitive to their patients’ 

cultural and spiritual differences and many freestanding 

hospices and home hospices in the MECC region support 

their patients spiritually, where appropriate. In Israel there 

is a spiritual counseling training program.

Health care professionals noted often significant inequalities for patients needing access to services. Problems are 

deemed as particularly acute where community or primary 

health care awareness is inadequate. Professionals describe 

situations where a lack of awareness of palliative care 

needs in the general health care system leads to unnecessary suffering. For example, remote rural areas almost 

always lack services, with some exceptions in Israel, 

which has relatively comprehensive community health 

services, including oncology nurses who are educated in 

basic palliative care. Jordan is addressing the problem by 

training professionals who are already working within the 

relatively new community health care system introduced 

in the early 2000s. 

Military conflict is another problem that poses significant 

ethical issues. In the Palestinian Authority, the Israeli/

Palestinian conflict results in severe difficulties for patients attempting to access services. A positive aspect of 

the development of palliative care services is the potential 

to work together in the humanitarian effort to support all 

communities in the region. For example, the value of sharing experience and building bridges across communities, 

even those in conflict, is illustrated by this quote:

“They [gave] me the money to open the hospice in the 

Arab city of Nazareth, and then I was in [the] United 

States with an Arab social worker, and she was working 

for the hospice here, and we did some projects together 

Illustration 2.5 Negev Palliative Care Services “Desert Mobile 

Unit,” visiting a home care patient near Beersheba, Israel. 

[photograph: Amanda Bingley, May 2005]

Illustration 2.6 Bedouin Arab settlement in the Negev Desert, 

southern Israel. Palliative care is provided to this community 

via the Negev Palliative Care Services “Mobile Desert Unit.” 

[photograph: Amanda Bingley, May 2005]
Chapter 2 A Comparative Analysis

National Cancer Institute 12 MECC Palliative Care Monograph 

with the community of Israel and [the] United States... 

Sometimes when you are talking about mutual issues 

that are important for both communities, you are not 

talking about peace but things that improve peace and 

understanding, because, you see, we are people the same.” 

Hospice director, Israel, May 2005 (14).

Another area of ethical concern across the region is the 

problem of insecure funding. Many palliative care providers are not-for-profit organizations relying on donations. 

This kind of funding, although limited, may be reasonably 

stable if fundraising is well managed and supported by 

regular donors. In Israel, Cyprus, and to a small extent 

Jordan, some organizations have their income supplemented by a varying percentage of health system funds. 

Where the services are wholly dependent on government 

or insurer health care systems, resources are vulnerable 

to political or economic shifts, particularly if there is 

insufficient awareness about palliative care needs. In 

some cases, government or insurer funds have been withdrawn or reduced with little warning, leaving services 

collapsing or severely cut back, with consequent stress 

on the general health care service, patients, families, and 

the workforce. Organizations and individuals involved 

in palliative care provision see the raising of public and 

government awareness as a crucial factor in improving 

this situation and in encouraging a more stable funding 

policy. Many professionals echo the concern that lack 

of awareness of the needs for palliative care leads to 

considerable unrelieved pain and suffering at the end 

of life for patients with cancer and other life-limiting 

illnesses, as this quote suggests:

“I’m a person who works in darkness, because I do realize that in this part of the world what is being said in 

conferences, what is being said under lights, does not 

really reflect the reality. There are closed homes, there 

are people who are suffering, and whoever reaches those 

people will exactly know the value of palliative care.” 

Hospice director, Jordan, May 2005 (15). 

Finally, important ethical issues arise from opioid phobia 

and lack of training in prescribing opioids, which results 

in often inadequate pain and symptom management.

Review of range and type of 

published material relating to 

palliative care

Only one MECC member country, Israel, has any consistent and dedicated research activity regarding palliative care (see Chapter 6). Consequently, Israel has the 

largest number and range of publications specifically on 

this topic, as well as an impressive record of publication in international peer-reviewed journals reporting on 

wide-ranging clinical, psychosocial, cultural, and social 

science research. 

Cyprus is the only other MECC member that produces 

specialist palliative care literature, although it is very 

limited (see Chapter 4). Cyprus has the disadvantage of 

being a small island with no higher education institutions. 

Consequently, only a handful of health care academics 

and clinicians have international links and are able to 

publish in international peer-reviewed journals. 

The Palestinian Authority has a small amount of public 

health literature and a very limited “grey” literature in 

palliative care (see Chapter 8). Health care professionals 

in Turkey and Egypt have focused on cancer treatment 

and pain control, and both countries have a relatively 

wide range of cancer treatment and pain management 

literature, some published in international journals. Egypt 

has virtually no literature on specialist palliative care pain 

and symptom management (see Chapter 5). In Turkey 

there is relatively extensive national literature on pain 

management and a small amount of international medical 

ethics literature (see Chapter 9).

Barriers to development and

future plans

In this concluding section, we outline key barriers to the 

development of palliative care and hospice services, as 

identified by health care professionals across the MECC 

region. These barriers include a lack of the following: 

training, resources, relevant government legislation, and 

secure funding. Future plans are outlined that aim to 

address these problems, in order to develop and improve 

palliative care services. 

In Cyprus, there are moves by health professionals from 

the two palliative care NGOs to negotiate with the Ministry of Health to have palliative care integrated into 

general health services accessible throughout the health 

care system. Palliative care professionals have a longterm aim to treat patients with cancer as well as those 

with other illnesses at the end of life.

In Egypt, there is an urgent need to develop basic palliative 

care training and education. The only two freestanding 

hospice services are based in the private sector. A small 

group of health care professionals based in governmental 

health services aim to develop palliative care that would 

be accessible throughout the health care system, buil-
Chapter 2 A Comparative Analysis

National Cancer Institute 13 MECC Palliative Care Monograph 

ing on hospital oncology units’ existing role in pain and 

symptom management. 

In Israel, the aim is to expand the number and scope of 

existing services and to treat a greater range of illnesses. 

Palliative care specialists are negotiating with health insurance companies to cover palliative care as part of the 

“basket of services.” This coverage would secure financial resources and encourage the development of service 

provision. There is great pressure on medical education 

to make palliative care a medical specialty and add it to 

core curricula in medical schools; it is already part of 

standard nurse training in Israel. There are also continuing efforts to increase opportunities for postgraduate and 

professional specialist palliative care training.

In Jordan, the aim is to expand both home care services 

and specialist inpatient units. By encouraging education 

and training for community and hospital-based health care 

professionals educators aim to support the development 

of palliative care in community services and oncology 

units. Jordan is actively using support offered by the 

World Health Organization and the Jordanian Royal Court 

to develop effective training programs and government 

legislation.

In the Palestinian Authority, there is a need to raise awareness of palliative care at the government level. However, without international efforts the ongoing conflict 

draws potential resources away from palliative care. It 

is hoped that international support will increase to aid 

the development of palliative care education, training, 

and services. However, given the problems of access in 

Gaza and the West Bank, there is a need to ensure flexible service provision. 

In Turkey, there are concerted efforts in several university 

hospitals and one military hospital to develop specialist 

palliative care training and education. Health care professionals are actively working to develop an inpatient 

hospice and new home care services. The aim is to broaden 

hospital-based services to move beyond supportive care 

and start to provide multidisciplinary approaches to palliative care. Turkish pain specialists continue to raise 

professional, government, and public awareness of the 

importance of opioid medication in palliative care.

Conclusion

Cyprus, Egypt, Israel, Jordan, the Palestinian Authority 

and Turkey have very different palliative care needs and 

are at various stages of palliative care service development. Israel is “approaching integration” in palliative 

care services and has the most advanced development. 

Cyprus is also “approaching integration” but is disadvantaged by the absence of higher education institutions 

on the island, limiting access to academic and clinical 

research (Cypriot medical students have to seek their 

undergraduate education abroad).

Jordan and Egypt have some “localized provision,” but 

this is more developed in Jordan than in Egypt, where 

there are very few specialist palliative care services; all 

state-funded services are still at the level of “capacity 

building” and the focus is on pain and symptom management. The Palestinian Authority and Turkey are at the 

point of “capacity building.” However, the Palestinian 

Authority, at the time of writing, has no resources for 

service development and struggles to find sufficient resources to provide basic pain and symptom management. 

In contrast, Turkey is currently witnessing an increase 

in awareness about the need for specialist palliative care 

services; Turkish oncologists and pain specialists are active in the palliative care service development within 

existing pain clinics and oncology units. 

The following chapter provides a detailed overview of 

population patterns, levels of human development, health 

care systems and epidemiology in Cyprus, Egypt, Israel, 

Jordan, the Palestinian Authority and Turkey.

endnotES

1. WHO definition and criteria, accessed 3 January 2008 at 

www.whoint/cancer/palliative.en.: “Palliative care improves 

the quality of life of patients and families who face lifethreatening illness, by providing pain and symptom relief, 

spiritual and psychosocial support from diagnosis to the end 

of life and bereavement. Palliative care provides relief from 

pain and other distressing symptoms; affirms life and regards 

dying as a normal process; intends neither to hasten or postpone death; integrates the psychological and spiritual aspects 

of patient care; offers a support system to help patients live 

as actively as possible until death; offers a support system to 

help the family cope during the patient’s illness and in their 

own bereavement; uses a team approach to address the needs 

of patients and their families, including bereavement counseling, if indicated; will enhance quality of life, and may also 

positively influence the course of illness; is applicable early 

in the course of illness, in conjunction with other therapies 

that are intended to prolong life, such as chemotherapy or 

radiation therapy, and includes those investigations needed to 

better understand and manage distressing clinical complications.”

2. Typology developed by: Wright M and Clark D. Hospice 

and palliative care in Africa: a review of developments and 
Chapter 2 A Comparative Analysis

National Cancer Institute 14 MECC Palliative Care Monograph 

challenges, Oxford: Oxford University Press, 2006. See 

also Wright M, Wood J, Lynch T, Clark D. Mapping levels 

of palliative care development: a global view, International 

Observatory on End of Life Care, Lancaster University, UK 

with Help the Hospices, UK and NHPCO, USA, 2006.

3. For full discussion of these issues see comments by professionals in Cyprus (Chapter 4), Israel (Chapter 6), Jordan 

(Chapter 7) and the Palestinian Authority (Chapter 8).

4. IOELC interview: Dr. Jim Shalom, Dr. Eyal Goldberger, 

Specialist Nurse: Yael Bleich and Social Worker: Yaniv 

Ben-Shoshan, (Nancy Caroline Hospice of the Upper Galilee, 

HUG) – 9 May 2005.

5. IOELC interview: Clinical nurse specialist at PA.SY.KAF, 

Jane Kakas - 8 April 2005.

6. See Ward C.The need for palliative care in the management of 

heart failure, Heart 2002;87:294-298 heart.bmjjournals.com 

accessed 19 October 2006.

7. Wright M and Clark D. Hospice and palliative care in Africa: 

a review of developments and challenges, Oxford: Oxford 

University Press, 2006.

8. See details of specific services outlined in Chapter 6 (Israel) 

and Chapter 7 (Jordan).

9. See details of specific services outlined in Chapter 4, Cyprus; 

Chapter 5, Egypt; Chapter 8, Palestinian Authority; and 

Chapter 9, Turkey.

10. 2006 data on access and availability of medications in Gaza 

and the West Bank can be found on the WHO Health Crisis 

in Action Report, July 2006. See updated information on the 

WHO weblink millenniumindicators.un.org/unsd/mi/mi_results.

11. Dr. Jim Shalom in IOELC interview: with team members 

Dr. Eyal Goldberger, Yael Bleich and Yaniv Ben-Shoshan, 

at Nancy Caroline Hospice of the Upper Galilee (HUG) – 9 

May 2005.

12. IOELC interviews: Dr. Alexander Waller, Tel Hashomer, Tel 

Aviv – 8 May 2005; Dr. Nathan Cherny, Sha’are Zedek, Jerusalem – 4 May 2005; Dr. Amitai Oberman, Home Hospice in 

the Valleys, Nazareth – 10 May 2005. 

13. Oguz NY, Miles SH, Buken N, Civaner M. End of life care in 

Turkey, Cambridge Quarterly of Healthcare Ethics, 2003;12, 

279-284.

14. IOELC interview: Mali Szlaifer, Home Hospice of the Valleys, Nazareth - 8 May 2005.

15. IOELC interview: Rana Hammad – 12 May 2005.
National Cancer Institute 15 MECC Palliative Care Monograph 

This chapter outlines and compares the socio-demographic 

context within which MECC members aim to support the 

development of hospice and palliative care services. The 

first part of the chapter describes population patterns, 

including density, distribution, age structure, and human 

development indicators (see also detailed statistical data in 

Freedman et al., 2006) (1). We also examine and compare 

the different health care systems across the region, and 

provide an overview of relevant epidemiological and public 

health issues. For a summary of the political economy in 

the region, see Appendix 3.

Population patterns

The region represented by MECC members (Cyprus, Egypt, 

Israel, Jordan, the Palestinian Authority, and Turkey) encompasses significantly different geographical areas, as 

shown by the map in Figure 3.1, with vastly differing 

population size (Table 3.1), density, and distribution (Figure 3.2). 

Turkey and Egypt are the two largest MECC members 

and have the highest populations. Egypt is the second 

most populous country in the African continent (2), with 

terrain that is mostly uninhabitable desert. Almost the 

entire population lives along the Nile River Valley, in the 

capital Cairo, and around the delta in the coastal cities of 

Alexandria and Port Said; over half live in densely peopled 

urban areas (3). Turkey has the largest land area, and in 

contrast to Egypt, all but the most mountainous areas are 

habitable. There has been a marked migration of people 

from rural to urban centers in Turkey. In 1960, 70% of the 

population lived in rural areas and 30% in urban areas. 

By 2000, only 25% were living in rural areas and 75% 

in urban areas, the majority migrating from eastern areas 

to western areas into the three largest cities: Istanbul, 

Ankara, and Izmir (4,5). 

Cyprus has the smallest population of the MECC members 

(6). Many parts of the island are mountainous with rugged 

terrain, but the populations of Greek Cypriots in the south 

and Turkish Cypriots in the north are widely distributed 

Chapter 3

The MECC Region in Context:

Socio-Demography, Health Care Systems,

Epidemiology, and Public Health 

Fig 3.1. Map showing region represented by MECC members: 

Cyprus, Egypt, Israel, Jordan, occupied Palestinian territories 

(West Bank and Gaza Strip), and Turkey 
Chapter 3 The MECC Region in Context

National Cancer Institute 16 MECC Palliative Care Monograph 

in rural areas and the urbanized coastal plains. Around a 

quarter of the Greek Cypriots live in the divided capital, 

Nicosia. 

Jordan, like Egypt, is largely a desert country, with a 

mountainous northwest region. The majority of the population (around 90%) lives in semi-urban and urban areas; 

63% of these live in the central region of Jordan in the 

capital city Amman and in smaller regional areas of Zarqa, 

Balqa, and Madaba (7). Around 10% of the population 

is nomadic groups inhabiting desert areas (8). 

Israel and the Palestinian Authority have the most densely 

concentrated urban populations in the MECC region. Israel 

is a relatively small country; about half of its land area to 

the south is a sparsely populated desert. The vast majority of the population (around 91%) lives in the urbanized 

upland areas in central and northern Israel, and along the 

western coastal plains--mostly in the large metropolitan 

areas in and around Tel Aviv and Jerusalem, and in the 

northern port of Haifa (9,10). The Palestinian Authority 

in the West Bank and the Gaza Strip are densely populated, 

urbanized areas in semi-arid terrain. Gaza is a narrow 

strip of coastal land, with the highest population centers 

located in Gaza City in the north, Khan Yunis in the central 

area, and Rafah near the southern border. The West Bank 

is a small, semi-arid, landlocked area to the west of the 

River Jordan. The majority of the population is urban, 

living in the larger settlements and camps running north 

to south from Ramallah, East Jerusalem, and Bethlehem 

to Nablus and Hebron (11). 

Table 3.1. Population estimates and life expectancy at birth in 

the MECC region, 2004 

Population 

(millions) a

Life expectancy at birth 

(years)

Male Female

Cyprus 0.8 77 82

Egypt 72.6 66 70

Israel 6.7 78 82

Jordan 5.7 69 73

Palestinian 

Authority b 3.9 71 74

Turkey 73.2 69 73

a Source WHO Statistics (data from 2004 returns) (2006 Report) www.who.int/country/en.

b Source WHO Health Action in Crisis Report July 2006 http://millenniumindicators.

un.org/unsd./mi/mi_results.asp?crID=275&fID=5.

Figure 3.2. Comparative population densities (population/

km2) in the individual countries and areas in the region 

represented by MECC, 2006

87 79 308 64 91 427

3889

0

500

1000

1500

2000

2500

3000

3500

4000

Pop density

Cyprus

EgyptIsrael

Jordan

Turkey

West BankGaza Strip

Source: World Factbook (UN returned data) July 2006

Figure 3.3. Age range (years) as a percentage of the population 

in the MECC region, 1998-2001*

0

10

20

30

40

50

60

70

80

Cyprus

Egypt

Israel

Jordan

Palestinian Authority

Turkey

% population

Age(yrs) % pop 0-29 yrs Age(yrs) % pop 30-69 yrs

Age(yrs) % pop 70+ yrs

*2001 estimates for Cyprus, Israel and Egypt; 1999 estimates for Jordan; 1998 estimates 

for Palestinian Authority and Turkey.

Source: http://mecc.cancer.gov/complete_table.html

Illustration 3.1: View from East Jerusalem toward Beit Jala and 

Bethlehem in the West Bank, Palestinian Authority, May 2005. 

[photograph: Amanda Bingley]
Chapter 3 The MECC Region in Context

National Cancer Institute 17 MECC Palliative Care Monograph 

Population and age structure vary considerably across 

the region, but the trend is towards increasingly young 

populations (Figure 3.3). This trend is particularly marked 

in Jordan (34% of the population < 14 years; 4% > 65+), 

the Palestinian Authority (45% of the population < 14 

years; 3% > 65+), and Egypt (33% of the population < 14 

years; 4% > 65+). It is less so in Turkey (26% of the 

population < 14 years; 7% > 65+) and Israel (26% of 

the population < 14 years; 10% > 65+) (12). In contrast 

to other MECC members, Cyprus has a slightly aging 

population (20% of the population < 14 years), with the 

greatest number of older people (12% are > 65+) and the 

longest life expectancy. Several socioeconomic factors 

contribute to this trend in Cyprus; for instance, there is a 

relatively large economically advantaged, retired population, including a significant number of non-Cypriots. 

Young people often have to seek educational and work 

opportunities off the island. These population patterns are 

relevant to the development and provision of effective 

palliative care. For example, aging populations tend to 

make high demands on health care services, particularly 

end-of-life care. In Cyprus, these needs have been addressed by some determined and dedicated individuals 

in the Greek Cypriot south. Their task is helped by the 

fact that the island is small and most areas accessible 

enough to enable teams to travel relatively easily, which 

has facilitated the development of effective home care 

services. 

In contrast, the vast landscapes of Turkey, Egypt, and 

Jordan (the latter with much inhospitable desert terrain), 

tend to force the focus for all health care services into 

large urban centers. This can leave small, widely dispersed 

rural populations seriously under-resourced. Where palliative care is undeveloped even in urban centers, the 

situation is particularly difficult for those in far-flung 

regions. In the case of the Palestinians, sheer pressure of 

population puts a massive strain on health care services, 

already in crisis as a result of the long-running political 

conflict. Although the land area is small, people have great 

difficulty traveling to treatment centers, as the conflict 

restricts free access across the region.

Human development in the

region

The human development indicators (HDI) (13) longevity, 

knowledge, and standard of living, when measured in the 

MECC region, show marked variations in levels of development within the individual countries (Table 3.2). 

Israel and Cyprus are located in the high range of development and share similar levels of high life expectancy 

(Israel, 79 years; Cyprus, 78 years), high levels of education, and percentage of adult literacy within the population 

(Israel, 79%; Cyprus, 78%), as well as a relatively high 

standard of living (Gross Domestic Product [GDP] Index 

(14): Israel, 0.88; Cyprus, 0.87). Jordan and Turkey are 

ranked closely in the HDI medium range of development. 

Both countries share similar levels of relatively lower life 

expectancy (Turkey, 70 years; Jordan, 71 years). Jordan 

has a higher level of education and percentage of adult 

literacy within its population (Jordan, 91%; Turkey, 87%) 

but a slightly lower standard of living than Turkey (GDP 

Index: Jordan, 0.67; Turkey 0.69). The Palestinian Authority and Egypt are ranked lower in the medium range. 

Although the Palestinian Authority is on a par with Jordan 

and Turkey, sharing similar life expectancy (72 years) 

and slightly higher levels of education and percentage of 

adult literacy within its population (Palestinian Authority, 

90%), it has considerably more poverty per capita and a 

lower standard of living than either Jordan or Turkey (GDP 

Index: Palestinian Authority 0.52). Egypt has the lowest 

HDI ranking of all the MECC members, with the lowest 

life expectancy at 69 years, low levels of education, and 

only 56% literacy within its population. Nevertheless, 

Egypt has a higher standard of living (GDP Index: 0.61) 

than the Palestinian Authority.

Health care systems compared

across the MECC member region

Health care systems across the region are, without exception, based upon government-funded services; however, 

Table 3.2. Human Development Index (HDI) in MECC member 

region, 2006

HDI value Rank/177 Level of 

development

Cyprus 0.903 29 High

Egypt 0.702 111 Medium

Israel 0.927 23 High

Jordan 0.760 86 Medium

Palestinian 

Authority 0.736 100 Medium

Turkey 0.757 92 Medium

Source: UNDP (HDI) Report 2006 – data http://hdr.undp.org/hdr2006/statistics/indicators/1.

html (accessed 15 Jan 2007) 
Chapter 3 The MECC Region in Context

National Cancer Institute 18 MECC Palliative Care Monograph 

there is considerable variation between systems, in terms 

of the proportion of government-funded services versus 

health insurance-funded services that are either not-forprofit or privately run (Table 3.3). 

Each MECC member has developed a range of funding 

routes and service provision. The absence of primary care 

systems is notable in some parts of the regions, although 

some MECC members provide community health services 

for mothers and children or nursing services for older 

people. All countries maintain a government public health 

service that is responsible for monitoring community 

health, including control of epidemics and provision of 

maternity and child health services, vaccination programs, 

and psychiatric services. Many public health departments 

oversee preventative health initiatives such as campaigns 

to promote anti-smoking, cancer prevention, or the control 

of tuberculosis or HIV/AIDS.

The efficiency of overall health system performance--as 

measured by the World Health Organization (WHO)--is 

highest in Israel and Cyprus (Table 3.4) (15). 

Although Egypt has a higher-ranking health system performance than Jordan or Turkey, it actually has the lowest levels of per capita health expenditure in the MECC 

region. This apparent anomaly may arise because Jordan 

and Turkey preside over significant health inequalities, 

and within the context of poorer economies, greater inequalities of wealth. 

In the MECC region, as Figure 3.4 illustrates, health care 

expenditure, measured in International US dollars (Intl $), 

is highest per capita in Israel (Intl $1,911) and Cyprus 

(Intl $1,143). Turkey (Intl $528) and Jordan (Intl $440) 

have considerably lower expenditure. Egypt (Intl $235) 

has the lowest expenditure per capita. No data are available 

for the Palestinian Authority for per capita expenditure 

on health care. 

Expenditure ranking is reflected in the data giving health 

care as a percentage of GDP, as illustrated in Figure 3.5. 

Table 3.3. Summary of main providers of health care services across the MECC region

Primary Care Hospitals/

Nursing Homes Community Services Private NGO*

Government 

Ministry of 

Health (MoH)

Health 

Insurance 

--public/

not- for-profit 

(HI)

MoH HI MoH HI 

Including HI 

schemes, i.e. 

for primary care, 

hospitals, nursing 

homes

Cyprus X Developing X X

Egypt X X X

Israel X X X X X X X X

Jordan X X X X X

Palestinian 

Authority X X X X X X X X

Turkey X X X X X X

*Non-government organization

Table 3.4. WHO overall health system performance 

(efficiency) score (where 1 is the most efficient and 191 

the least efficient), 2001

Rank/191 countries a

Cyprus 24

Egypt 70

Israel 28

Jordan 83

Turkey 88

a There are no WHO data for the Palestinian Authority.

Source: Tandon A, Murray C.L.J, Lauer J.A, Evans D.B. Measuring overall health 

system performance for 191 Countries, GPE Discussion Paper Series: No 30; WHO 

www.who.int/health-systems-performance/docs/efficattain_docs.htm
Chapter 3 The MECC Region in Context

National Cancer Institute 19 MECC Palliative Care Monograph 

In 2003, MECC members spending the highest percentage 

of GDP on health care were Jordan (9.4%), Israel (8.9%), 

and Turkey (7.6%). Cyprus (6.4%) and Egypt (5.8%) were 

in the lowest range of spending. The Palestinian Authority 

spends a relatively high percentage of GDP (8.7%) on 

health care, despite serious economic problems. To some 

extent, this may reflect a situation where a significant part 

of a relatively low level of governmental expenditure is 

taken up by the high demand for health care services. 

Individual MECC members’ health care systems often 

involve complex arrangements between government 

ministry of health (MoH) departments and health insurance schemes that are run variously by government, by 

government-approved not-for-profit independent insurers, 

or by private insurers. All MECC members have privatesector health providers offering a range of hospital and 

individual consultation services, though very rarely including palliative care.

Cyprus has no primary care or community medicine services, although at the time of writing a community-nursing 

scheme is being developed in the capital, Nicosia. Health 

care services are provided to all Cypriot residents via 

government-funded hospitals in the Greek Cypriot south 

of the island. Medical cards entitling eligible residents 

to free or reduced-payment services are issued from the 

MoH. Residents not eligible for a medical card pay for 

all treatments according to a sliding scale of charges. 

Private-sector primary and hospital health care is available 

throughout the south. Turkish Cypriot patients with cancer 

can access free services provided by the two not-for-profit 

NGOs in the Greek Cypriot south; Turkish Cypriots in the 

north have access to government health provision as on 

the Turkish mainland, and this does not currently include 

palliative care services.

In Egypt, the government provides a health insurance 

scheme for all eligible residents, and there are governmentfunded hospitals and community clinics throughout the 

country. 

Israel has a health care system based on health plans 

provided by four not-for-profit institutions. Originally 

known as “sick funds,” and established in 1948 by workers’ associations, they were politicized by affiliation with 

different party factions. Before 1995, when the government 

National Health Insurance (NHI) law was introduced, Israelis paid voluntary contributions into the health plan of 

their choice. Since 1995, contributions to the health plan of 

choice have been collected compulsorily as health tax; in 

exchange, all Israeli citizens, irrespective of their income 

or age, are entitled to full medical insurance with a health 

benefits package (stipulated by the NHI) from the health 

plans. Individuals can also pay additional Voluntary Health 

Insurance (VHI) for supplements to their basic benefits, 

which cover private medical provision and complementary therapies. There are four health plans, known as 

Health Maintenance Organizations (HMOs): Clalit (the 

largest and oldest HMO, still insuring around 55% of the 

public), Maccabi (24%), Meuhedet (11%), and Leumit 

(10%). The government role, carried out by the MoH, is 

to provide services not covered by HMOs; most importantly, this covers public health, including communicable 

disease control, mother and baby care, psychiatric care, 

and long-term hospitalization. The MoH also subsidizes 

.

Health expenditure per capita (Intl $)

1143

235

1911

440

528

Cyprus

Egypt

Israel

Jordan

Turkey

*No data available for Palestinian Authority. 

Source: World Health Organization (WHO) Report 2006

http://www.who.int/countries/en/

Health expenditure as % of GDP (Intl $)

6.4

5.8

8.9

9.4

8.7

7.6 Cyprus

Egypt

Israel

Jordan

Palestinian Authority

Turkey

Source: World Health Organization (WHO) Report 2006

http://www.who.int/countries/en/

Figure 3.4. Total health expenditure (Intl $) per capita in the 

MECC region,* 2003

Figure 3.5. Total health expenditure as a percentage of GDP 

in the MECC region, 2003
Chapter 3 The MECC Region in Context

National Cancer Institute 20 MECC Palliative Care Monograph 

some HMO activities by an NHI per capita reimbursement system, and also plans, supervises, regulates, and 

licenses different aspects of health services. The MoH 

has developed, owns, and operates government-funded 

hospitals, which account for around half all the acute 

beds in Israel (16). Currently, palliative care services are 

not a stipulated NHI benefit or an essential component 

of the health plans’ “basket of services.” Health funding 

for palliative care is discretionary from the HMOs and 

the degree to which they are prepared to fund services 

either completely or, depending on whether the service 

is based within a health plan institution, in part alongside 

MoH funds or charitable monies.

The Jordanian health system operates through health insurance schemes, with 59% provided through private health 

insurance (17). Government health insurance schemes 

are available for government employees (civilian and 

military) and their families. Royal Court insurance provides funds for 90% of the costs for all cancer patients 

(18). Health services are delivered through governmental 

and private hospitals, family/community health centers, 

and hospital-based health professionals. Since the early 

2000s, the MoH has been developing a primary health 

care system through family health centers (19). 

The Palestinian Authority provides a health insurance 

scheme for government employees and funds government 

hospitals. In 2003, an estimated 28% of the population 

was enrolled in health insurance plans (20). The majority 

of the population, however, relies heavily on charitable, 

United Nations, and other foreign aid programs, such as 

the United Nations Refugee and Works Administration 

(UNRWA) and the Union of Health Work Committees 

(UHWC), among others, to support access to health care 

and provide services. Access to medical care is severely 

hindered by the difficulties of traveling within the territories and getting through checkpoints. Hence, small clinics 

have been built to provide some basic health care in areas 

without easy access to the major hospitals. Volunteers 

are also trained to provide basic health care support in 

refugee camps and isolated communities (21). Of 619 

primary health care centers in the Palestinian Authority, 

around 63% are government funded; the remainder are 

NGO funded (22). 

Of all MECC members, Turkey has the most complex 

health care system: a partly nationalized health care service 

established in 1961, and a well-established private sector. 

As Savas et al. explain: “Turkey’s health care system is at 

once centralized and fragmented. Health care is provided 

by public, quasi-public, private and philanthropic organizations but relations among them are not well structured 

or regulated. Health care is financed by the government 

(through the Ministry of Finance), social security institutions such as the Social Insurance Organization (SSK), 

the Social Insurance Agency of Merchants, Artisans and 

the Self-employed (Bag Kur), and the Government Employees’ Retirement Fund (GERF) and private, out-ofpocket, payments.” (23) 

The government public health services in Turkey include 

MoH hospitals, health clinics, specific health centers (family, maternal and child health, tuberculosis dispensaries), 

Ministry of Defense military hospitals, and Higher Education Council-funded university hospitals (24). Philanthropic organizations include the Red Crescent, which 

provides aid in natural and war-related disasters, as well 

as support in dispensaries. A variety of philanthropic 

NGOs, known collectively as the “Foundations,” offer 

help to people with illnesses such as diabetes, cancer, 

and AIDS, but as yet, not for palliative care. People can 

access free services (including inpatient medication, but 

excluding outpatient prescriptions) in all MoH institutions and when referred to university hospitals if they 

have a “low income” Green Card. The municipalities of 

the three largest cities run their own hospitals and offer 

free home care for the poor, which includes care at the 

end of life (25). People without a Green Card cover 

their medical costs either through one of the three social 

security government schemes (SSK, Bag-Kur, GERF), 

or they have private health insurance. Estimates by the 

State Planning Organization suggest that roughly 83% of 

the population have state health coverage. In total around 

87% of the population are covered by some kind of state 

or private insurance, either directly or as a dependent. 

The actual figures are thought to be lower. Over half the 

population of more than 73 million contribute to one of 

the social security schemes, and 34 million contribute to 

the SSK, the most flexible and comprehensive scheme. 

There are continuing concerns that a substantial proportion of the population is not covered by insurance, or 

that some schemes offer inadequate coverage. This is 

especially problematic for people at the end of life; some 

government insurance schemes do not cover outpatient 

prescribed medication, which means many people have to 

be hospitalized if they or their families cannot afford the 

costs of medication when at home. Conversely, private 

health care at the end of life is not always available. Many 

private nursing homes will not admit patients who are 

known to be in the terminal stage of their illness (26). 

Epidemiology and public health

Epidemiological and public health issues are essential 

indicators of the dimension of end-of-life care needs in 

different countries and areas (1).
Chapter 3 The MECC Region in Context

National Cancer Institute 21 MECC Palliative Care Monograph 

There are distinct and variable patterns of life expectancy 

at birth and rates of mortality (crude death rate) (27) in 

populations across the MECC region (see Figures 3.6 

and 3.7). Cyprus and Israel, with older populations but 

better standards of living, have longer life expectancy 

but a higher mortality rate in quite sharp comparison to 

the other MECC members. Mortality rates in Turkey and 

Egypt are on a par with Cyprus and Israel, but coupled 

with lower life expectancy may reflect poorer standards 

of living with concomitant higher rates of life-limiting 

diseases at younger ages. In comparison, the lower mortality rates in the Palestinian Authority and Jordan together 

with lower life expectancy may reflect a younger population combined with poor standards of living. 

The prevalence of specific diseases is similar throughout 

the region, although where figures are available, incidence 

and rates of death from specific diseases vary within the 

different populations. Consistent across the whole region 

is the prevalence of cardiovascular and heart disease, 

accounting for over a quarter to half of all deaths (Table 

3.6).

Cancer is the second most common cause of disease-related 

death throughout the region. In Jordan, road accidents 

Figures 3.6 and 3.7. Comparison between life expectancy at 

birth (years) and mortality rates (crude death rate (CDR)/1000 

population) in MECC populations, 2004 

Figure 3.6. Life expectancy at birth (years)

78

69

79

71

72

70

64

66

68

70

72

74

76

78

80

Years

Cyprus Egypt Israel Jordan Palestinian

Authority **

Turkey

Life expectancy (years)

Source: WHO statistics (2004 est.): http://www.who.int/countries/en/

Figure 3.7 Mortality rates

7.68

5.23

6.18

2.65

3.9

5.97

0

1

2

3

4

5

6

7

8

CDR/1000

Cyprus Egypt Israel Jordan Palestinian

Authority **

Turkey

Mortality: Crude Death Rate /1000 (2004)

Source: World Factbook https://www.cia.gov/cia/publications/factbook/index.html

Table 3.6. Primary causes of death in MECC region, 2004 

% primary causes of death 

Cardio/

heart Cancer Injuries AIDS

Cyprus 60 13 4.0 0.00

Egypt 42 8 2.0 0.10

Israel 31 27 5.6 0.00

Jordan 31 14 16.0 0.00

Palestinian 

Authority 25 10 11.0a 0.00

Turkey 54 11 6.4a 0.02

a

 indicates deaths included from injuries resulting from war and conflict

Source: percentages calculated using WHO December 2004 statistics: estimates of total 

deaths (2002) http://www.who.int/healthinfo/statistics/bodgbddeathdalyestimates.xls

*Statistics from Palestinian Authority from WHO Health Crisis in Action Report, July 2006 

http://millenniumindicators.un.org/unsd/mi/mi_results.asp?crID=275&fID=r15

Figure 3.8. Comparative total cancer deaths /annum, 1998-

2003

Cancer deaths/year

1263

34429

8878 8400

955

23775 Cyprus

Egypt

Israel

Jordan

Palestinian Authority

Turkey

Source:

Cyprus: cited from Cancer Research UK, Information Resource Centre, Cancer in 

the EU: incidence and mortality in the European Union based on estimates in 2000. 

info.cancerresearchuk.org/cancerstats/cancerineu/incidenceandmortality/. Accessed 

29th June 2005

Egypt and Jordan: Ferlay J, Bray F, Pisani, P, Parkin DM. (2001) GLOBOCAN 2000: 

Cancer incidence, mortality and prevalence worldwide. V1.0 IARC Cancerbase No.5 

Lyon: IARC Press, 2001

Israel: Calculated from returns by Israel Ministry of Health Statistics 2002 www.health.

gov.il/english/

Palestinian Authority: Salhab, A.R. and El Najjar, K. (2001) Palestinian National Cancer 

Registry: Cancer Incidence in Palestine, 1998-1999, Palestinian National Authority, 

Ministry of Health

Turkey: State Institute of Statistics (T.C. Basbakanlik, Devlet Istatistik Enstitusu) (2004), 

Turkey’s Statistical Yearbook 2004, State Institute of Statistics, Prime Ministry, Republic 

of Turkey www.die.gov.tr/yillik/yillik_2004_eng.pdf

.
Chapter 3 The MECC Region in Context

National Cancer Institute 22 MECC Palliative Care Monograph 

are the second most common cause of death (16%). In 

the Palestinian Authority, WHO reports that in 2004 the 

primary cause of death “for the age groups 1-4 (22.9%), 

5-19 (56.1%), and 20-59 (29.3%)” was “injuries, whether 

domestic, road or conflict-related” (estimated as 11% of 

deaths in the whole population) (28). 

The numbers of cancer-related deaths correlate with the 

relative population size in Egypt and Turkey (both large 

populations with the highest number of cancer-related 

deaths per year), and in Israel and Jordan (of similar 

population size, and reporting comparable numbers of 

cancer deaths). Israel has the highest percentage/population of cancer deaths of all MECC members in the 

region. Freedman et al. note, for instance, the incidence 

of lymphoma in Israeli Jews is one of the highest in the 

world (1). Cyprus has a disproportionately larger number 

of cancer deaths than the Palestinian Authority, but this 

is likely to be influenced by the older average age of the 

Cypriot population relative to the younger average age 

of the Palestinian population (Figure 3.8) (29). 

Throughout the MECC region, lung cancer is the most 

common cancer in men; breast cancer is the commonest 

cancer in women (1). For example, in 2003 the reported 

incidence in Egypt of breast cancer in women represented 

18.9% of the country’s total cancer cases. In Israel, of 

21,000 new cases of cancer reported in 2002, lung cancer 

in men accounted for 4.5% of all new cancer cases and 

9.7% of all cancer deaths; breast cancer in women accounted for 15% of all new cases and 10.3% of all cancer 

deaths (30,31). The Palestinian Authority had 1,730 new 

cancer cases in 1999 (32). 

In Turkey in 2003, cancer accounted for 13% of all registered deaths (8% of deaths in men; 5% of deaths in 

women) (34,35). Cancers of the trachea, bronchus, and 

lungs were the most common in men (61.6% annual incidence). Breast cancer was the most common in women 

(24.4% annual incidence) (36). Colorectal cancer was 

the second most common cancer. The prevalence of lung, 

breast, and colorectal cancer is similar to cancer incidence 

percentages across Europe (37).

UNAIDS (2004) (38) reports the incidence of HIV/AIDS 

as very low in Jordan and the Palestinian Authority (prevalence <0.1%). There is no systematic HIV surveillance 

in Jordan, and available data consist mainly of compiled 

testing results among blood donors and foreign workers 

residing in Jordan (39). HIV seroprevalence among blood 

donors still remains below 0.03% in Jordan. There are 

no UNAIDS reports for Turkey, but in 2004 the Turkish State Statistics Institute reported that a total of 197 

HIV/AIDS cases had been reported by the end of 2003 

(40). In Turkey, tuberculosis is a greater problem than 

HIV/AIDS, with an estimated 18,000 people undergoing 

treatment each year (40). Numbers of HIV/AIDS cases 

are slightly higher in Cyprus, Egypt, and Israel. UNAIDS 

notes that in Cyprus, “Since the start of the epidemic 

[data registered from 1986] and as of May 2003, 400 

persons have been diagnosed with HIV, but no AIDS 

deaths have been reported.” (41) Egypt has a very low 

prevalence of HIV/AIDS (<0.2%) compared with other 

African countries, but relatively high prevalence compared 

with other populations in the MECC region. Estimates 

suggest that between 5,000 and 31,000 people were living with HIV/AIDS in Egypt at the end of 2003. In the 

same year, up to 1,600 adults and children are thought 

to have died from the disease. 

In comparison to Egypt, Israel has low rates of HIV/AIDS. 

UNAIDS (2004) suggests that around 5,000 people with 

HIV/AIDS were living in Israel (prevalence 0.1%—0.2%) 

(42). An epidemiological study on the change in rates and 

pattern of infection in Israel from 1991 to 2000 reports 

a rise in HIV incidence, thought to be mainly influenced 

by immigration of people from countries with a high 

incidence of the disease (43,44).

Conclusion

MECC members Cyprus, Egypt, Israel, Jordan, the Palestinian Authority, and Turkey have widely different 

population patterns and human development indices. 

Their health care and public health systems reflect this 

demographic and economic diversity, despite many similarities in epidemiology across the region.

Cyprus and Israel, with relatively small populations in 

comparison to other MECC members, have the highest 

standard of living, and also have comparatively wellresourced and comprehensive health care services. Jordan, 

with a fairly small but rapidly growing young population, 

has a lower standard of living than Cyprus and Israel, but 

has a relatively well-resourced and developing health care 

system. Egypt and Turkey have the largest populations but 

with a standard of living similar to Jordan. Both countries 

have relatively comprehensive, though less well-resourced 

health care systems; they have significant inequalities 

in wealth and access to health care. The Palestinian Authority, located across two separate areas, both small but 

densely populated and with a rapidly expanding young 

population, struggles to provide adequate health care in 

the face of ongoing political conflict, limited access and 

scarce financial resources. 

Across the MECC region, cardiovascular and heart disease 

accounts for over a quarter to half of all deaths. Cancer is 
Chapter 3 The MECC Region in Context

National Cancer Institute 23 MECC Palliative Care Monograph 

the second most common cause of disease-related death 

throughout the region. Israel has the highest percentage per 

population of cancer deaths. Due to the older average age 

of its population, Cyprus has a disproportionately higher 

number of cancer deaths than the Palestinian Authority, 

with a larger young population. There is a reportedly 

very low incidence of HIV/AIDS in the MECC region, 

with the highest number of cases of HIV/AIDS reported 

in Egypt. 

The following chapters (4-9) provide detailed reports of 

current services and the history of palliative care development in Cyprus, Egypt, Israel, Jordan, the Palestinian 

Authority and Turkey.

EndnotES

1. Freedman LS, Edwards BK, Ries LAG, Young JL (eds.) 

Cancer incidence in four member countries (Cyprus, Egypt, 

Israel, and Jordan) of the Middle East Cancer Consortium 

(MECC) compared with US SEER. National Cancer Institute. 

NIH Pub. No. 06-5873. Bethesda, MD, 2006. This publication is available on the SEER web site at seer.cancer.gov under Publications, and on the MECC web site at mecc.cancer.

gov under Cancer Registry Project.

2. Egypt’s population is made up of the following ethnic groups: 

Eastern Hamitic stock (Egyptians, Bedouins, and Berbers), 

99%: Greek, Nubian, Armenian, other European (primarily 

Italian and French), 1%. Religious groups include: Muslim 

(mostly Sunni), 94%; Coptic Christian and other, 6%. Statistics from 2001: 

www.cia.gov/cia/publications/factbook/geos/eg.html.

3. For more details, see the United Nations website 

www.uneca.org/aisi/nici/country_profiles/Egypt/egyptab.htm.

4. Savas BS, Karahan O, Saka RO. In Thomson S & Mossialos E, 

eds. Health care systems in transition: Turkey. Copenhagen: 

European Observatory on Health Care Systems, 2002;4:4.

5. Turkey’s population is made up of ethnic groups, the largest of 

which is Kurdish. Religious groups include: Muslim, 99.8% 

(mostly Sunni); other, 0.2% (mostly Christians and Jews).

6. The population of Cyprus is made up of the following ethnic 

groups: Greek, 77%; Turkish, 18%; and other, 5%. Religious 

groups include: Greek Orthodox, 78%; Muslim, 18%; Maronite, Armenian Apostolic, and other, 4%. (Statistics from 

2001: www.cia.gov/cia/publications/factbook/geos/cy.html.)

7. Al Kayed S & Al Hijawi B. (2005) Report of the National 

Cancer Registry, incidence of cancer in Jordan 2002, The 

Hashemite Kingdom of Jordan, Ministry of Health.

8. Jordan’s population of around 5,329,000 is made up of the 

following ethnic groups: Arab 98%, Circassian 1%, Armenian 

1%. Religious groups include: Sunni Muslim 92%, Christian 

6% (majority Greek Orthodox, but some Greek and Roman 

Catholics, Syrian Orthodox, Coptic Orthodox, Armenian 

Orthodox, and Protestant denominations), other 2% (several 

small Shi’a Muslim and Druze populations) (2001 est.). www.

cia.gov/cia/publications/factbook/geos/jo.html.

9. The population of Israel is made up of the following ethnic groups: Jewish 80.1% (Europe/America-born 32.1%, 

Israel-born 20.8%, Africa-born 14.6%, Asia-born 12.6%), 

non-Jewish 19.9% (mostly Arab) (1996 est.). Religious 

groups include: Jewish 80.1%, Muslim 14.6% (mostly Sunni 

Muslim), Christian 2.1%, other 3.2% (1996 est.) www.cia.

gov/cia/publications/factbook/geos/is.html.

10. For more details and a full country profile, see the United 

Nations website at 

www.unodc.org/egypt/en/country_profile_israel.html. 

11. The Palestinian Authority population is made up of the following ethnic groups: Palestinian Arab and other, 99.4%; 

Jewish, 0.6%. The West Bank population is made up of the 

following ethnic groups: Palestinian Arab and other, 83%; 

Jewish, 17%. Religious groups in the Gaza Strip include: 

Muslim (predominantly Sunni), 98.7%; Christian, 0.7%; 

Jewish, 0.6%. In the West Bank religious groups include: 

Muslim, 75% (predominantly Sunni); Jewish, 17%; Christian 

and other, 8%. 

www.cia.gov/cia/publications/factbook/geos/we.html.

12. Statistics from 2001: 

www.cia.gov/cia/publications/factbook/geos/cy.html.

13. See Report of the United Nations Development Programme 

2004 (Human Development Index 2002). Launched by the 

United Nations in 1990, the Human Development Index 

(HDI) measures a country’s achievements in three aspects 

of human development: longevity, knowledge, and a decent 

standard of living. It was created to re-emphasize that people 

and their lives should be the ultimate criteria for assessing 

the development of a country, not economic growth. Current 

values range from 0.956 (Norway, 1/177 countries) to 0.273 

(Sierra Leone, 177/177 countries). Countries fall into one of 

three groups: countries 1-55=high development; 56-141=medium development; 142-177=low development. See: 

hdr.undp.org/statistics/data/indic.

14. GDP Index is an aggregate figure based on all relevant HDI 

data. For details of calculations of UNDP refer to: Statistical 

feature 2: Note to table 1: About this year’s Human Development Index. hdr.undp.org/statistics/data/indic.
Chapter 3 The MECC Region in Context

National Cancer Institute 24 MECC Palliative Care Monograph 

15. This composite measure of overall health system attainment 

is based on a country’s goals relating to health, responsiveness, and fairness in financing. The measure varies widely 

across countries and is highly correlated with general levels 

of human development as captured in the human development index. For details on how this measure is calculated, 

see Tandon A, Murray CLJ, Lauer JA, Evans DB. Measuring 

overall health system performance for 191 Countries, GPE 

Discussion Paper Series: No 30; WHO 

www3.who.int/whosis/discussion_papers/pdf/paper30.pdf. 

16. For full details of the health care history and structure in Israel, see Rosen B. In Thomson S & Mossialos E, eds. Health 

care systems in transition: Israel, Copenhagen: European 

Observatory on Health Care Systems 2003;5:1.

17. Banks DA, Millburn L, Sabri H. Profile of the uninsured in 

Jordan, Technical Report No. 37, PHR, 1999.

18. IOELC interview: Ahmad Al Khateib, 11 May 2005.

19. IOELC interview: Bassam Hijawi, 11 May 2005,

20. Health Indicators—health services. www.moh.gov.ps/index.

asp.

21. UNDP (2004) UNDP Focus, 3, published by United Nations 

Development Programme and the Programme of Assistance 

to the Palestinian People.

22. Health Indicators—health services. www.moh.gov.ps/index.

asp.

23. Savas B, Karahan O, Saka R. In Thomson S & Mossialos E, 

eds. Health care systems in transition: Turkey. Copenhagen: 

European Observatory on Health Care Systems, 2002;4:4.

24. Ministry of Health, Ankara, 2001. www.saglik.gov.tr. 

25. Email communication: Professor Yasemin Oguz—18 September 2005.

26. Oguz NY, Miles SH, Buken N, Civaner M. End of life 

care in Turkey, Cambridge Quarterly of Healthcare Ethics, 

2003;12:279-284.

27. We have used the crude death rate (CDR/1000) because it is 

the only comparative measure where figures are available for 

all MECC members.

28. Source: Cited from Cancer Research UK, Information Resource Centre “Cancer in the EU: incidence and mortality in 

the European Union” based on estimates in 2000. Accessed 

29th June 2005 info.cancerresearchuk.org/cancerstats/.

29. Ferlay J, Bray F, Pisani P, Parkin DM. GLOBOCAN 2000: 

Cancer incidence, mortality and prevalence worldwide, v1.0 

IARC Cancerbase No. 5 (Lyon: IARC Press), 2001.

30. All figures in this section have been calculated from returns 

by the Israel Ministry of Health Statistics 2002 www.health.

gov.il/english/.

31. Omar S, Khaled H, Gaafar R, Zekry AR, Eissa S, El-Khatib 

O. Breast cancer in Egypt: a review of disease presentation 

and detection strategies, La Revue de Santé de la Méditerranée orientale, 9, No. 3, 2003. www.emro.who.int/Publications/EMHJ/0903/PDF/26%20Breast%20Cancer%20in%20

Egypt.pdf.

32. The Palestinian Authority developed the Cancer Registration Project in 1998, with the support of MECC, the National 

Cancer Institute, Bethesda, MD, and the International Agency 

for Research on Cancer (IARC).

33. Salhab, AR and El Najjar K. Palestinian National Cancer 

Registry: Cancer Incidence in Palestine, 1998-1999, Palestinian National Authority, Ministry of Health, 2001.

34. State Institute of Statistics (T.C. Basbakanlik, Devlet 

Istatistik Enstitusu) (2004) Turkey’s statistical yearbook 

2004, State Institute of Statistics, Prime Ministry, Republic 

of Turkey. www.die.gov.tr/yillik/yillik_2004_eng.pdf. Actual 

figures: 23,775 male and female total deaths from neoplasm; 

184,330 male and female total all deaths.

35. “The Izmir Cancer Registry (ICR) is a recording and research 

center that collects cancer data from the whole population in 

line with international standards, since April 1992. Not only 

all of the hospitals of Izmir province concerned with cancer 

diagnosis and/or therapy, but also all oncology centers and 

pathology laboratories are among the data resources of ICR. 

Software of ICR is CanReg-4 of IARC (International Agency 

for Research on Cancer) and the coding base is the Turkish 

version of ICD-O-3. ICR is a member of IARC (International 

Association of Cancer Registries) and ENCR (European 

Network of Cancer Registries).” The first international paper 

of the center was published in 2001: Fidaner C, Eser SY, 

Parkin DM. Incidence in Izmir in 1993–1994: first results 

from Izmir Cancer Registry, European Journal of Cancer, 

2001;37,83-92. mecc.cancer.gov/turkey.html.

36. Izmir Cancer Registry www.ato.org.tr/konuk/kidem/Edoc3.

htm.

37. Boyle P and Ferlay J. Cancer incidence and mortality in 

Europe, 2004 Annals of Oncology 2005;16:481-488.

38. Source cited from UNAIDS 2004 Update: Cyprus at: 

data.unaids.org/Publications/Fact-Sheets01/cyprus_

en.pdf?preview=true.

39. El-Tayeb EM. Strengthening AIDS/HIV Surveillance in 

Jordan: 17-31 October 1994, World Health Organization, 

Regional Office for the Eastern Mediterranean, February, Assignment report, 1995.

40. State Institute of Statistics (T.C. Basbakanlik, Devlet Istatistik Enstitusu) (2004) Turkey’s statistical yearbook 2004, 

State Institute of Statistics, Prime Ministry, Republic of 

Turkey www.die.gov.tr/yillik/yillik_2004_eng.pdf.

41. Source: EMCDDA 2003 candidates.emcdda.eu.int/en/

page70-en.html.

42. “In 2003 and during the first quarter of 2004, UNAIDS and 

WHO worked closely with national governments and research institutions to recalculate current estimates on people 

living with HIV/AIDS. These calculations are based on the 

previously published estimates for 1999 and 2001 and recent 

trends in HIV/AIDS surveillance in various populations.” 

www.unaids.org.
Chapter 3 The MECC Region in Context

National Cancer Institute 25 MECC Palliative Care Monograph 

43. Chemtob D and Grossman Z. Epidemiology of adult and 

adolescent HIV infection in Israel: a country of immigration, 

International Journal of STD & AIDS, 2004;15:691-696.

44. Since the mid-1990s, an Israeli NGO, The Jerusalem AIDS 

Project, has run regular training workshops for health professionals and “supports an ongoing network of concerned health 

professionals, devoted to AIDS prevention.” For details, see 

Schenker I (1997) HIV/AIDS in the Middle East and Israel: The 

Jerusalem AIDS Project, Shalom Magazine 2 www.jewishvirtuallibrary.org/jsource/Health/HIV.html.

National Cancer Institute 27 MECC Palliative Care Monograph 

Cyprus (population 775,927) is an island republic covering 

an area of 9,250 square kilometers in the far northeastern 

corner of the Mediterranean Sea. The island of Cyprus 

has been divided since 1974, when conflicts between the 

Greek Cypriot majority and the Turkish Cypriot minority 

culminated in a Turkish military invasion. The UN buffer 

zone, known as the “Green Line,” separates the two ethnic 

communities inhabiting the island (Greek Cypriots in the 

south and Turkish Cypriots in the north). This separation 

dominates Cypriot life and has a significant impact on 

provision of health services in the two communities. The 

internationally recognized Greek Cypriot Republic of 

Cyprus in the south is now a member of the European 

Union, having joined in May 2004 (see Appendix 3) (1). 

Palliative care service provision

Current services

There are two nongovernmental organizations (NGOs) 

providing palliative care services in the Greek Cypriot 

south: The Cyprus Association of Cancer Patients and 

Friends (PA.SY.KAF), and the Cyprus Anti-Cancer Society 

(CACS).

Supportive care is also provided in three hospital oncology 

units; two are government-funded, and one is joint 

government- and commercially-funded. A total of eight 

palliative or supportive care services are provided across 

the Greek Cypriot south (Table 4.1). There are no palliative 

care services for Turkish Cypriots in the north, but there is 

some voluntary support for cancer patients. Palliative care 

services in Cyprus currently only provide for adult patients 

with cancer.

The Cyprus Anti-Cancer Society runs three services: 

18-bed inpatient unit at the Arodaphnousa Hospice in 

Nicosia;

home care service based at the hospice that covers all 

districts in the Greek Cypriot south;

Chapter 4

Palliative Care in Cyprus

Table 4.1 Palliative care provision in Cyprus, 2005

Adult ServicesFreestanding unit

Hospital unit

Hospital

support team

Home care

Day care 

Clinic/ Drop-in 

center

Grand Total

The Cyprus Association of Cancer Patients and 

Friends 1 1 2

Cyprus Anti-Cancer Society 1 1 1 3

Government-funded oncology units:

~Nicosia General Hospital Oncology Center

~Limassol Hospital Oncology Unit

Commercially-funded unit

~ Bank of Cyprus Oncology Center

1

1

1 3

Total 1 3 2 2 8
Chapter 4 Palliative Care in Cyprus

National Cancer Institute 28 MECC Palliative Care Monograph 

day care centers open twice a week in four districts: 

Nicosia, Limassol, Paphos and Famagusta (see Table 

4.2).

Patients, or their families, can self-refer to the Society. 

Gradually since the mid-1990s, as links have improved 

with the oncology centers, more patients are referred by 

oncologists.

The Arodaphnousa Hospice has increased the number 

of patients treated each year in the inpatient unit by 

reducing unnecessary and lengthy inpatient stays. Once 

symptoms are controlled patients are able to return home, 

only returning for inpatient treatment if needed. With 

improvements to the home care service the numbers of 

patients treated at home increased from 280 in 1999 to 

660 in 2004 (2). A total of 1400 patients in 2004 attended 

one or more home care, inpatient, or day care services, all 

of which provide medical and nursing care, psychosocial 

support, and physiotherapy (3). The four day care 

centers also offer a range of other services which can 

include music and art therapy, aromatherapy, reflexology, 

massage, hairdressing and manicure. Free transportation 

is provided for patients to access services, which in 2004 

transported around 400 patients (4). 

The Cyprus Association of Cancer Patients and Friends 

(PA.SY.KAF) offers three services, including home care, 

day care and psychosocial support (see Table 4.3).

Within these services the Association runs a lymphoedema 

clinic and a psychosocial support team. Additional 

services offered include: 

social support and activities;

a free prosthesis service;

a stop smoking clinic;

free transport to oncology units and day care centers;

financial help in situations where patients and their 

families are suffering hardship as a result of the illness.

Hospital oncology and specialist units

There are now two oncology units in government-funded 

hospitals which offer supportive care and some palliation 

(5) at the end of life to cancer patients: Nicosia General 

Hospital Oncology Center (6) and the oncology ward in 

Limassol Hospital. There is also the joint government- and 

commercially-funded Bank of Cyprus Oncology Center, 

in Nicosia, which opened in 1998 (7,8). There is a six-bed 

specialist AIDS ward in Larnaca Hospital.

Cancer patients, and their families, may opt for the patient 

to stay in one of these oncology units, where they can 

now receive specialist pain and symptom relief, or they 

may decide to self-refer or be referred to one of the two 

organizations providing the full range of palliative care 

cancer services (3). There are no private palliative care 

services available.

There are no specialist palliative care services for children 

or for patients with other life threatening illnesses such 

as AIDS, but there is some interest in offering supportive 

care for these groups of patients, as Jane Kakas of The 

Cyprus Association of Cancer Patients and Friends 

describes:

“There is an AIDS department in Larnaca Hospital, but 

I don’t think they see themselves under the umbrella of 

Table 4.2 Patient attendances in the different services run by the Cyprus Anti-Cancer 

Society – activity from 1999-2004

Service Attendances per year

1999 2004

Arodaphnousa Hospice (inpatient) 145 276

Hospice home care (daytime only) 280 660

Day care (twice weekly) - 14-18 per center

Total attendances – all services 1400

Table 4.3 Patient numbers in the two key services run by the Cyprus Association of Cancer 

Patients and Friends – activity from 1998-2003

Service Attendances per year

1998 2003

Home Care Service (5 daytime teams) 700 791

Day Care (4 units, each opens twice weekly) 

	 psychosocial support service

	 other supportive and clinical services

	 transportation service

-

1277

-

-

75

1204

120

634
Chapter 4 Palliative Care in Cyprus

National Cancer Institute 29 MECC Palliative Care Monograph 

palliative care. We invite them [to seminars], and we 

send them anything interesting that comes through. If 

there was something that was relevant I would keep them 

informed, same as I do with the pediatric oncologist. I 

always send him copies of anything that comes through, 

especially related to opioids or pain in children. They do 

use morphine with children. But children don’t really die 

at home, they tend to be admitted to the ward and given 

IV fluids with morphine. At least they are using morphine 

now for the children, which is a move forward. There are 

no government community services in Cyprus so families 

don’t feel secure to have the children at home. They would 

love to have community services, of course, but it’s a long 

way off.” (9)

Since 2003, Turkish Cypriots can access the inpatient 

and day care hospice services in the Greek Cypriot south. 

Although no palliative care at home is available in the 

north, there are two NGOs that aim to offer support for 

cancer patients. 

The Help Those with Cancer Association is run by 

volunteers (many are cancer survivors) and, with the help 

of a small number of nurses, it offers some limited home 

nursing care and support, as well as social and financial 

support to cancer patients during and following treatment, 

including those at the end of life. Volunteers will also 

support families, if needed, after a patient has died (10). 

The Kemal Saracoglu Anticancer and Anti-leukemia 

Association aims to offer support for Turkish Cypriot 

patients, but as of June 2005, the Association remains at 

the planning stage in developing a home care service (11). 

Reimbursement and funding for services (12) 

Cancer patients needing palliative care in the Greek 

Cypriot areas of the island are offered free services funded 

by either one of the two charitable organizations:

The Cyprus Association of Cancer Patients and Friends 

(PA.SY.KAF) is given an annual government subsidy, 

which in 2004 was CY£90,000. From 2005, due to 

problems with government funds, the subsidy is being 

reduced to around CY£70,000. The Association raises the 

rest of the total CY£1 million it needs to run its services 

entirely from public donations (9).

The Cyprus Anti-Cancer Society is given an annual 

government subsidy, up to 2003 this was CY£10,000. 

From 2004 the government has reduced its subsidy to 

CY£1000. The remainder of the required annual budget 

of more than CY£1 million is raised mainly from public 

donation, with some additional commercial sponsorship 

(13). There is an annual, highly popular fund-raising 

event in Nicosia called the Christadoula March, dedicated 

to the memory of “Christadoula,” a woman who died of 

breast cancer during the 1974 hostilities, and her doctor 

Demitris Soulitis, who inspired the formation of the 

Society to help cancer patients (14). In April each year 

marches are held in cities all around the south of the 

island, along with other fund-raising events, during which 

the majority of public donations are pledged (2).

The Cyprus government provides free medication via 

the oncology departments in local hospitals, and also 

for inpatients at the hospice. The hospice has access to 

laundry services via Nicosia General Hospital. There are 

no palliative services (in government-funded hospitals) 

for patients with other life-threatening illnesses. There 

are no private (fee-paying) palliative care services in 

Cyprus. Government health provision in all governmentfunded (including joint- and part-funded) hospitals or 

centers is free or at reduced payment for residents who are 

categorized as eligible for a medical card. Non-eligible 

residents are required to pay varying rates for different 

services (15). 

Opioid availability and consumption

Opioids and other related medications are available in all 

Greek Cypriot areas of Cyprus. Where necessary, opioids 

are given by injection and syringe drivers are used for 

pain relief in home care patients. However, there are still 

some problems accessing oral opioid preparations in larger 

dosages. As Sophia Pantekhi explains: 

“We’re trying to follow the guidelines from the pain step 

ladder of the World Health Organization (WHO). We 

have enough medication for pain control: MST, sevredol, 

oromorph, and fentanyl patches. We don’t have any other 

kind of morphine like oxycodone or hydromorphone. If 

we want to improve pain control, we need higher dosages 

of sevredol tablets, at the moment we only have sevredol 

10 and 20 mg. We need to increase awareness in health 

care professionals about how and when to prescribe 

opioids for their patients.” (2)

The problem of ensuring that opioid medications are 

prescribed safely has required that teams trained in 

palliative care educate health professionals (physicians, 

pharmacists and nurses) throughout the health system, 

as well as giving clear instructions to the patient. Jane 

Kakas, a British clinical nurse specialist with palliative 

care training and experience, describes the shift in 

understanding that took place in 1997, following a 

conference on palliative care pain relief:

“After the Cancer Pain conference in ’97 here in Limassol, 

we met many worldwide palliative care specialists and 

some people from the WHO, including David Joranson 

—we realized that we have to be not just a cancer 

association, we have to look at palliative care issues. 

One of the issues was that we didn’t have enough basic 
Chapter 4 Palliative Care in Cyprus

National Cancer Institute 30 MECC Palliative Care Monograph 

formulations of opioids in Cyprus. So we got together a 

presentation and we presented to oncologists, government 

doctors, pharmacists and any other doctors, anyone that 

was remotely connected, drug reps, anesthetists. We told 

them that although there are many options of new drugs 

on the market we believe you only need to have a small 

handful of drugs. So we suggested five formulations 

and an alternative opioid. Janssen was there already 

introducing Durogesic anyway. And we took this forward 

and with the backup of one specific oncologist and 

government pharmacists who understood what we were 

saying–we presented it to the government and they said 

yes and they ordered them for us. So we got of MST 10 

mg and 100 mg, morphine in 30 ml ampoules of (we don’t 

have diamorphine here), and we needed this morphine for 

the syringe drivers. We also got morphine suppositories 

and MST 30 mg in sachets for easy swallowing. We tried 

to influence doctors and nurses about how to use these 

new drugs, and even the pharmacists–I always mention 

the pharmacists because pharmacists play a huge role, and 

they have to know why somebody’s going to the hospital 

to collect so many ampoules of morphine for the syringe 

driver. If they’re not aware of what a syringe driver is and 

that’s why we require a large dose of morphine regularly, 

they question the patient and sometimes send them away 

and tell them, ‘Why do you need all this? You had some 

three days ago. You can’t come back for more.’ We just 

need to convince the policymakers that it’s okay and 

the pharmacists should have adequate information and 

education. So the achievement, I think, was to get the 

medications imported and dispensed by the government 

pharmacies. For us in home care who knew how to use 

them it was great because we were suggesting to the 

doctors to please prescribe that and we were very happy as 

they were, mostly, willing to cooperate with us.”

As Jane Kakas points out, there is still a great need to 

develop a protocol and to continue to provide basic 

education in palliative pain control:

“We need to have some protocols and education for 

the selection of patients that go onto fentanyl because 

sometimes patients who are not stable on their pain control 

are prescribed fentanyl. Some doctors aren’t sure of the 

basic WHO ladder, they’re not aware of breakthrough 

pain, they’re certainly not aware of breakthrough pain 

dosages when using Durogesic, so there’s a huge amount 

of work to be done still on very basic symptom control. 

Now I know there are great opportunities for oxycodone 

and all these other things. But I think we are not ready 

to handle more opioids than we already have. There’s a 

risk of confusing people, and the stuff we’ve got, they 

don’t know how to use that yet. So there’s a lot of basic 

education still needs to be done on that front.” (9)

Palliative care coverage

There are palliative care inpatient facilities at the 

Arodaphnousa Hospice in Nicosia. Pain and symptom 

relief is offered at the inpatient oncology unit within the 

general hospital in Nicosia—and at the Bank of Cyprus 

Oncology Centre. In Limassol there are facilities for care 

on the oncology ward in the general hospital. In Larnaca 

there are facilities for care of AIDS patients on the 

specialist ward in the general hospital (see Table 4.4).

The two palliative care NGOs provide home care teams 

throughout the five Greek Cypriot administrative districts 

(Larnaca, Limassol, Paphos and in Greek Cypriot areas of 

Nicosia and Famagusta). There are day care centers in all 

five Greek Cypriot districts offering patients a minimum 

of twice weekly services. Both NGOs offer a range of 

psychosocial services throughout these districts, although 

there are no formal bereavement services.

There is no palliative care coverage in the north (including 

the districts of Kyrenia and the Turkish Cypriot areas in 

Nicosia, Famagusta and a small area of Larnaca).

Palliative care workforce capacity

The Cyprus Anti-Cancer Society: As of 2005 the 

Society employs around 69 full- and part-time health 

professionals, 18 administrative staff, 10 kitchen and 

cleaning staff; including at the Arodaphnousa Hospice: 

Table 4.4 Palliative and supportive care in-patient services in Cyprus

Facility Service Provision

Arodaphnousa Hospice Specialist palliative care unit 18 beds

Oncology Unit:

Nicosia General Hospital

Pain and symptom relief 22 beds

Bank of Cyprus Oncology Center: Nicosia Pain and symptom relief

30 beds

Oncology Unit:

Limassol Hospital

Pain and symptom relief Inpatient facility on 

general ward

AIDS ward: Larnaca Hospital Symptom relief 6 beds
Chapter 4 Palliative Care in Cyprus

National Cancer Institute 31 MECC Palliative Care Monograph 

one medical director, one physician, 24 nurses, one social 

worker, one physiotherapist, one aromatherapist, one 

volunteer reflexologist. The Society employs two full-time 

and five part-time psychologists to work across all their 

services. The home care team is supported by hospice 

staff and in addition employs 13 nurses including a senior 

nurse, and a nurse coordinator. Volunteers support day care 

services.

The Cyprus Association of Cancer Patients and Friends 

(PA.SY.KAF): as of 2005 the Association employs around 

53 staff, with 13 administrative staff and 40 full- and parttime health professionals (three physicians, nurses, social 

workers, psychologists, physiotherapists). Each of the five 

home teams has four nurses. Volunteers support all services.

National and professional organizations

The Cyprus Anti-Cancer Society was established in 1971. 

In 1976 the Society established the Arodaphnousa Hospice 

in Nicosia, which was dedicated to nursing patients dying 

of cancer. From late 1991, the organization started to offer 

home care, through the services of hospice nurse, Neophyta 

Kouppi, who had completed a palliative care training course 

at St. Christopher’s Hospice, UK. Over the last 10 years 

hospice staff have developed a multi-professional palliative 

care team, including five separate teams for a daytime 

home care service and a lymphoedema clinic. In 2000 the 

hospice was officially recognized as a palliative care center. 

Through the hospice, the Society has developed and now 

funds the 18-bed inpatient service, the home care service, 

and since 1998 has opened day care centers in Nicosia, 

Limassol, Paphos and Famagusta (17). The Society funds 

public education programs such as the “Non-smokers 

League,” “Quitline,” a call-in stop smoking service and 

also a stop smoking clinic, and supports public lectures 

on cancer prevention. It also funds specialist training and 

education for health professionals working in palliative care 

and oncology in Cyprus.

The Cyprus Association of Cancer Patients and Friends 

(PA.SY.KAF) was founded in 1986 by anesthetist Dr. Anna 

Achilleoudi, who was herself a breast cancer survivor, 

together with a small group of women dedicated to “the 

improvement and safeguarding of the quality of life of 

cancer patients and their families.” (18) In 1992 the 

Association was keen to develop palliative care by setting 

up a home care service, and employed Jane Kakas to start 

the first team, based in Nicosia. Through the combined 

efforts of many health professionals and administrators, the 

Association has since funded the development of offices in 

five districts around the Greek Cypriot south, from which 

they run teams for home care, day care and psychosocial 

support. The three aims of the Association are:

to promote awareness about prevention and early detection 

of cancer to the public; for instance, publishing leaflets 

about having regular checkups and healthy eating;

to educate health professionals in cancer care and 

palliative care;

to provide patient services such as home care for cancer 

patients, over the age of 16, at any stage of the disease.

There is also a small organization called “Friends for Life” 

in Limassol, whose members plan to raise funds for a new 

hospice and day care service in the area. (19)

Education and training

Both the cancer NGOs in Cyprus see education and 

training as an important part of their work. Both, for 

example, are members of the European Association 

for Palliative Care (EAPC) and encourage their staff to 

attend EAPC conferences and training programs. A recent 

series of lectures, organized as a combined NGO effort 

to disseminate the Council of Europe Recommendations 

for Palliative Care, attracted a total of 220 local health 

professionals.

In the last five years the Cyprus Anti-Cancer Society has 

funded two physicians to complete Masters in Palliative 

Medicine courses in the UK. In recent years three nurses 

have completed specialist palliative care training, although 

only one nurse has stayed on working with the Society. 

There is now a two week introductory placement in the 

hospice for all second or third year student nurses at the 

School of Nursing in Cyprus. The Society is committed to 

encouraging its entire staff to take part in training, some at 

seminars provided by the hospice, but it also funds travel 

to international conferences or scholarships to complete 

specialist courses, such as Diplomas in Palliative Nursing. 

Sophia Pantekhi explains:

“We try, every year, to encourage our staff to attend courses 

related to palliative care. For example, every year we 

organize a two day seminar on psychosocial oncology. 

We have had courses on lymphoedema treatment. Our 

staff attends seminars in Athens and a few members of 

the nursing staff try to attend the hospice program in 

St. Christopher’s, either the multi-professional week or 

the three-week program. Every year we have, with the 

cooperation of the oncology department, had a closed 

workshop for the support of the staff to prevent burnout.” 

(2)

The Cyprus Association of Cancer Patients and Friends 

(PA.SY.KAF) funds training programs, such as distance 

learning courses in palliative care at the degree and 

diploma level for doctors and nurses. The Association also 

organizes short seminars and conferences. Since 1999, the 

Association has also funded specialist training courses for 

doctors, nurses, and physiotherapists in different aspects of 
Chapter 4 Palliative Care in Cyprus

National Cancer Institute 32 MECC Palliative Care Monograph 

palliative care such as pain relief, wound management, 

and lymphoedema care, as well as short courses in 

psychosocial, communication, and bereavement issues, 

symptom control, and breast cancer. The Association also 

has links with the School of Nursing in Nicosia. Jane 

Kakas:

“The School of Nursing has recognized our work, and they 

send us their training community nurses, who are doing on 

a postgraduate one year community nursing course.”

To date three courses have run with around 26 students in 

each year, but as Jane notes:

“None of them have actually gone into the community; 

they’ve all gone back into the hospital because there is 

no infrastructure. So they’ve been sending us for the last 

three years their nurses to spend time working with us, so 

at least they can see an aspect of community care. It’s very 

experiential learning for them; we don’t have the backup 

for such training in a very organized fashion. We might 

organize a bit of a study day on grief and bereavement or a 

pain lecture for half a day, but it’s very informal. However, 

they get the experience of community nursing. We try and 

place them in the community actually with the home care 

nurse for anything from 3-6 days, that’s all we can offer. 

We sometimes offer a day with the lymphoedema service 

and a day with a psychologist.” (9)

Both NGOs express the need for an expert committee to 

work with the government in planning and developing 

palliative care services and to lobby for policy 

development. In particular, they would like to see policy 

which allows provision of the full range of palliative care 

services in government-funded hospitals, available to all 

patients with other life threatening illnesses (20). 

Ethical issues

Both Greek and Turkish Cypriot communities have a 

strong tradition of family support. When a relative falls 

ill, the family will care for them and has, in the past, 

always tended to protect the relative from bad news. 

Until the 1990s, the issue of whether or not patients knew 

their diagnosis and prognosis presented difficult ethical 

dilemmas for those involved in palliative care. However, 

partly as a result of improvement in cancer survival rates, 

which reduces the fear of cancer, and partly because of 

more support for the patient and their families there has 

been a significant shift in attitudes; over time, patients and 

their families have become more willing to speak openly 

about their illness. As Neophyta Kouppi describes: 

“There are families actually, they need to protect the 

patient, and they visit the oncologist before and they say 

‘please don’t tell my father his diagnosis, tell everything 

to me.’ You know they want to protect the patient, so 

they stop the doctor giving information. But if I go back 

and think about the time we started till now, there are big 

changes, big steps. Now more patients know about their 

illness and they know their prognosis and they do things 

before they die, and they speak more openly.” (3) 

Marie-Christina Tchopourian agrees that there have been 

great changes since 1999 when she started work in the 

hospice: 

“I’ve seen a change in the way they speak with their 

families about this issue. Before it was much more 

difficult, there was more of an act around this issue. Now I 

think people are a bit more honest. I think a lot of it has to 

do with our doctors changing, and informing the patients 

about their condition, instead of hiding information like 

they used to. On the other hand, the patients are more 

ready now to talk about these issues. The families are not 

always so ready, and at times we work with the families to 

prepare them to talk with the patient. Ten or 12 years ago, 

you would rarely hear the word cancer being mentioned, it 

was always referred to with other names: that’s changing 

radically. Part of the reason for that is that the doctors 

are changing; another big part is all the patients that are 

surviving cancer. Because Cyprus is a small community, 

these things are easily made known: that this person had 

cancer but is OK now, so people are less afraid.”

Marie-Christina Tchopourian identifies the biggest ethical 

problem now: how much information a patient has. She 

explains: 

“The biggest problem a psychologist faces is when we 

know more information than the patient, because we 

really ask the patient to be honest and we are expected to 

be honest. It really puts us in a difficult position to know 

more about their illness than they know because they often 

ask. It’s not a psychologist’s job to inform a patient about 

their illness or prognosis, but the ethical issue lies in the 

fact that we work to develop a trusting relationship and 

it feels unethical to know and act as if we don’t know. 

Encouraging a more honest relationship between the 

doctors and patients might solve some of the problem. 

But, still I think there might be points where the doctor 

is reluctant to reveal to the patient a poor prognosis, for 

example. Yet they would openly share it with the multidisciplinary team. Other members of the team might 

face the same difficulty, but a trusting relationship might 

not be so crucial for their job, as it is for a therapeutic 

relationship between psychologist and patient. A 

psychologist is expected to really be there.” 

The different ways people relate to spiritual attitudes seem 

to have influenced and been influenced by more open 

discussions about death and dying. As Barbara Pitsillides 

affirms in her 2003 report on palliative care in Cyprus, 

there is a great diversity in beliefs and values of patients 
Chapter 4 Palliative Care in Cyprus

National Cancer Institute 33 MECC Palliative Care Monograph 

and their families (22). Neophyta Kouppi comments:

“We have a priest from the Greek Orthodox church in 

the hospice. For the other people who come here, like 

Turkish Cypriots or people from Sri Lanka, Russia or 

other religions, we always encourage them to bring their 

own spiritual representative, their own religion if they 

want to talk, or to have any kind of service, and we try to 

give them a single room so they can have their privacy. I 

think people speak more openly now; even if they don’t 

believe in any god, there is something more, life after 

death. They are more open, and they talk more about their 

family problems, like for example, if they have a child 

at home who is sick and probably the mother is anxious 

who is going to take care after her death, or if they feel 

angry with somebody from the family, then they talk more 

openly. So people from our multi-disciplinary team can 

help. We can bring in family members and we can help 

them find solutions for their anxiety.” (3)

History and development of 

­palliative care

Narrative history of palliative care

In Cyprus specific care for cancer patients at the end of 

life started to be established in the mid-1970s, initiated by 

the Cyprus Anti-Cancer Society, whose founder members 

recognized a need for support in the population. As 

Neophyta Kouppi, now the Matron at the Arodaphnousa 

Hospice, Nicosia, explains, in the early days:

“Few people in Cyprus knew about hospice and palliative 

care. We started because we wanted to help the cancer 

patients to have somebody to care about them. Because 

after the Turkish invasion and all the problems we’d had 

in the general hospital with refugees with cancer and 

nobody to look after them and all those problems, we 

thought we needed to build a home for them and take care 

of them. But we didn’t know about hospice philosophy. 

Later on, we heard about hospice care and that was 

after, I think, the second meeting in London with Cicely 

Saunders. One of our members, Dr. Soulitis, an oncologist, 

heard about St. Christopher’s, so he went there to visit and 

he returned with many ideas about hospice care and how 

to control pain and symptoms. So we started to do more 

things actually about pain, with medicine; for example, to 

give medications regularly, so as not to be in pain. After 

a few years we helped the families to spend time with the 

patients, and encouraged them to go home on weekends, 

you know, to spend time with their family. But we didn’t 

know that this kind of care is hospice care.” 

By the beginning of the 1990s, there was increasing 

awareness of the concepts of palliative care. Both 

organizations, Cyprus Anti-Cancer Society and The 

Cyprus Association of Cancer Patients and Friends (PA.

SY.KAF), independently recognized the need to develop 

home care services. Neophyta Kouppi describes her early 

work setting up the home care service as part of her role in 

Arodaphnousa Hospice:

“From the end of 1991 in November, I started to visit the 

Oncology Department in the general hospital and meet the 

patients who had finished their treatments and were going 

home. I used to visit the Oncology Department twice 

a week in cooperation with the oncologist to meet the 

patients and their families. I gave them information about 

the home care we could offer them. After their agreement 

we would start visiting them at home.” (3)

Within a year she had started to enlist more help from 

two other nurses and had engaged medical support from 

the hospital oncologists, who prescribed medication 

to be taken at home. She encouraged the Society to 

develop services in more districts of the island, initially 

in Limassol. By the end of the 1990s, services had been 

extended to four of the five Greek Cypriot administrative 

districts. 

In 1992, Jane Kakas had started to set up the first 

independent home care team, at the instigation of PA.SY.

KAF, in Nicosia. Since this time both NGOs have 

developed teams in all five Greek Cypriot districts. One 

important innovation developed by PA.SY.KAF has been 

the “DITIS” computerized patient record system, which 

allows the home care team to access a central patient 

record by internet or mobile. Although still in early 

stages of implementation, the aim is for all members of 

the team to be able to share and communicate with each 

other anywhere on the island and adjust records or discuss 

problems as needed (23). About 35% of cancer patients 

now die at home with support from home care teams 

provided by either Cyprus Anti-Cancer Society or PA.SY.

KAF.

Since the late 1990s, both NGOs responded to the need 

to have dedicated full-time physicians in their services, 

by funding specialist training. For instance, in PA.SY.

KAF one part-time physician has completed a Master’s 

in Palliative Care and another part-time physician has 

completed a Diploma in Palliative Care. In the Cyprus 

Anti-Cancer Society, two full-time physicians have 

completed a Master’s in Palliative Medicine in the UK.

Psychosocial support has been increasingly prioritized 

by both NGOs. In 1996 the hospice staff requested that 

the Cyprus Anti-Cancer Society employ their first social 

worker. In 1999 the Society appointed its first full-time 

psychologist, Marie-Christina Tchopourian. She explains 

the ways the psychosocial staff now work: 

“We are two full-time psychologists and five part-time, 
Chapter 4 Palliative Care in Cyprus

National Cancer Institute 34 MECC Palliative Care Monograph 

covering all the Greek Cypriot districts. The hospice 

I would say is about 30% of my work. The oncology 

centers in Cyprus don’t have a position for a psychologist, 

so the voluntary organizations cover the patients’ needs. 

In the hospice, if the team and the doctor feel it would be 

beneficial, we meet with the patient or their family. At the 

beginning, there were only a few referrals, but now it’s the 

majority of the patients we have here. We also do home 

visits, working with patients cared for by the home care 

teams, other nurses, and the oncology centers, so a patient 

can meet with us at any point in their treatment, either 

at home, in the hospice, the oncology centers or at our 

offices. The same psychologist will stay with the patient 

throughout the different stages of their disease.” (21)

Hospice success stories

The Arodaphnousa Hospice was established in 1976 by 

the Cyprus Anti-Cancer Society initially as a nursing 

home for patients dying of cancer. For the first 20 years 

the hospice was run entirely by nurses. In 1991, inspired 

by the UK hospice movement, the Matron, Neophyta 

Kouppi, attended a course in palliative care at St. 

Christopher’s Hospice in London. On her return, she 

encouraged the Society to develop a dedicated palliative 

care team. By the mid-1990s they had well-established 

links with oncologists who would make weekly visits and 

advise, prescribe and adjust medications. The nurses, led 

by Neophyta Kouppi, ran the inpatient unit and provided 

home care, often working long hours in remote areas of 

the island. In 1996, the Society employed a social worker, 

who could develop much-needed psychosocial services, 

and in 1999 employed a full-time psychologist.

In 1998, the Society funded a scholarship for Dr. Sophia 

Pantekhi to take a Master’s in Palliative Medicine 

at Glasgow University, UK. She returned in 1999 to 

take the first full-time post of Medical Director for the 

hospice. Since 2002, the Society has been able to fund 

the specialist training and full-time post of a second 

physician, Dr. Eleni Karatzia, who is now working with 

the Medical Director. By 2000, the hospice had gained 

recognition as a palliative care center, able to provide 

palliative care education, with a multi-professional team. 

A purpose-built conference room and library is currently 

being completed at the hospice.

Arodaphnousa Hospice has increased the numbers 

of patients treated by supporting more people to be 

discharged back home, once their symptoms are 

controlled, and to receive care from the home care team. 

As Sophia Pantekhi explains:

“We’re trying to keep the patients at the hospice no 

longer than 14 days depending on their need for pain and 

symptom control, complementary therapies and whether 

the family need support with respite care. In the past they 

just leave the patients to stay here for months and a few 

of them for a year. We have increased the discharge of 

patients: we refer them to the home care service.” (2)

Neophyta Kouppi relates the success of the home care 

service and how it developed from a clear response to the 

need of patients:

“I found ladies crying in the sitting room of the Oncology 

Department, not because the husband has cancer or 

because he was going to die, but because they couldn’t 

help him at home and the doctor had said, ‘You have 

to take him home, we finished treatment.’ And that was 

very difficult for the family. So I wanted to do something 

and I was very enthusiastic. I wanted to do many things 

for cancer patients and I thought that first to go to their 

house and help them and then they will trust me and 

trust Cyprus Anti-Cancer Society, and slowly, slowly 

we changed things, especially with the oncologists. I 

believe that when they saw the benefits from visiting the 

patients at home the oncologists were willing to improve 

cooperation with us. Gradually we started to employ 

nurses in other districts too, and I used to work here and 

go round the districts and help the nurses, and slowly we 

start to cooperate with the local doctors in districts with 

the social workers, and with the government Welfare 

Office about economic problems and other problems. And 

we asked the psychologists from the government services 

to support patients. Now the Cyprus Anti-Cancer Society 

employs social workers, psychologists and their own 

doctors. Now things are much better and easier.” (3)

Life/oral histories

Neophyta Kouppi—Matron: Arodaphnousa 

Hospice, Nicosia: interviewed by Amanda Bingley, 8 March 2005—duration of interview: 35 

minutes

Neophyta Kouppi relates how she was the first member of 

staff to work in the Arodaphnousa Hospice when it was 

a nursing home, before the Cyprus Anti-Cancer Society 

knew about specialist palliative care: 

“I started with general nursing in the government hospital. 

But as soon as this hospice was started in 1976, I came 

here before the patients actually, after the builders went 

away. Well, I didn’t know anything about hospice by 

that time. Later on in 1991 I heard about hospice care 

and I went to London for a Master’s, and then to St. 

Christopher’s for the training course 931: ‘The Care of the 

Dying and Care of Family.’” 

With renewed confidence in her skills, following this 

specialist training, Neophyta describes how she single-
Chapter 4 Palliative Care in Cyprus

National Cancer Institute 35 MECC Palliative Care Monograph 

handedly and with great dedication started extending 

services beyond the inpatient nursing home. From 1991 

she started nursing patients in their own homes and 

through this work set up the first home care team from the 

hospice, providing care in the Nicosia area. She went on 

to set up further teams in four other districts around the 

island. She is now Matron of the 18-bed inpatient unit at 

the hospice, and over the last ten years has promoted the 

development of psychosocial and day care services.

Dr. Sophia Pantekhi, Medical Director: 

Arodaphnousa Hospice, Nicosia: interviewed by 

Amanda Bingley, 2 February 2005 – duration of 

interview: 37 minutes

Sophia Pantekhi speaks of how she was invited to start 

working as Medical Director in the Arodaphnousa 

Hospice. In 1998, after having completed her specialty in 

internal medicine, she applied for a scholarship offered by 

the Cyprus Anti-Cancer Society to do a full-time Master’s 

in Palliative Medicine at Glasgow University, UK. At 

the instigation of oncologists Dr. Helen Soteriou and Dr. 

Adamas Adamou, the Society was seeking a specialist, 

full-time Medical Director at the inpatient Arodaphnousa 

Hospice. Having completed her Master’s in 1999, Sophia 

returned to take up the position of Medical Director. She 

has encouraged a number of important initiatives at the 

hospice, including the training of a second doctor, Eleni 

Karatzia, who is completing a Master’s degree from 

Kings’ College, London, and began work at the hospice 

in 2003. With the help of other staff, Sophia has overseen 

the continuing development of psychosocial services, 

including art and music therapy; new support services 

for staff; and improvements to the home-care service 

so patients can have more options to transfer back to 

their own home if they wish. Sophia has worked hard 

to develop training for health professionals at student, 

postgraduate and professional level. She is keen to work 

towards an integrated palliative care service available 

within government hospitals and to develop services for 

all patients at the end of life, regardless of their illness.

Maria-Christina Tchopourian, Psychologist: 

Cyprus Anti-Cancer Society, Nicosia: interviewed by Amanda Bingley, 10 March 2005 – duration of interview: 35 minutes

Maria-Christina Tchopourian speaks of how she came to 

be involved in palliative care: 

“I studied psychology, and then when I did my Master’s 

I did ‘thanatological’ counseling, specializing in deathrelated issues and people with chronic diseases: cancer, 

AIDS, any disease that’s considered chronic. So that was 

my early interest. At the beginning I was more interested 

in bereavement and death, but gradually I realized that 

palliative care could be implemented and I could help 

people not only at the end of their life but throughout the 

course of the disease. So I decided that this was what I 

really wanted to do.”

She applied for a job with the Cyprus Anti-Cancer 

Society, and in 1999 was employed full-time as the 

Society’s first psychologist. She now works with one 

other full-time and five part-time psychologists and three 

full-time social workers providing psychosocial support 

for patients at home, in the hospice and in the oncology 

centers.

Jane Kakas - Clinical Nurse Specialist, Home 

care service, The Cyprus Association of Cancer 

Patients and Friends (PA.SY.KAF ): interviewed 

by Amanda Bingley, 8 April 2005 – duration of 

interview: 75 minutes

Jane Kakas talks about becoming interested in palliative 

care from her early nursing days: 

“When I worked as a nurse, as a surgical ward sister in the 

UK, we used to get a lot of referrals from GPs that were 

patients who were perhaps end stage, into our ward, and 

I got interested there in pain management and care of the 

dying. Then when I went to live in Cyprus, I worked in a 

private hospital where there was little knowledge of pain 

management. I felt very distressed and frustrated and left 

as I had an opportunity to go to the UK for a short period. 

I looked for a relevant course which would benefit my 

work in Cyprus and luckily got a place on the Care of the 

Dying 931, the ENB course and I did that at Epsom, at 

Princess Alice Hospice at Esher. And it was just the nicest 

six-week time I’ve had: it was so enjoyable and I learned 

so much. When I came back to Cyprus I was introduced 

to the current president of our Association – the Cyprus 

Association of Cancer Patients and Friends – and she said, 

‘let’s meet and see what we can do, we want to start home 

care.’ So in 1992 I went to this Association, had an office 

- I didn’t really know what to do with it, I didn’t know 

where to start - but I started to do home care in Nicosia. 

In 1995, I did the two-year, distance learning diploma 

in pain management at the University of Wales, College 

of Medicine, in Cardiff. I feel quite passionate about 

pain and the concept of suffering. I have done my best 

to share any knowledge with my colleagues and they are 

all excellent at pain and symptom control, so it was well 

worth it.”

After quite a few years in home care, Jane helped organize 

the use of a wider range of opioids. She is currently 

working towards developing national procedure and 

policy for palliative care. Although there is no primary 

medical care system or community nursing service in 
Chapter 4 Palliative Care in Cyprus

National Cancer Institute 36 MECC Palliative Care Monograph 

Cyprus there are plans to develop policy and procedures for 

registered nurses in the community, with a new community 

nurse training in place. In the last year a pilot study has been 

set up in a small area of Nicosia, with two nurses working 

in the community. Jane Kakas at PA.SY.KAF has been 

asked to jointly help write the policies and procedures with 

the School of Nursing in Nicosia.

REFERENCEs

Stjernswärd J, Clark D. Palliative medicine—a global perspective. In: 

Doyle D, Hanks G, Cherny N, Calman K (eds.) Oxford Textbook of 

Palliative Medicine. Oxford: Oxford University Press; 2003.

www.who.int/cancer/palliative/en/

ENDNOTES

 1. Throughout this report, in order to avoid unintended misunderstandings, we have used the definitions and nomenclature used by 

the United Nations to describe the two communities of the Greek 

Cypriots in the south and the Turkish Cypriots in the north (also 

referred to in Reports by the Secretary General as the Greek Cypriot 

side and the Turkish Cypriot side). We may also refer simply to 

north and south. For details about the history of conflict and the 

ongoing negotiations towards a peaceful resolution between the 

Greek Cypriots in the south of the island and Turkish Cypriots 

in the north see United Nations Peacekeeping Mission in Cyprus 

UNFICYP website: 

www.un.org/Depts/dpko/missions/unficyp/index.html.

 2. IOELC interview: Sophia Pantekhi - 2 February 2005.

 3. IOELC interview: Neophyta Kouppi – 3 March 2005.

 4. Information from Cyprus Anti-Cancer Society: 

www.anticancersociety.org.cy – as of 10 June 2005.

 5. The terms supportive care and palliative care (or palliation) are 

used to denote both different approaches to stages of treatment 

and illness, as well as the intention of care. There are a number of 

definitions in current circulation and some literatures use the terms 

interchangeably. We are following definitions of the care, generally 

considered appropriate to different stages of illness, broadly in accordance with the European Society of Medical Oncology (ESMO) 

where supportive care is all care at all stages of illness, palliative 

care is care when no cure is possible, and end-of-life care is care 

when death is imminent. www.esmo.org. 

 6. Malas S. From Cyprus. Palliative Medicine 2003;17:150. [Dr. 

Simon Malas is a specialist in oncology and palliative medicine, 

Department of Oncology, Nicosia General Hospital.]

 7. Costello J and Christoforou C. Palliative care in a Mediterranean 

culture: a review of services in the Republic of Cyprus, International Journal of Palliative Nursing 2001;7:286-289.

 8. Bank of Cyprus Oncology Centre 

www.bococ.org.cy/english-pdf/english.pdf.

 9. IOELC interview: Jane Kakas - 8 April 2005.

 10. IOELC interview: Raziye Kocaismail – 3 August 2005.

 11. Information about the Kemal Saracoglu Anticancer and Antileukemia Association: 

www.hri.org/news/cyprus/tcpr/2003/03-08-26.tcpr.html.

 12. Amounts given in local currency: Conversion rate into Intl $ at 

June 2005: CY£ 1 = $2.09.

 13. The Cyprus Anti-Cancer Society budget information for 2003.

 14. Pitsillades N. Palliative care in Cyprus, Hospice Bulletin, December 1995.

 15. Ministry of Health, Cyprus: Medical Card General Regulations 

and Application for a Medical Card as of 10 June 2005 

www.moh.gov.cy/moh/moh.nsf/medcard_en/medcard_

en?OpenDocument.

 16. Kakas J and Pitsillides B. Managing cancer pain at home: the 

experience of Cyprus 

www.whocancerpain.wisc.edu/eng/10_2/cyprus.html 

(accessed 29/06/05).

 17. Andronikou A. The Cyprus Anti-Cancer Society, EAPC Newsletter No. 33, December 1998.

 18. The Cyprus Association of Cancer Patients and Friends information as of 10 June 2005 www.cancercare.org.cy/EN/.

 19. Personal communication Kate Kottam 10 March 2005.

 20. Discussion MECC conference, Larnaca, Cyprus 2-3 February 

2004.

 21. IOELC interview: Marie-Christina Tchopourian – 10 March 2005.

 22. Pitsillides B. From Cyprus Palliative Medicine 2003;17: 121. 

[Barbara Pitsillides is a specialist palliative care nurse for PA.SY.

KAF.]

 23. Pitsillides B and Pitsillides A. A virtual multidisciplinary team for 

terminal care, European Journal of Palliative Care 2004;11:202-

203. (Aspects of this paper have been presented at the following 

conferences; “Cancer care: focus on cancer pain” at Limassol 28-31 

May 1997; 8th Congress EAPC at The Hague, Netherlands, April 

2003; High Level Ministerial Conference: eHealth: ICT for Health 

at Brussels, 22-23 May 2003.) See also Pitsillides A, Pitsillides B, 

Samaras G, et al. DITIS: a collaborative virtual medical team for 

home healthcare of cancer patients. In: Istephanian RH, Laxminarayan S, Pattichis CS, eds. M-Health: emerging mobile health 

systems, London: Kluwer Academic/Plenum; 2003.
National Cancer Institute 37 MECC Palliative Care Monograph 

Egypt (population 76,117,421) is a country in Northern 

Africa which covers an area of 1,001,450 square kilometers, 

bordering the Mediterranean Sea, between Libya and the 

Gaza Strip, and the Red Sea north of Sudan, and includes 

the Asian Sinai Peninsula. Egypt borders Israel, Libya, the 

Palestinian Authority Gaza Strip, and Sudan. 

The regularity and richness of the annual Nile River flood, 

coupled with semi-isolation provided by deserts to the 

east and west, allowed for the development of one of 

the world’s great civilizations. Today, a rapidly growing 

population (the largest in the Arab world), limited arable 

land, and dependence on the Nile all continue to overtax 

resources and stress society. 

Palliative care service provision

Current services

In Egypt, two organizations provide a total of six hospice/

palliative care services (Table 5.1). The National Cancer 

Institute in Cairo offers pain relief and symptom management at the end of life. The Cairo Evangelical Medical 

Society provides inpatient and day care hospice facilities 

at the Cairo Evangelical Medical Hospice and at Elhadara 

Elromany, in Alexandria.

Dr. Naguib Elnikhaily reports on the services at Cairo 

Evangelical Medical Hospice, developed and opened in 

2001: 

“At first there were four beds, now 11. We have a waiting 

list. We may double the number of patients in each room. 

We also have a home care program: ‘Care with Love’ 

and two outpatient clinics and are aiming for a day care 

service.” (1) 

In February 2005, inpatient numbers averaged eight to 

nine. Naguib Elnikhaily has plans for up to three more 

projects in the southeast of Cairo (2).

In contrast to such individual nongovernment organized 

services, the emphasis in government hospital oncology 

units is on the provision of basic pain relief to patients 

with advanced disease. During 2004, however, palliative 

care—seen more widely—became included in the oncology 

nursing program at the National Cancer Institute (NCI) 

(3).

Egypt has national guidelines for the management of acute 

pain and chronic cancer pain. Guidelines for symptom 

management, end-of-life care, and home-based hospice 

care are currently being developed.

Chapter 5

Palliative Care in Egypt

MECC Palliative Care Review 2006 

Chapter 5: Palliative care in Egypt 

Egypt (population 76,117,421) is a country in Northern Africa which covers an area of 1,001,450 

square kilometers, bordering the Mediterranean Sea, between Libya and the Gaza Strip, and the 

Red Sea north of Sudan, and includes the Asian Sinai Peninsula. Its boundaries border Israel, 
Chapter 5 Palliative Care in Egypt

National Cancer Institute 38 MECC Palliative Care Monograph 

Reimbursement and funding for services

The NCI is a government-funded facility. An estimated 

65% of patients are treated free of charge; the remainder 

have health insurance which covers their treatment costs. 

Cairo Evangelical Medical Hospice provides privatelyfunded inpatient hospice and home care. Patients are required to cover their own costs, but fees are reportedly 

kept to a minimum.

Opioid availability and consumption

The International Narcotics Control Board (4) has published the following figures in 2002 for the annual consumption of narcotic drugs in Egypt: codeine 296 kg (down 

from 1983 kg in 1998); morphine 5 kg (down from 12 kg 

in 2000); pethidine 87 kg (up from 30 kg in 1999). 

For the years 2000-2002, the average defined daily dose 

consumption of morphine for statistical purposes (S-DDD) 

(5) in Egypt was two. 

Palliative care coverage

There are six university-based hospital oncology units 

around the country committed to providing pain relief. 

The main oncology unit at NCI, based at Cairo University, is taking the lead to actively develop services within 

the NCI by building on work in the pain relief units. In 

addition, there are eight small cancer centers in various 

parts of the country.

Cairo Evangelical Medical Hospice receives patients from 

the local area, most of whom are referred by themselves 

or by family members. 

Palliative care workforce capacity

As of February 2005 no available data exists for numbers 

of government-funded medical and related professionals 

specifically involved in palliative care in Egypt. 

Cairo Evangelical Medical Hospice has one medical director, one senior nurse, and four assistant nurses (6).

Nursing and medical staff involved in developing palliative 

care at the National Cancer Institute, Cairo University, are 

keen to seek government and World Health Organization 

(WHO) support to initiate a needs assessment (7).

National and professional organizations

Although there are many NGOs involved in general health 

care in Egypt, currently none are dedicated to palliative 

care.

National Cancer Institute (NCI), Cairo University. This 

government organization is actively engaged in planning 

and developing services. 

The Cairo Evangelical Medical Society, a Christian organization, supports and runs one private hospice in Cairo 

and another recently opened in Alexandria.

Education and training

The Eastern Mediterranean Regional Office (EMRO) 

based in Cairo, as a WHO office aims to promote health 

in the 22 states of the region, of which Egypt is one. At 

present EMRO is proposing to develop a training program 

as part of a plan to promote palliative care services in 

Table 5.1. Palliative care provision in Egypt, 2005

Adult ServicesFreestanding unit

Hospital unit

Hospital

support team

Home care

Day care 

Clinic/ Drop-in 

center

Grand Total

Cairo Evangelical Medical Society 

~ Cairo Evangelical Medical Hospice

~ Elhadara Elromany, Alexandria

 

1

1 1 2 41

National Cancer Institute (NCI), Cairo University 1 1

Total 2 1 1 2 6
Chapter 5 Palliative Care in Egypt

National Cancer Institute 39 MECC Palliative Care Monograph 

these states, since palliative care services remain underdeveloped (8).

A palliative care training program is being developed 

at NCI, which aims to provide basic training as part of 

general medical education for doctors, nurses and other 

professionals (9).

At the Cairo Evangelical Medical Hospice, Naguib Elnikhaily has organized training courses provided by visiting 

nurses from the UK (1).

Ethical issues

Egypt has a strong cultural tradition of family support. 

When a family member is diagnosed with a life-threatening 

disease the family will assume the care for their relative. 

However, as Dr. Ahmed Helmy at NCI outlines, in addition to the problem of financial support for providing 

services there remains a lack of adequate knowledge about 

the importance of palliative care. Dr. Nagwa Elkateb also 

explains that there is a great need to educate “families 

about home palliative care” and not to rush into an inappropriate approach. As she notes, “we have a shortage of 

nurses; and we need to teach families [about palliative 

care]. We have a high respect for families.” (10) 

As several authors have highlighted in their observations 

around the world, different cultural approaches to death and 

dying may present considerable challenges in developing 

palliative care services that are sensitive to and appropriate 

for the different communities they serve (11). There is a 

continuing ethical challenge and debate concerning openly 

discussing diagnosis and prognosis with patients. For many 

of the cultural and religious traditions in this region, as 

in other parts of the world, there is marked resistance to 

openly discuss with a patient the fact of their imminent 

death. The family will tend to protect their relative and 

talk with the medical professionals directly, regardless of 

whether the patient would wish to know their prognosis 

and prepare themselves for death (12).

History and development of palliative care

Palliative care in Egypt is in the early stages of development. For many years the major support for patients with 

life-threatening illness, most particularly cancer, has been 

via oncology units specializing in pain relief (13). Tawfik 

(1993) reports that in the early 1990s he located one clinic 

focused on training a member of the patient’s family in 

pain relief with the help of the supporting doctor. 

The system of guidelines for pain relief provision and the 

focus of pain relief in oncology clinics is well-established. 

The NCI has led the way in developing pain relief for 

cancer patients. The NCI was opened in 1969, inspired 

by cancer specialist Professor Aboul-Nassr and supported 

by Professor El Sebai. As the largest cancer hospital in 

Egypt, the NCI was renovated in 1989 with a capacity of 

500 beds and a further extension built in 1993 providing 

a further 230 beds. Pain relief has always been a priority, 

particularly as the estimated 55,000-65,000 patients with 

cancer per year “usually present at a relatively advanced 

stage of their disease.” (14)

Dr. Nagwa Elkateb (Director of Nursing, NCI) reports that 

at present there is much debate about how and in what 

form palliative care might become established in Egypt; 

solutions are still unclear. She explains:

“We have good guidelines on opioids, but we have to 

assess the needs in Egypt–motivated by the workshop 

[Larnaca MECC conference, February 2004], but we don’t 

know the needs. Do we need supportive care, palliative 

care? Do we start with cancer or other diseases? Maybe 

we don’t need other hospices? Maybe a terminal care unit 

in each hospital? (10) There is felt to be a need for some 

input from experienced international organizations who 

can offer support and guidance.” (3)

Life/oral histories

Dr. Naguib Elnikhaily describes how he became interested 

in palliative care after he was treated for cancer at the 

Cleveland Clinic in the US and saw a hospice unit there. 

On his return to Cairo he discussed it with the hospital 

and started the Cairo Evangelical Medical Hospice with 

only four beds (1).

endnotes

1. Dr. Naguib Elnikhaily in discussion MECC conference, Larnaca, 

Cyprus (February 2004)

2. Personal Communication with Dr. Naguib Elnikhaily (February 2005)

3. Personal communication with Dr. Nagwa Elkateb, Director of 

the Technical Institute of Nursing, NCI, Cairo University (February 2005)

4. International Narcotics Control Board (2004) Narcotic Drugs: 

estimated world requirements for 2004. Statistics for 2002. New 

York: United Nations, 2004.

5. ‘The term defined daily doses for statistical purposes (S-DDD) 

replaces the term defined daily doses previously used by the 

Board. The S-DDDs are technical units of measurement for the 

purposes of statistical analysis and are not recommended prescription doses. Certain narcotic drugs may be used in certain 

countries for different treatments or in accordance with different 

medical practices, and therefore a different daily dose could 
Chapter 5 Palliative Care in Egypt

National Cancer Institute 40 MECC Palliative Care Monograph 

be more appropriate.’ International Narcotics Control Board. 

Narcotic Drugs: estimated world requirements for 2004. Statistics for 2002.

6. Personal communication: Dr. Fouad Bekeheit – 20 April 2005.

7. Personal Communication with Dr. Ahmed Helmy and Dr. Nagwa 

Elkateb at NCI, Cairo University (February 2005)

 8. Al-Shahri M, Brown S, Ezzat A, Khatib O. (2004) Palliative care 

initiative for the Eastern Mediterranean Region: a proposal Ann 

Saudi Med 24:6 pp.465-468

 9. Personal Communication with Dr. Ahmed Helmy, NCI, Cairo 

University (February 2005)

10. Dr. Nagwa Elkateb in discussion MECC conference, Larnaca, 

Cyprus (February 2004)

11. Musgrave C. (1995) “Rituals of death and dying in Israeli Jewish 

culture” European Journal of Palliative Care 2:2 pp.83-86

12. Gatrad AR & Sheikh A. (2002) “Palliative care for Muslims and 

issues before death” International Journal of Palliative Nursing 

8:11 pp. 526-531

13. Tawfik MO (1993) “Egypt: status of cancer pain and palliative care” Journal of Pain and Symptom Management 8 (6) 

pp.409-411

14. Khaled HM (2000) “The National Cancer Institute in Cairo” 

INCTR Newsletter 1:20 http://www.inctr.org/publications/2000_

v01¬_n20_a11.shtml
National Cancer Institute 41 MECC Palliative Care Monograph 

Israel (population 6,352,117) (1) is a country in the Middle 

East that covers an area of 20,770 sq. km. It borders the 

Mediterranean Sea between Egypt and Lebanon, and its 

land borders Egypt, Jordan, Lebanon, and the Palestinian 

Authority in the Gaza Strip and West Bank.

The population includes about 187,000 Israeli settlers on 

the West Bank, about 20,000 in the Israeli-occupied Golan 

Heights, and fewer than 177,000 in East Jerusalem (2).

PALLIATIVE CARE SERVICE PROVISION

Current services

Eleven organizations offer palliative care for adults in 

Israel, delivering a total of 27 services mainly for adults 

via seven home hospices (includes one mobile unit), four 

inpatient hospice units (three are freestanding units, one 

is hospital-based) and two hospitals offering inpatient 

palliative care. About six of these services offer pediatric 

palliative support (Table 6.1).

In addition to these specialist services, some 80 community 

health centers provide at home pain and symptom relief 

for patients at the end of life. Some oncology clinics also 

provide psychosocial palliative support. There are over 

500 oncology nurses in Israel, most of whom have completed a formal postgraduate oncology nursing qualification which includes symptom management and palliative 

care. About 30 oncology nurses have completed further 

palliative care training. These nurses work in hospital 

oncology units or in community health settings; some 

of those with further training are based in the specialist 

palliative care organizations.

A National Cancer Control Program (NCCP) for Israel 

was established during the early 2000s (3,4). A national 

HIV/AIDS policy was established in the late 1990s (5). 

These policies include an acknowledgment of palliative 

care as a component of the management of HIV/AIDS and 

cancer control. The NCCP has an advisory committee set 

up to examine palliative care needs (6). 

Tel Hashomer Hospice (Miriam and Max 

Freedman House), Sheba Medical Center, Tel 

Aviv

TelHashomer provides end-of-life care and support to 

cancer patients and their families (7). The hospice is situated at the Chaim Sheba Medical Center, a large regional 

1,563-bed hospital. The hospice, founded in 1983 by Dr. 

Marian Rabinowitz (8), was the first specialist palliative 

Chapter 6

Palliative Care in Israel

Israel
Chapter 6 Palliative Care in Israel

National Cancer Institute 42 MECC Palliative Care Monograph 

care service to be established in Israel. The service has 

developed an interdisciplinary team (physicians, nurses, 

physiotherapist, social workers, clinical psychologist and 

spiritual counselor) who are particularly experienced in 

offering specialist pain and symptom relief, together 

with psychosocial care and physiotherapy. The service 

includes:

a purpose-built, 22-bed inpatient unit (staff and 

patients moved into the new building from the original, older facility in 2003), 

a home care team providing 24-hour care for up to 

25 patients from within a 25 mile radius from the 

hospice

a palliative care outpatient clinic at the oncology 

department of the Sheba Medical Center. 

The service is based on an ethos of providing the best 

quality care at the end of life in a tranquil environment 

with adequate symptom management and support, but 

with as little intervention as possible (8). The service 

does not encourage unnecessary tests, or routine use of 

oxygen or antibiotics (7). The average duration of care 

is 16–18 days. Patients are referred by their physician 

or oncologist – dependent on approval from the Medical 

Center’s health insurance provider (9). 

Ina and Jack Kay Hospice, Hadassah Mount 

Scopus, Jerusalem

The hospice, founded in 1986 by Dr. Theodor Fink and 

Ruth Gassner RN, MA, and situated in the grounds of 

the 300-bed Hadassah Mount Scopus Hospital, provides 

end-of-life care and support to adults with cancer and 

their families. Working as a multi-professional team 

(physician, nurses, social workers, physiotherapist and 

occupational therapist) under the directorship of Ruth 

Table 6.1: Palliative care provision in Israel, 2005

Freestanding 

unit

Hospital unit 

Hospital 

consultation

Pediatric 

support

Home care

Day care 

OPD clinic

Drop-in center

Grand Total

Tel-Hashomer Hospice, Sheba Medical Centre 1 1 1 3

Ina and Jack Kay Hospice, Hadassah, Mount Scopus 1 1 2

Cancer Pain and Palliative Medicine Service, 

Sha’are Zedek Medical Center 1 1 1 1 4

Hannah Eshed Hospice, Nof Hadar Hospital, Haifa 1 1

Negev Palliative Care Services

~ home hospice 

~ desert mobile unit

~ hospital consultation service

~ Ma’agan House

1 1

1

1

1 5

Milton and Lois Shiffman Home Hospice in the Valleys 1 1

Home Care Hospice of Kiryat Tivon 1 1

Jerusalem Home Hospital 1 1 2

Nancy Caroline Hospice of the Upper Galilee 1 1

St. Louis Mission, Jerusalem 1 1

Italian Hospital, Haifa 1 1

Edmond and Lily Safra Children’s Hospital 1 1

Meyer Children’s Hospital 1 1

The Marion and Elie Wiesel Children’s Pavilion 1 1 2

Schneider Children’s Medical Centre 1 1

Total 3 4 2 6 8 1 2 1 27
Chapter 6 Palliative Care in Israel

National Cancer Institute 43 MECC Palliative Care Monograph 

Gassner, the service offers specialist pain and symptom 

control, physiotherapy, occupational therapy and psychosocial support. A part-time art therapist also attends the 

hospice at various times (10).

The hospice service includes:

a 14-bed inpatient unit (renovated in 2004)

a home care service providing 24-hour care for up to 

20-25 patients 

links with the charitable organization Yad Sarah that 

lends nursing and home care equipment (hire is free 

or in exchange for a donation). 

In 2003, the inpatient unit cared for 170 patients. Fifty 

patients were cared for by the home care service which 

provides 24-hour nursing care from a team of nurses working from the hospice (11). The hospice has developed a 

highly individualized service with dedicated and skilled 

psychosocial support led by social worker Malka Yehezkel. 

The team also works with trained volunteers who are able 

to offer general support to patients and their families. The 

social worker and other team members provide opportunities from the first assessment for patients and families to 

share anxieties and discuss concerns with hospice staff. 

Families are encouraged and supported to be involved 

in their relatives’ care equally at home or in the hospice 

unit. Members of the hospice team (the senior physician 

and home care nurses) run a counseling support service 

for patients in the hospital who transfer to the hospice. 

The hospice also offers bereavement support. 

Part of the palliative care in this service includes maintaining varying degrees of medical intervention. For instance, 

senior physician and researcher Dr. Daniel Azoulay may, 

in addition to pain relief and symptom management, also 

prescribe antibiotics, oxygen and subcutaneous fluids, if 

appropriate (10). Patients or their families can self-refer, 

or they are referred by staff in a hospital unit, or by their 

family physician or oncologist (12). 

Cancer Pain and Palliative Medicine Service, 

Sha’are Zedek Medical Center, Jerusalem

The Cancer Pain and Palliative Medicine Service, established in 1994, is part of the oncology unit at Sha’are 

Zedek, a large 500-bed medical center in Jerusalem. The 

diverse, multi-professional, multi-lingual team includes 

physicians, general and oncology nurses, a research coordinator (who is also a clinical pharmacologist), social 

workers, a spiritual counselor and a consultant psychiatrist. The team offers integrated oncology and palliative 

care, including spiritual counseling to adult patients with 

cancer. The service has:

an outpatient unit

a day care service

a 22-bed inpatient unit (opened in 2003)

inpatient consultation service.

The inpatient unit was opened for the acute management 

of hematology and oncology patients and for those in 

need of palliative care. Dr. Nathan Cherny, Director of 

the Palliative Medicine Service, explains:

“The average census is that there will probably be about 

12 palliative care inpatients at any one time. The sorts of 

problems that are dealt with are acute symptom control 

problems, patients who are imminently dying, patients who 

are not coping at home but are not imminently dying. We 

will generally stabilize them and in most cases pass them 

on to the hospice or the French Hospital. Occasionally 

they will stay with us until they die.” (13)

In 2004 a full-time spiritual counselor, Jonathan Rudnick, 

joined the Service and his role in the team has proved 

successful for many patients whether they are religious 

or secular, and is felt by staff to have provided a very 

positive contribution to the Service’s overall ethos of 

supporting the whole person (14). The Service provides 

palliative care for around 500 new patients per year, seeing 

around 1000 patients per month, of which a third require 

palliative care. Patients are referred to the palliative care 

services by oncologists within the unit and from other 

departments.

Negev Palliative Care Services, Beersheba 

Negev Palliative Care Services is a multi-disciplinary 

team (physicians, nurses, social workers) offering specialist pain and symptom relief and a range of psychosocial 

support for adults and children with cancer (15). It was 

established in 1991 as a home-care service for adults in 

the city of Beersheba. In 1994, a more extensive homebased service was initiated and a hospital consultation 

service developed for adults (16). Since the establishment 

of the children’s oncology unit at Soroka Medical Center 

in 1999, the service also offers inpatient palliative care 

consultation for children.

Based in Beersheba, the only major city in the south of 

Israel in the Negev desert, the service has to serve a large 

multi-cultural population dispersed over hundreds of miles 
Chapter 6 Palliative Care in Israel

National Cancer Institute 44 MECC Palliative Care Monograph 

(17). The organization has responded to this challenge by 

developing several different multi-professional services 

including:

three home care teams working over a wide area 

from different urban locations 

Beersheba: up to 24 patients 

Qiryat Gat: up to 46 patients per year

Rahat: between 4-6 patients (up to 14 per year)

a mobile desert unit (set up in May 2004): up to 26 

patients 

a bereavement service based in Beersheba and run 

by trained volunteers

Ma’agan House, a charitable drop-in day center, 

situated in Beersheba; this center offers psychosocial support including therapy support groups, art 

and music therapy

a hospital-based adult and pediatric palliative care 

consultation and support offered at the only regional hospital, the 1,000 bed Soroka Medical Center in 

Beersheba (18). 

The home care teams offer 24-hour support. Each year, 

the teams care for around 140 patients at the end of life. 

Roughly 78% of these patients are able to be supported to 

die in their own home. Seventy per cent of those who die 

in hospital are only admitted in the last 24 hours of life. 

Admission to the home care service is based on three criteria, as Medical Director Dr. Yoram Singer explains: 

“There must be a main caregiver, so the patient is never 

alone and he must be in such a situation that he can’t get 

his medical care in the local clinic. He has to be more 

or less housebound. Average duration of treatment is 47 

days, so we’re really talking about the very end.”

The hospital consultation service is accessible to all patients in Soroka Medical Center, Beersheba: they have 

either to be referred by their physician or oncologist, 

or they or their family may request referral. Dr. Singer 

reports:

“This year [2004-2005] I’ve seen about 450 patients. I 

see patients at the oncology daycare and I get called to 

the various wards to give consultations... Many services 

are supported by volunteers; for example, the bereavement service—currently being developed—is organized 

by social workers with a large group of trained volunteers.” (15)

Patients may self-refer to one of the three home care 

service teams, or be referred by one of the hospice service oncologists following a hospital consultation, or be 

referred by their own physician or oncologist from another 

department. The home care service has strong team support for permanent and student placement staff (family 

medicine trainee physicians). The team convenes once 

weekly for report and supervision meetings and senior 

team members provide 24-hour on-call advice.

Milton and Lois Shiffman Home Hospice in the 

Valleys 

The hospice, founded in 1999, provides home-based 

specialist palliative care including pain relief, symptom 

management and psychosocial support for adults at the 

end of life regardless of their illness, although the majority have cancer. The hospice has focused on developing 

a service sensitive to a culturally diverse, multi-religious 

population (19). For example, in Arab Nazareth the team 

may include a Jewish physician, Muslim nurse,and social 

worker, and Arabic-speaking Jewish nurses with additional 

support from Christian and Muslim volunteers and clergy 

(20). The hospice service includes: 

Seven multi-professional, culturally diverse, multilingual teams (each with supporting physician, 

nurses and social workers): providing care for up to 

45 patients at any one time

good links with local community health centers 

strong support of trained volunteers 

palliative care training programs for primary health 

care providers 

on-call consultation services for community health 

care clinics in the area. 

A total of 162 patients were cared for in 2004, for an 

average duration of 60 days. Since 1999, the hospice 

has cared for around 600 patients. The emphasis is on 

supporting patients and families to cope with the endof-life process; hospice staff will educate caregivers and 

also undertake to stay with patients and their families as 

long as they are needed (21). Around 74% of patients are 

supported to die at home. Hospice Director Mali Szlaifer 

explains: 
Chapter 6 Palliative Care in Israel

National Cancer Institute 45 MECC Palliative Care Monograph 

“When you give [the family] good education—and also 

if you give them some tips what to do to feel better, so 

they can manage with [the patient] they are not afraid and 

they feel comfortable, confident in being there and they 

know that now it’s not an emergency.” (22)

Patients can self-refer but more usually they are referred 

by their physician or oncologist. The hospice has also developed strong support for its staff. There are regular team 

meetings, group supervision (plus individual if needed), 

and 24-hour on-call advice from senior team members.

Jerusalem Home Hospital

This large organization, established in 1991 and run by 

health maintenance organization (HMO) Clalit Health 

Services (Kupat Holim Clalit) (23), offers communitybased “home hospitalization” for patients, the majority 

over 65 years old, suffering a range of subacute and chronic 

illnesses, including cancer, renal and heart failure, and 

ALS. The service provides treatment, rehabilitation, and 

for patients at the end of life, specialist palliative care (24). 

The service will also support young people and children at 

the end of life. The multi-professional team (physicians, 

specialist oncology nurses, nurses, physiotherapists, social 

workers, nutritionist, occupational and speech therapists) 

is led by geriatrician Dr. Jeremy Jacobs and palliative 

care consultant Dr. Ora Rosengarten. The service offers 

pain relief, symptom management, physiotherapy, psychosocial support, occupational therapy, speech therapy, 

nutritional advice, and home help. The service currently 

cares for around 300 patients at any one time. Roughly 

half of all patients admitted to the service are palliative 

care patients and on average 30% of these have cancer. 

The criteria for admission to the service include:

Diagnosis is clear, but the patient no longer needs 

continuous monitoring

The patient is in need of hospital-level care 

The patient and family must both agree to homebased care

There must be a supportive caregiver for the patient 

at home (not necessarily a family member)

The patient’s home is a suitable environment in 

which to nurse the patient

The patient is insured with the Kupat Holim Clalit.

The aim is to reduce hospital admission and maintain a 

high quality of total care for patients at home. Around 

50% of palliative care patients are supported to die at 

home or within 24 hours if admitted to hospital in the 

last hours. Since the service was established it has cared 

for over 13,000 patients (24).

Nancy Caroline Hospice of the Upper Galilee 

(HUG) Hospice of the Valleys

This hospice is a specialist, not for profit, home care service 

primarily for adults with cancer. The hospice was founded 

by Professor Nancy Caroline in 1994. She herself became 

ill and died in 2002. Since 2001 the multi-professional 

team has been led by Medical Director Dr. Jim Shalom. 

The hospice provides pain relief, symptom management, 

physiotherapy, nutritional advice and dedicated psychosocial support.

The hospice is committed to highly individualized care with 

the focus on a holistic approach. The multi-professional 

team (physicians, specialist oncology nurse, nurses, social 

worker who is also a family therapist, clinical psychologist, 

art therapist, music thanatologist—a harpist) are attentive 

to skilled symptom management but also to supporting 

a patient’s emotional and spiritual needs, drawing particularly on the use of creative therapies. House calls are 

typically made by a physician and nurse together. Rather 

than replace existing services, the HUG team coordinates 

care with both the primary care team and the regional Oncology Department. Trained volunteers are an important 

part of the team, offering personal support and assistance 

to the patient and families when requested. The hospice 

staff is equally involved in training volunteers.

As of 2005 the service can care for up to 35 patients at any 

one time, and the service is being expanded to increase 

care capacity. Patients are self-referred or referred by 

their physician or oncologist. Around 70-80% of patients 

are supported to die in their own home.

Home Care Hospice of Kiryat Tivon, Northern 

Israel

The hospice is a small not-for-profit home care service 

for adults living in Kiryat Tivon with cancer at the end of 

life; it is run by volunteers. The hospice was co-founded 

in 1983 by sociologist Dr. Ilene Ora Cibulski and other 

multi-professional colleagues. Dr. Cibulski is also a founding member and first chair of the Israeli Association of 

Palliative Care. Under her direction the hospice developed 

an emphasis on providing practical support for the patient 

and their family that includes:

coordinating volunteer professional medical, nursing, therapeutic, and psychosocial support (the 
Chapter 6 Palliative Care in Israel

National Cancer Institute 46 MECC Palliative Care Monograph 

patient continues to receive care from their hospital 

physician and oncologist)

arranging support from trained volunteers who as 

“friendly visitors” offer: 

home help

social support

help with child care

collection of prescriptions

cooking, shopping or other special needs 

hospice volunteers who provide a telephone information helpline for families living outside Kiryat 

Tivon

support to other organizations around Israel to develop volunteer groups

links with the other charitable organizations:

the Association of Services for the Elderly 

Yad Sarah, that lends nursing and home care 

equipment (free or in exchange for a donation) 

The hospice head nurse and social worker evaluate the 

needs of the patient and family caregiver, and they coordinate the visits of the volunteer multi-professional team 

members (physician, nurse, psychiatrist, social worker, 

physiotherapist, occupational therapist, and yoga teacher) 

who are supported by a dedicated group of nonprofessional 

volunteers. All volunteers do a basic course together and 

continue to meet on a regular basis. The service is able 

to care for between 10-18 patients at any one time, for 

an average of three months.

Hannah Eshed Hospice, Nof Hadar Hospital, 

Haifa

The hospice was founded in 1992 as a unit within the 

private Nof Hadar Hospital. A multi-professional team 

provides palliative care in the 17-bed inpatient unit. The 

hospice has always worked closely with trained volunteers who provide support for patients and families (25). 

The unit is one of the four inpatient palliative care units 

formally recognized by the Israeli government. 

French Hospital, St. Louis Mission, Jerusalem

This “free” hospital is run by a French religious order, the 

Sisters of St. Joseph. The 44-bed hospital is dedicated to 

the care of all patients with “advanced disease,” regardless 

of their faith or belief (26). They have an 18-bed inpatient 

palliative care facility. Patients may be referred by physicians or oncologists from other hospitals (13).

Al-Taj for Health and Heritage Association

This charitable association is being established as a 

volunteer-run home hospice service in north Israel. The 

service is operating with the founder, Kassim Baddarni, 

who is a registered nurse, able to undertake home visits 

to around 20 cancer patients. A needs assessment for the 

organization is completed. A multi-disciplinary team of 

two full-time and 10 part-time volunteer health professionals and lay support staff enrolled for an official start 

in January 2006 (27).

Additional hospital-based services

The Italian Hospital, Haifa provides palliative care for 

patients at the end of life (28). The 95-bed hospital, founded 

in 1905 by Italian doctors and staffed by a religious order of nursing sisters, developed an oncology unit in the 

1950s; this is now supervised by the Rambam Hospital, 

a large regional medical center in Haifa (29). The unit 

offers palliative care (including palliative radiotherapy 

with a treatment capacity of up to 500 patients a week) 

and psychosocial support (28).

A Reiki healer is currently working as a volunteer in the 

Rambam Hospital oncology unit, offering Reiki healing to 

all cancer patients at the unit who request it, at whatever 

stage in their illness (30).

Pediatric Support

At the time of this report (2005) there are no governmentrecognized or formal specialist palliative care services 

available for children in Israel (31). There are, however, 

a number of informal and general services offering consultation, advice and psychosocial support for children 

at the end of life. Palliative consultation and support is 

offered by pediatric oncologists at:

Chaim Sheba Medical Center, Tel Aviv 

Edmond and Lily Safra Children’s Hospital 

The Marion and Elie Wiesel Children’s Pavilion 

(although specialist palliative care is no longer the 
Chapter 6 Palliative Care in Israel

National Cancer Institute 47 MECC Palliative Care Monograph 

emphasis in this unit, support is provided for children at the end of life)

Rambam Medical Center, Haifa

Meyer Children’s Hospital (This hospital, based 

at Rambam Medical Center, has no formal palliative care service; however, medical oncologists 

Dr. Sergey Postovsky and Professor Miriam Ben 

Haroush are dedicated to providing pediatric palliative care whenever needed.)

Negev Palliative Care Services (Ben-Gurion University of the Negev–Faculty of Health Sciences) offer 

pediatric palliative care consultation at the 

Children’s Hospital (Soroka Medical Center, Beersheba)

The home care multi-professional team at:

Jerusalem Home Hospital will care for children and 

young people at the end of life

Members of the Psycho-Oncology Society working at:

Schneider Children’s Medical Center, Rabin Medical Center, Petah Tikva, Tel Aviv offer palliative 

support for children and also provides bereavement 

support for parents (32).

Community Health Centers 

There is a network of around 80 community centers that 

offer a home medical and nursing care service for patients 

with a range of sub-acute and chronic conditions, including those at the end of life (33). These community-based 

services vary in different locations; the extent and expertise 

of the palliative care offered depends on whether medical and or nursing staff have had specialist training (15). 

Within the available cancer services throughout Israel, 

there are around 500 oncology nurses with specialist oncology postgraduate training, which includes training in 

palliative care and symptom management. These nurses are 

working in hospital oncology units or community settings. 

Currently, around 30 oncology nurses have completed further training in palliative care and some are now working 

within hospices (hospital- or home-based) (34).

Oncology Units

Several oncology units provide psychosocial support for 

patients. A particularly comprehensive service has been 

developed by psycho-oncologists at the Beilinson Unit, 

part of the Davidoff Center, opened in 2005, at the Rabin 

Medical Center, Petah Tikva near Tel Aviv. This support 

is offered not only for inpatients at the end of life but 

also for patients attending the unit throughout treatment, 

regardless of outcome (32).

Reimbursement and funding for 

services

Specialist palliative care services in Israel are provided in 

a number of different health care settings most of which 

rely on complex sources of funding (Table 6.2). Patients 

with cancer are entitled to free medication. Patients with 

other illnesses are entitled to medication, including opioids, at a discounted rate depending on their health plan 

insurer; usually this is a flat rate per prescription.

Palliative care services which are entirely charitable and 

relying on donations are able to offer all patients free care 

and consultation. There is one private service available 

to any patients able and willing to pay fees. Health plan 

insurers are also referred to as health maintenance organizations (HMOs) (35). Three services receive a combination of charitable funding and HMO funds. One service 

has made the transition from combined funding to HMO/

Ministry of Health (MoH) funding only; HMO funds all 

include an annual per capita proportion of government 

MoH funds. Some palliative care services operate within 

one of the institutions owned and run by Clalit Health 

Services; the oldest and largest of the four nongovernmental health plans providing insurance, which provides 

services to 55% of the population. Where an HMO, such 

as Clalit Health Services (Kupat Holim Clalit) runs all or 

part of the service the patient can only receive free care 

for a certain number of services if they are signed up to 

that HMO insurance. 

Charitable funding may include monies from national and 

international donors from institutional or private sources. 

Currently the largest and most generous national, institutional donor funding palliative care services is the Israeli 

Cancer Association. The Jewish Federation in the USA 

(specific donor branches include New York and Detroit) 

is a major international donor. Charitable funds support 

a range of activities in a service: funding a health professional post; providing financial support to run a service; 

funds for individual projects as part of establishing a 

service; new facilities within a service; research and development.

Although an institution within which the palliative care 

service is based also receives a percentage of MoH funds, 

the palliative care service does not itself receive any direct 
Chapter 6 Palliative Care in Israel

National Cancer Institute 48 MECC Palliative Care Monograph 

government funds. The competitive nature of government 

versus HMO allocation can result in loss of funds for the 

service (36). Some elements of community-based services and half of all acute or rehabilitation hospitals are 

government funded, and patients can access free care if 

they have Israeli ID with paid up National Health Insurance (NHI) benefits. However, no government-funded 

NHI directly funds any specialist palliative care service. 

Hence, access to any degree of specialist palliative support 

within government-funded settings is entirely dependent 

on whether physicians or nurses in that unit or institution 

have received specialist training elsewhere (15).

Palliative care is not in what is known as the “basket of 

services” of the four national HMOs, who consequently 

are under no obligation to fund end-of-life care (13). 

HMO funding is subject to continual negotiation, i.e. 

year on year (or in some cases month on month)(37) and 

accordingly the palliative care services funded through 

a HMO have been found to be financially precarious 

and subject to sudden loss of funds (38). In fact, some 

(though not all) services funded either entirely or in part 

through charitable, nongovernment organizations (NGOs) 

may have greater financial security if they are fortunate 

to have highly committed benefactors and regular donations (39).

Opioid availability and 

consumption

In Israel the commonest generic opioid in use is morphine 

sulphate used as oral tablets, as injectable solution, or in 

IV infusions and subcutaneous “pumps” (syringe drivers). 

There is widespread and increasing use of proprietary 

opioids such as fentanyl (Durogesic), oxycodone and 

Table 6.2 Funding sources for hospice and palliative care services in Israel

Organization or service Institution (if applicable)

HMO Health plan funded – all with Kupat Holim Clalit (includes annual per capita proportion of MoH 

funds)

Tel-Hashomer Hospice * 

Edmond and Lily Safra Children’s Hospital 

The Marion and Elie Wiesel Children’s Pavilion

Chaim Sheba Medical Centre

Cancer Pain and Palliative Medicine Service, 

Sha’are Zedek Medical Center

Sha’are Zedek Medical Centre

Negev Palliative Care Services 

~ home hospice 

~ hospital consultation service

Ben Gurion University of the Negev / Soroka 

Medical Centre

Jerusalem Home Hospital

Schneider Children’s Medical Centre Rabin Medical Centre

Meyer Children’s Hospital Rambam Hospital, Haifa

Combined HMO (all with Kupat Holim Clalit) + charitable – (international /national and or local 

donations)

Negev Palliative Care Services 

~ desert mobile unit

~ Ma’agan House

Ben Gurion University of the Negev

 Nancy Caroline Hospice of the Upper Galilee

Milton and Lois Shiffman Home Hospice in the 

Valleys

 Ina and Jack Kay Hospice Hadassah Mount Scopus Hospital

Charitable – (international /national and or local donations)

Home Care Hospice of Kiryat Tivon

St. Louis Mission, Jerusalem Sisters of St. Joseph

Italian Hospital, Haifa

Private fee paying

Hannah Eshed Hospice Nof Hadar Hospital, Haifa

*Tel Hashomer Hospice inpatient unit has made a transition from combined charitable/HMO to HMO/MoH funding
Chapter 6 Palliative Care in Israel

National Cancer Institute 49 MECC Palliative Care Monograph 

hydromorphone. Pethidine is used for palliation in some 

hospitals and nursing homes, but more physicians are 

now prescribing either generic or proprietary morphine 

salts (40). Some physicians find that patients and pharmacists are happier to be prescribed proprietary opioids 

as the names do not suggest an obvious association with 

morphine (16).

Other synthetic drugs with opioid properties, such as 

tramadol, are used extensively by some physicians in 

cases of moderate to severe pain, particularly as these 

analgesics are subject to fewer restrictions and can be 

used for people who are morphine intolerant. Non-opioid 

sedatives such as midazolam are widely used by specialist 

palliative care physicians (41).

The current law permits physicians to prescribe up to 10 

days’ supply of opioids per prescription which can be 

increased up to 30 days’ supply if there is good justification. There is no upper limit set on opioid dosage per 

prescription. Dr. Nathan Cherny, Director, Cancer Pain 

and Palliative Medicine, Sha’are Zedek, describes the 

current legislative and access situation: 

“We have excellent access to all analgesics and for patients 

with advanced cancer the analgesics are all free of charge 

and we don’t have dosing limitations. The prescribing 

limitations; you can prescribe only one month at a time 

but that’s not insurmountable and so there is excellent 

availability of drugs.” (13)

In spite of legislation permitting 30 days’ supply, the 

preference is a maximum 10-day prescription, as Dr. 

Amitai Oberman, Medical Director, Home Hospice of 

the Valleys, explains:

“There is a possibility that if you write on the prescription 

that the patient is bed-bound, you can get it for 30 days. 

That’s more tricky and the pharmacies sometimes don’t 

like it, but if you give them a call it’s fine, but otherwise 

you would have to fill it for 10 days.” (42)

Unless, however, prescribing physicians are specifically 

trained in palliative care or pain management, it is still 

the case that not all physicians have the necessary confidence or training when prescribing opioids. Amitai 

Oberman continues:

“You know, you have to learn how to write a prescription 

for opioids and people don’t know how to write such a 

prescription, they make mistakes and some of the pharmacies are a bit hesitant when they see, like, colossal doses 

of fentanyl, but on the whole I think we’re doing OK.”

There continues to be a need for improvements in prescribing practices for palliative pain relief and symptom 

control (43). Most commentators emphasize the importance of ensuring adequate and sustained education and 

training for physicians (and pharmacists) at all levels. 

Dr. Jim Shalom, Medical Director of the Nancy Caroline 

Hospice of the Upper Galilee (HUG) describes some issues in the current situation: 

“One of the [notes] that [hospice founder] Nancy [Caroline] had on her refrigerator was that ‘Pain is a medical 

emergency.’ In other words we encounter problems with 

two types of physicians. We encounter problems with 

what I would—and I’m generalizing—with physicians 

who just back away from any involvement with cancer 

patients, including referring them to us. For a long time, 

and probably still in areas that are underserviced, people 

just don’t get treated properly: they don’t get treated by 

the hospital and they don’t get treated by the family physicians properly—although hopefully there are less and 

less of them. So that’s one category. The other category 

is the sort of proud family physician; he knows his stuff 

and thinks that he can handle it, when today really palliative care is different than it was 15 years ago. It’s far 

more complex, you know, the drug regimens are more 

complex and the orientation is far more sophisticated 

than it was before.” (44) 

Aliza Yaffe, Head Nurse at the Israeli Cancer Association, 

echoes these concerns, particularly the ongoing need to 

teach the principles of pain management: 

“The other day, one of the nurses came and said she went 

to see a patient in our regular surgical department. The 

doctor said that the patient that I was visiting, he’s not 

in pain but he is very restless. So we have to decide, 

do you treat that restlessness or not? Everybody must 

treat restlessness. But [the doctor] said, ‘No, that’s not 

pain so I’m not giving anything, bring the oxygen.’ You 

know, you have to teach all the time, all the time, all the 

time.” (34)

Palliative care coverage

There is relatively wide palliative care coverage in some 

major cities and well-populated regions of central and 

northern Israel (Table 6.3).

Despite the existing range of services, there is considerable concern about the shortfall in palliative care provision, particularly in remote, rural areas of the country, 

but also in large population centers, such as around the 

Tel Aviv region. 
Chapter 6 Palliative Care in Israel

National Cancer Institute 50 MECC Palliative Care Monograph 

Although many people at the end of life may have access 

to supportive care from one of the 80 community health 

services throughout the country, only a small proportion (relative to needs of the population) have access to 

one of the 27 specialist home hospital-based or inpatient 

hospice services. 

Central Israel

In central Israel there are five specialist palliative care 

services for adults and four centers supporting children. 

Four of the five available services can only care for cancer patients: 

four of these services are based in Jerusalem (with a 

combined city and district catchment population of 

829,800) (45). 

Tel Aviv (with a combined city and district catchment population of 1,177,300) has one specialist 

service for adults with cancer; three centers support 

children. Only an estimated 15-20% of the population has access to specialist services. Supportive 

care for adults is offered via hospital and community services. 

Southern Israel

There is one specialist service in the south that provides 

coverage in three cities and some of the surrounding 

desert region including:

Beersheba, the capital city of the Negev Desert, 

with a catchment population of about 180,000 

people. 

Rahat, a Bedouin city, providing for a population 

of around 32,000. A palliative care team cares for 

patients in the city and in the neighboring Jewish 

kibbutzim outside the city. 

Qiryat Gat, a city 50 kms to the north of Beersheba 

with a population estimated at 50,000. A team cares 

for patients in the city and those living within a 

radius of around 20-30 minutes drive from the city. 

The mobile palliative care unit provides coverage 

for the Bedouin people living in remote settlements 

up to 40-50 kms south of Beersheba in the desert 

region (15).

Table 6.3 Palliative care coverage in Israel (2005 estimate)

Service Inpatient bed 

capacity

Home hospice capacity 

(maximum)

Day/outpatient/ hospital 

capacity (estimate)

Tel-Hashomer Hospice, Sheba Medical 

Centre

22 25

Ina and Jack Kay Hospice, Hadassah, 

Mount Scopus

14

Cancer Pain and Palliative Medicine 

Service, Sha’are Zedek Medical Center

22 1000

Hannah Eshed Hospice, Nof Hadar 

Hospital, Haifa

17

Negev Palliative Care Services 75 (estimate) 450

Milton and Lois Shiffman Home Hospice in 

the Valleys

45

Home Care Hospice of Kiryat Tivon 18

Jerusalem Home Hospital 300

Nancy Caroline Hospice of the Upper 

Galilee

35

St. Louis Mission, Jerusalem 18 44

Italian Hospital, Haifa 95

Total 93 498 1589
Chapter 6 Palliative Care in Israel

National Cancer Institute 51 MECC Palliative Care Monograph 

Northern Israel

There are three home care hospices in the north; one 

service provides coverage in Nazareth with a catchment 

population of 350,000 (22). In the Upper Galilee and 

northern Golan Heights areas another service based in 

the small town of Rosh Pina covers a catchment population in the region of 150,000 (37). In Kiryat Tivon one 

service provides coverage for the population of 14,000.46

There are two hospital-based services in Haifa, the largest 

northern city (with a combined city and district catchment 

population 852,600) (47).

Palliative care in Israel is focused on patients with cancer. 

In 2004 a study of palliative care services in Israel conducted by Dr. Netta Bentur at the Myers-JDC Brookdale 

Institute, Jerusalem, estimated around 95% of all palliative care patients have cancer. Only 5% of patients with 

other illnesses have access to one of the four specialist 

palliative care services able to care for them. In 2004, 

only an estimated 2,000 cancer patients received specialist hospice care of the total new cases of 15,000 cancer 

patients that year, many of whom would benefit from 

these services (48).

Palliative care workforce

capacity

The total palliative care workforce capacity (full- and 

part-time) in Israel estimated in 2005 is shown in Table 

6.4.

Tel Hashomer Hospice

The hospice employs around 30 full- and part-time staff: 

medical director, inpatient hospice physician (who also 

coordinates research for the inpatient unit), 10 full-time 

nurses including head nurse and 10 part-time nurses, 

secretary, part-time staff including social worker, physiotherapist, and clinical psychologist. Other professionals 

are called in as needed including occupational therapists 

and a spiritual counselor. The home care staff includes 

one physician, three home care nurses, and a part-time 

social worker (9). The home care team can request a 

physiotherapist from the HMO for a patient if needed. 

The hospice also has support from about 22 volunteers 

(49,50). 

Ina and Jack Kay Hospice

The hospice employs around 29 full-time and part-time 

staff: hospice director, physician, 25 nurses (three nurses 

rotate duties between home care and inpatient unit), and 

two social workers. They can also call on external services for a psychologist and physiotherapist when needed 

(10).

Cancer Pain and Palliative Medicine Service, 

Sha’are Zedek Medical Center, Jerusalem

The service employs around 32 full-time staff: five fulltime physicians, including two oncologists, a physician 

fellow, a consultation psychiatrist, a clinical psychologist, 

a specialist palliative care nurse, a research and education 

coordinator (who is also a clinical pharmacologist), three 

multi-lingual social workers, a spiritual counselor, a palliative care nurse for the day care unit, seven oncology 

nurses; inpatient ward staffing is allocated an additional 

six nurses according to patient numbers, and four nursing 

aides. There are also regular placements for up to four 

medical internees, and for medical, nursing, and spiritual 

counseling students. 

Negev Palliative Care Services

The service employs a total of around 22 full- and part-time 

staff. The service also has placements for three or four 

physicians at any one time who are completing residencies 

in palliative medicine as part of their family medicine 

training. Around 12 full-time and part-time staff are based 

in Beersheba: head of division, medical director, four 

part-time physicians, one full-time and three part-time 

nurses, a full-time social worker and a part-time social 

worker who can be called upon from another facility. 

Two part-time physicians and two part-time nurses are 

based in Qiryat Gat. One part-time physician, one partPHOTOGRAPHS for Chapter 6

Photographs were taken during field visits. 

Suggested placing of images is indicated in the 

manuscript – subject to editorial preference. 

Chapter 6

Illustration 6.1: Tel Hashomer Hospice, Tel Aviv, Israel 

[photograph: Amanda Bingley, May 2005]
Chapter 6 Palliative Care in Israel

National Cancer Institute 52 MECC Palliative Care Monograph 

time nurse and a part-time driver are based in Rahat. 

The mobile desert unit is allocated three part-time staff: 

a physician, a nurse and a driver. A social worker and a 

group of volunteers are based at Ma’agan House (15).

Milton and Lois Shiffman Home Hospice in the 

Valleys 

The hospice employs 31 part-time staff: hospice manager, 

six physicians including the medical director, 16 nurses, 

six social workers, and a team secretary. One of the social workers is also the volunteer coordinator managing 

around 20 volunteers at any one time (22).

Jerusalem Home Hospital

The service employs around 50 staff including two consultant geriatricians, a consultant medical oncologist, 30 

part-time physicians (paid on a fee per patient basis), seven 

full-time and five part-time senior nurses (including a 

specialist oncology nurse), 35 part-time nurses, speech 

therapist, occupational therapist, physiotherapist, social 

worker, and dietician. Volunteers offer additional support 

for patients and families (24).

Nancy Caroline Hospice of the Upper Galilee 

(HUG)

The hospice employs 13 staff: medical director, three 

physicians, four nurses (one is a specialist palliative care 

nurse) a social worker, part-time music thanatologist, art 

therapist, secretary, and clinical psychologist. The hospice 

has support from a group of trained volunteers (37).

Home Care Hospice of Kiryat Tivon, Northern 

Israel

The hospice is run by 12 paid and volunteer professionals 

and 20 trained lay volunteers. Professional staff include 

four on-call physicians plus an internist physician, head 

nurse, two oncology nurses, social worker, physiotherapist, 

occupational therapist and a yoga teacher (46).

Exact numbers of workforce are not available for other 

adult and pediatric hospital-based services, community 

or other non-specialist services. There are Israeli Cancer 

Association funded individual specialist nurses in some 

adult and pediatric oncology units.

National and professional 

organizations

There are three national and professional organizations 

concerned either totally or in part with palliative care; 

for example, promoting awareness, organizing or advising on training programs, raising or providing funds 

for services; the Israeli Association of Palliative Care 

(Tmicha); the Israeli Cancer Association; and the Israel 

Palliative Medical Society, which is affiliated with the 

Israel Medical Society. 

Israeli Association of Palliative Care (Tmicha)

Established as a voluntary (not for profit) association in 

1993, the Israeli Association of Palliative Care (Tmicha) 

(IAPC) is an organization for all health professionals and 

trained volunteers actively involved in palliative care 

in Israel. IAPC membership includes leading figures in 

palliative care, who encourage professional and public 

education about the concepts of palliative care and proTable 6.4 Estimated palliative care workforce capacity in Israel (2005)

Role in palliative care Estimated workforce employed 

full- or part-time

Estimated workforce available on 

needs basis

Administrative staff / director

Physician/medical director 69

Nurses 

 ~ of which specialist nurses

142

~ 2

Social worker 20

Psychologist 4 1

Physiotherapist 4 1

Occupational therapist 3 1

Music / art / yoga 1 / 1 / 1 

Spiritual counsellor 2 3

Volunteers (trained) 60+
Chapter 6 Palliative Care in Israel

National Cancer Institute 53 MECC Palliative Care Monograph 

mote the development of services. Membership, which is 

currently around 800, is open to all health professionals, 

volunteers and interested lay people that identify with 

its philosophy. 

Initially chaired by Dr. Ilene Ora Cibulski, the IAPC 

produced a biannual Hebrew/English newsletter, Support, until her retirement in 2000 (51). Since 2001, the 

IAPC has been chaired by Mali Szlaifer, who is dedicated 

to continuing to develop training and networking for 

its members and for palliative care services around the 

country. IAPC has an elected Board of Directors that 

aims to represent all the professions involved in palliative 

care and from a range of different services. The work of 

IAPC includes: 

Convening annual conferences, regular meetings 

and study days, seminars, and training programs for 

health professionals—including physicians, nurses, 

social workers—and also for trained volunteers, all 

of whom are actively working in the palliative care 

services (22)

Involving members in teaching on the professional 

palliative care programs in Israel

Promoting clinical and academic research by its 

members and the dissemination of findings within 

the association

Campaigning via conferences, publications and the 

media to have palliative care included in the NHI 

legislation; and to advocate for the rights of terminally ill patients with palliative care included in the 

NHI

Supporting local projects that are developing and 

expanding services throughout the public sector

Defining palliative care and developing standards of 

quality and adequate service provision

Collating data on existing services, with the aim 

of publishing a guide to services for use by health 

professionals and the public (52).

The association puts an emphasis on the importance of 

collaboration between health professionals from different disciplines with the aim of encouraging maximum 

support for patients and families. IAPC is a collective 

member of the European Association for Palliative Care 

(EAPC).

Israel Cancer Association (ICA)

Established in 1952, as a not-for-profit nongovernment 

organization, the Israel Cancer Association is dedicated 

to the education and development of services for professionals working in the field of oncology and to promoting 

treatment, support and services for cancer patients and 

their families. The ICA has a long-term aim to “reduce 

the mortality and morbidity rates of cancer.” (53) Since 

1983, with the opening of the first hospice (Tel Hashomer) 

which was funded collaboratively by the ICA, MoH and 

HMO Kupat Holim Clalit, the association has also addressed the need to support and fund the development 

of palliative care in Israel. The association is now the 

largest national source of nongovernment funding of palliative care services. 

The ICA works both independently and in collaboration 

with HMOs and the MoH, to fund service provision, work 

placements and posts (physicians and nurses) education, 

training and research. Since the early 1980s Aliza Yaffe, 

ICA Head Nurse has, with other professional colleagues, 

promoted the concept and development of specialist oncology nurses, which now includes offering additional 

palliative care training, by providing grants for training 

and posts. The concept of the specialist oncology nurse 

was initiated in part by recognizing and responding to 

the needs of health services and in part by those health 

services realizing the benefits of having specialist nurses, 

as Aliza Yaffe explains:

“The manager of the health service in that specific section came each year to Israel Cancer Society and said we 

would like to have an oncology community nurse. I did 

lots of lobbying for a while, and that nurse, her job would 

be this and that as needed [for example], specifically in 

Arab communities she will take care of, let’s say, more 

elderly people. The Cancer Society (ICA) gives a grant 

of half-time for a registered oncology nurse for three 

to five years. Afterwards, they [the community health 

service] will absorb that job.” (34)

Those oncology nurses working in community health 

centers who have completed palliative care training can 

now offer nursing care at the end of life, alongside their 

work with cancer patients during and after treatment. The 

ICA manages a website which provides information about 

promotion of cancer prevention, raising public awareness 

for example, about smoking. ICA also runs media campaigns, produces multi-lingual leaflets and publications 

about cancer prevention, early detection and available 

cancer-related services. The association has a telephone 

helpline providing public information (53).
Chapter 6 Palliative Care in Israel

National Cancer Institute 54 MECC Palliative Care Monograph 

Israel Palliative Medical Society (IPMS)

This organization, established in 1996, is a branch of the 

Israel Medical Association, and is chaired by hospice 

physician Michaela Bercovitch. Election to the board of 

directors is restricted to physicians but general membership is open to other health professionals including nurses, 

physiotherapists and social workers. The aim of the IPMS 

is to represent physicians and other health professionals 

involved in palliative medicine and to promote palliative 

medical services, education and research: there are plans 

to develop a training fellowship (9). The IPMS, together 

with the other national organizations, is actively working towards the recognition of palliative medicine as a 

specialty by the Ministry of Health and the development 

of national clinical guidelines in palliative care. The society, with its own publication, the Journal for Palliative 

Medicine, encourages meetings, seminars and participation 

in national and international conferences, and links with 

national and international palliative medicine organizations. The IPMS is a collective member of the European 

Association for Palliative Care (EAPC) (54).

There are two international organizations: European Association for Palliative Care (EAPC) and the European 

Society Medical Oncology (ESMO) both of whom support 

and provide educational links for palliative care professionals in Israel, involving professionals in conferences, 

networking, and dissemination of publications (55).

Education and training

Education and training for all health professionals is 

regarded as key to the development of palliative care 

services in Israel, and has been an important aspect of 

service development from the early 1980s, with the opening of the first hospice. Since the late 1990s there has 

been an increase in organizing and developing training 

with more courses available (42). Although palliative 

medicine is still not recognized as a specialty in the health 

care service, it is part of all general nurse training and 

also part of postgraduate oncology nurse training. Some 

medical schools include short units for fifth year medical 

students. There are currently also training opportunities 

in Israel for physicians at postgraduate level with a twoyear diploma course at Tel Aviv University for physicians 

coordinated by Alexander Waller, Medical Director and 

Michaela Bercovitch, hospice physician, Tel Hashomer 

Hospice (Table 6.5).

Nathan Cherny, Director of the Cancer Pain and Palliative Medicine Service, Sha’are Zedek Medical Center, 

Jerusalem, explains the current situation: 

“Palliative care is part of core training for nurses and it 

is an integral part of the training for oncology nurses. 

Palliative care training for oncologists is weak and relatively ad hoc, despite the fact that at least on paper they 

have adopted the curricular guidelines of the European 

Society of Medical Oncology (ESMO) which are fairly 

stringent guidelines as to what has to be incorporated in 

training, it’s between the policy and practice that there 

continues to be a gulf. Outside of the oncology framework palliative care is very under-developed; when the 

AIDS crisis was at its peak there was an inpatient hospice 

but the whole picture has changed. But for people with 

degenerative neurological diseases or whatever they fall 

into the rubric of whatever of the home care services but 

in a very ad hoc manner and not necessarily with a lot 

of skilled care. In terms of physician training there is a 

diploma program in palliative care that has been running 

for a number of years and I think has put through probably close to about 90 or 100 graduates. It’s a two-year 

part-time program through Tel Aviv University, which has 

been primarily coordinated by Alex [Alexander Waller, 

Medical Director, Tel Hashomer Hospice] and has been 

a very successful program, and people come to do that 

from a broad variety of disciplines and from very diverse 

parts of the country. The specialty accreditation is all 

coordinated through the Israel Medical Association. At 

present they are resistant to the development of palliative 

medicine as a subspecialty but there are moves afoot to 

have a fellowship recognized. In the presentation that was 

made the recommendations have gone to the Ministry of 

Health, this issue is being addressed but these decisions 

are not in the hands of the ministry alone.” (13)

In addition to formal education courses there are a variety of training programs for health professionals (physicians, nurses, social workers, psycho-oncologists, spiritual 

counselors and creative therapists) that are organized by 

individual palliative care services and also as part of the 

work of national associations (see IAPC, ICA, IPMS). 

These programs include study days, seminars, conferences, Continuing Medical Education (CME) courses and 

specialist training units.

Israel Cancer Association (ICA) has a strong commitment to professional and public education. Since 1978, 

Head Nurse Aliza Yaffe and her colleagues at ICA have 

pioneered a specialist community oncology nurse training, which includes stoma care, breast care and palliative 

care. One of the current goals is to create a palliative care 

nursing specialty. ICA funds short specialist programs, 

for example training radiographers in mammography. 

Regular public education programs are organized to raise 

awareness about cancer, early detection treatment, and 

support (34). ICA also funds research into cancer, in-
Chapter 6 Palliative Care in Israel

National Cancer Institute 55 MECC Palliative Care Monograph 

cluding initiating and evaluating new developments in 

medical and nursing services. 

Israeli Association of Palliative Care (IAPC), in collaboration with the Israel Cancer Association and Ben 

Gurion University of the Negev, is currently organizing short “train the trainer” courses in different centers 

around Israel. Three courses ran in 2004, and five in 

2005. These are run as a 40-hour course with the hours 

divided equally between psychosocial issues, physiology, 

symptom control and pharmacology. Nurses can get CME 

(Continuing Medical Education) points for attending. 

IAPC board member Dr. Amitai Oberman describes the 

future direction for palliative care education: 

“I believe that geriatric and oncology postgraduate nurses 

should know something about [palliative care]. On the 

whole the feeling is that positive things are happening, 

and the last two years have been very fulfilling and we see 

change, and there’s money and there’s more people, and 

people are coming to the conferences, which have been 

very, very successful. We are able to attract more professionals and more public figures and health professionals, 

key leaders in medicine. Tons of work to do, especially 

within the hospital system, but the fact is that we have 

this committee which also Pesach [Professor Pesach Shvartzman] headed, from the Health Ministry, is a major 

change. It will take time ’til it will be implemented and 

there will be money and funding for palliative care, but 

it’s a change, it’s a move.” (42)

Many services also train volunteers as part of their ongoing work. There are other specialist programs including 

spiritual counseling, and international opportunities, such 

as fellowships and Master’s courses. 

At Ben-Gurion University of the Negev there is a program 

of palliative care residencies for trainee family medicine 

doctors run through the Negev Palliative Care Service. 

Through the university’s Faculty of Health Sciences the 

Table 6.5 Palliative care education and training available in Israel - 2005

Core education National specialist education and training International education/

links

Physicians Nurses Diploma/MSc/CME/Specialist courses Short units/ 

seminars

Fellowships/diplomas/

Master’s/short courses/ 

etc.

Short units of 

palliative medicine 

accessible in some 

medical schools for 5th

yr medical students 

(full inclusion as part 

of core curricula in 

all medical schools is 

under development).

All general nursing 

courses include 

a unit of palliative 

care nursing.

Several inpatient 

hospice units offer 

placements for 

student nurses 

for training in 

palliative care.

Physicians: postgraduate diploma 

(2 yr/400 hours—includes 48 hrs clinical 

experience).

Nurses – postgraduate Oncology 

Nursing qualification includes training 

in palliative care and symptom 

management. Further training available, 

as below.

Physicians and nurses working in 

palliative care services can take 

available short courses for CME credits.

“Train the trainers” short courses (40 

hours) run in different venues around 

the country – these are mostly for 

physicians and nurses.

Specialist courses (which include 

placements for students within existing 

specialist services) are available for 

health care professionals/trainees 

including psycho-oncologists, 

psychologists, social workers (e.g. the 

Master’s course, with placements at 

Ina and Jack Kay Hadassah), spiritual 

counsellors. Many hospice teams train 

their own hospice volunteers.

Regular short 

courses run 

from the IAPC, 

ICA and from 

hospice services. 

These courses 

are designed 

for physicians, 

nurses, social 

workers, allied 

health care 

professionals 

and trained 

volunteers. 

Physicians and 

nurses can apply for 

Master’s level degree 

courses, diplomas and 

fellowships in other 

countries, e.g. USA and 

UK.

Short seminars 

and courses are 

accessible for health 

care professionals 

working in palliative 

care via international 

organizations, such as 

ESMO, ASCO, EAPC, 

MECC etc.

Specialist training for 

creative therapies in 

palliative care, e.g. 

art therapy and music 

thanatology, are 

accessible in the US and 

UK. 
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National Cancer Institute 56 MECC Palliative Care Monograph 

palliative care service runs a variety of postgraduate and 

undergraduate courses. These include short training units 

for medical and nursing students as part of their professional development; postgraduate courses, seminars, and 

specialist training for oncology nurses. Medical Director Dr. Yoram Singer explains current developments in 

palliative medicine education and research, including 

more details about the collaborative “train the trainer” 

courses:

“We are more and more involved in education, to get [palliative medicine] into [the] undergraduate curricula. At 

the moment we are more involved in Continuing Medical 

Education (CME) courses for medical professionals—

nurses and doctors mostly—and, because of the success 

of the mobile unit, we got extra funding for this from 

the New York Federation. [NYF funded the Negev desert 

mobile unit.] They are enthusiastic at how things work. 

We had a six-day get-together for a “train the trainer” 

course, and there we [developed] the curriculum. Now 

we’re in the middle of running [courses], ’til the end of 

June we will run three national courses on palliative care 

(40 hours each). It’s very interesting; the enrollment is 

from social workers, nurses and doctors: multi/interdisciplinary experience. Now we have requests from many 

other places and we’re slowly building it up. And, of 

course, [we have] the family medicine medical students. 

We do a little bit of research, more audit kind of research 

at this stage.” (15,56)

Middle East Cancer Consortium (MECC) as part of its 

ongoing educational and research work organizes regular seminars in cancer registry and in oncology (57). 

Since 2004 MECC has also started to address the need 

for information and education in palliative care for all 

health professionals working in the field. The consortium 

has funded members to attend courses with the American Society of Clinical Oncology (ASCO) and has set 

up a collaborative “training the trainers” palliative care 

course between Calvary Hospital, Virginia, USA and the 

oncology unit in the Italian Hospital, Haifa. In February 2004 and November 2005 palliative care seminars 

were run for health professionals from MECC member 

countries (28).

With the growth in education and training in Israel, there 

have also been more opportunities for research in the 

field. There is currently a well-established clinical and 

academic research base in palliative care, with a strong 

record of extensive national and international publications and dissemination at international conferences. Key 

research in palliative care is undertaken by clinical and 

academic researchers from all disciplines involved in palliative care provision, many in collaboration with major 

universities in the country (58). Major areas of research 

include pain and symptom management (59–62), pain 

assessment and needs (63,64), and cultural aspects of 

palliative care (65,66). Palliative care research publications are also internationally disseminated from nursing 

and related clinical health professionals including social 

work, psychologists (67), therapists, and academic health 

researchers.

Ethical issues

Several ethical dilemmas have been identified in palliative care in Israel. These include disclosure of prognosis, 

the impact of genetic testing on discussions of prognosis 

with patients, decisions about stopping treatment when a 

patient is at the end of life, children and bereavement, the 

new law of the dying patient, and inequalities and difficulties concerning shared responsibilities when managing 

service provision. There is also a continuing problem of 

opioid “phobia,” which affects access to pain relief and 

symptom control.

In Israel patients have the right to full disclosure of prognosis from their physicians. However, there are many 

problems that continue to arise with families requesting 

that the doctor not tell the patient, as Professor Shvartzman explains:

“The main issue that arises all the time is getting into the 

house and people telling you, family members telling you, 

‘Psst, don’t tell anything to the patient.’ I think that’s the 

most problem, ‘Don’t tell him anything at all, if he finds 

out he’ll commit suicide.’ And it’s a very complicated 

issue because, first of all, we are visitors, so you go to 

their house; you have to be polite, you cannot say, ‘Hey, 

I’ll tell you what I’ll tell you.’ But still you have to do 

what you have to do, so I think that’s the most common 

issue....What happens is the son says ‘Don’t tell Dad that 

he has cancer, or he’ll be upset.’ Dad says to his son, ‘Joseph, go in the kitchen, make a cup of tea for me, a cup 

of coffee for the doctor, get the cake from the larder and 

do something else...’ and as the son’s going out, ‘Don’t 

tell Joseph that I have cancer, he’ll be devastated if he 

finds out.’ That’s what usually happens.” (16)

This situation is changing as there is more awareness 

through the media. Although as Amitai Oberman explains, 

physicians still withhold information:

“They tend not to tell, on the whole. Nathan always says 

the physician is the first liar, which is true. Usually, in 

many cases it is up to us, or the oncologist will say, ‘You 

don’t have to come any more. If you want you can come 

again.’ In many situations we don’t directly speak to the 
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National Cancer Institute 57 MECC Palliative Care Monograph 

patients, but it varies from culture to culture and sometimes 

theoretically you would think that you would [discuss 

this less] with more orthodox people, but we’ve found 

that we will discuss death with the rabbis and imams and 

sheikhs. It varies: it’s not based on a socioeconomic or 

education level or anything like that, it’s very personal, 

I think. But, compared to America where I trained, we’re 

still more paternalistic in Israel, but the system is changing fairly rapidly and people are getting orders to tell 

patients and getting, ‘if you don’t tell patients, you may 

be liable, they can sue you.’ But still, there are problems, 

there are problems.” (42)

Shlomith Perry, who has specialized in research on the 

impact of genetic testing for women with breast cancer, is 

very aware of the ethical dilemma this poses for families 

of people who may have the test and then have to be told 

about a poor prognosis:

“[I feel that] people should learn how to deal with this 

issue, all the genetic issues, all the medical genetics which 

become very important, to change the attitude to who is 

ill and who is not ill. Is a carrier ill or not ill, because 

few of them have preventive mastectomies? How do you 

divide the division from illness and health? So I think 

that the issue of the family is very important in this, in 

the genetics because DNA is a family affair, and also at 

the end. So I think that in the medical continuum, there 

are a few areas where the family becomes very important: 

palliative care, genetics, donating [organs].” 

Shlomith Perry notes other ethical issues she has identified, around decisions by physicians and patients about 

whether to continue (or begin) treatment or when to stop 

treatment:

“It starts from the beginning, and here it will be more 

important. Palliative care will be well-established here, 

and part of the thinking in palliative care will be the influence on all the care of the patient. In Israel we don’t 

know when to stop [treatment]; the patient wants more 

and more drugs and doesn’t know when to stop. I think 

it’s a problem in Israel, a society’s not well educated to 

decide when to stop; they need all the time to continue. 

They all need education, how to be more conscious, more 

aware of the decision, not to take more chemotherapy and 

more chemotherapy because you can stop chemotherapy. 

I think we don’t know it. I think that in Israel we take 

the most and expensive drugs, because then people want 

more and more and more. This environment is that you 

must treat, you know, I think this is a Jewish cultural 

[thing] that you have to save people.” (32)

Ruth Gassner at Hadassah agrees that this is a problem 

at the very last stages of life and describes how they deal 

with the issue in the hospice: 

“The way forward is to talk with patient and family. I 

think they look at every case from a start at the zero point 

all over again. We haven’t made decisions like: we don’t 

give blood, or we don’t give feeding tubes, or we don’t 

do this. Every case is an individual case and we start 

depending on who the patient is, what the family wants. 

We are very open, talking to them.”10

There are many ethical concerns about how to support 

children in bereavement prior to their relative’s death. 

Social Worker Malka Yehezhel explains:

“Sometimes I feel when there are small children, that we 

won’t let them come and visit parents or grandfather or 

grandmother; the patient doesn’t want the visit, so what 

do we do? Usually, of course, first I try to explain and to 

work with the patient and to explain how important it is 

and that we can find a situation that will be OK for him, 

also not too difficult, not to let him feel he has to be nice 

and...even if he is sleeping just to let this child come and 

do his separation. ...I am so sure how important it is to 

help these children because I know how families try to 

protect them and try to avoid from them pain, so before 

death comes they try not to talk about, and I really do a 

lot of work with the family to help them understand how 

important it is to remember the children, to help them 

understand what’s happening.” (10)

There is an active debate in Israel about palliative care, 

euthanasia and assisted suicide, which, in 2005, culminated 

in the passing of a new law of the dying patient (68,69). 

Professor Abraham Steinberg, who chaired the committee 

on this debate, explains the kinds of ethical dilemmas 

they have attempted to address by passing a law that will 

attend to the needs of the majority of patients:

“I feel that it won’t be fair not to provide the best palliative care to those who are suffering, who want to die, 

but if we provide them with palliative care they may still 

want to live, or at least have some reason to continue to 

live. And therefore we included as part of the law, which 

I understand there are very few countries, if any, that the 

law provides for the government to be responsible to give 

palliative care. Which means that the law says that every 

dying patient, obviously we can extend it to the non-dying, 

but the law talks about the dying, so we talk about the 

dying, every dying patient should get the best palliative 

care according to the standard at that time...
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National Cancer Institute 58 MECC Palliative Care Monograph 

 “It should include finding for the accessories, for medications, for anything that palliative care demands, which 

nowadays is not available on a governmental level. And 

also we suggest that, not in the law but it comes out from 

this paragraph, that palliative care should be recognized 

as a field of medicine in the way that it should be studied, 

it should be recognized as a sub-specialty, there should be 

experts in the field - in other words it should be part of 

medicine like any other part of medicine, which I think 

is something new from a legal point of view, certainly 

in Israel but I think worldwide as well.

“On a philosophical level there might be differences on 

how we interpret palliative care: does it include always 

food and fluid and only no resuscitation, or does it include 

medication, routine medic-... I mean they are debates that 

are ongoing. So the standards of palliative care obviously 

will be presented by the experts and then there may be 

some variations on what is acceptable or not. Now whether 

it should be an acute care facility or in a hospice or in a 

home hospice or whatever, I mean, these are things that 

have to be worked out, I assume on individual levels, I 

mean, that has not to be decided on the legal, on a law

level. Because I think that certainly the hospices know 

how to work with such patients, that’s their job, but the 

problem I think is in acute care facilities where patients 

of this kind are admitted, they’re being treated like anyone else, no one knows how to take care of the aspect of 

suffering of pain, and that’s where she should put more 

emphasis. Now whether to move them out or not is a very 

individual decision, but as long as they are here or in an 

old age home or even at home, they should get the best 

palliative care—that’s the concept. ... I know some people 

say that part of palliation is hastening death because he is 

suffering and, let’s say the Dutch, their view of palliative 

care is active euthanasia, it’s a way of palliative care—that 

obviously is unacceptable from a Jewish point of view, I 

think from a true palliative care perspective as well. But 

if it involves medication and support and family and the 

social and psychological, that is very positively viewed 

even if medication occasionally may hasten death; that 

is taken into account. 

“In fact from a Jewish point of view pain and suffering 

is viewed as any other illness—let’s say someone has a 

brain tumor, what do you do for him? You take him to the 

operating room, you operate on him, and a few die on the 

table, so it doesn’t mean that you don’t operate because 

somebody died. So the same here, if you, if you equate 

pain to a brain tumor, the same way that there you give 

a treatment which is called operation and some die, you 

give a treatment which is called morphine or whatever 

and some die, so that really does not take away from the 

legitimacy, unless you purposely give such amounts that 

will kill because you think that this is the way to help the 

patient, that is not a help from the Jewish point of view... 

If the patient wants to live, to continue living, even though 

from a medical point of view it doesn’t make sense, it’s 

futile—whatever futile means—you must provide him 

whatever needed for him to continue living, including 

palliative care. Now if the patient doesn’t want to continue 

to live, then it depends what he wants. If he just wants to 

withhold treatment that is fine; if he wants to withdraw 

treatment it’s also fine as long as the withdrawal is not 

causing instant death. So for instance if he’s on dialysis 

treatment and he got ten rounds and now he doesn’t want 

any more, so you don’t give the next one because it’ll take 

days before he’ll die because of his decision, so that’s a 

withholding process from the law.” (70)

The ethics that Professor Steinberg is working to resolve 

are closely allied to the inequalities of access to adequate 

and appropriate service provision. Palliative care consultant Dr. Ora Rosengarten discusses some aspects of 

this dilemma, which she and other colleagues face in 

home hospice care:

“First there’s always the problem of keeping the patient 

at home or not. One of the problems encountered is the 

question of whether to go on with the home hospitalization or not because, if the family and the patient is 

able to manage with all this, sometimes we do have the 

feeling that—this is not a majority—but sometimes we 

have patients who call other doctors who are involved 

in the treatment. In that case we have a real medical 

problem in managing and taking the responsibility for 

the treatment.

“We do have a problem sometimes when a patient is 

alone, he doesn’t have a family to support him, and the 

dilemma is whether to get in there and give him what we 

can, but we know that it’s not optimal because there’s 

nobody there to take the responsibility. Or [can we] leave 

him like this, because if you’re not there then nothing 

will be done? But if you are there you know you cannot 

do your job properly.” (24)

In spite of the increase in education and training, several 

palliative care specialists noted that opioid phobia and 

fear of sedation continue to be problems, both among 

health professionals and the public (71). Amitai Oberman 

and Jim Shalom in the north of Israel note that they still 

encounter physicians who are afraid to prescribe opioids. 

Amitai Oberman describes the practice of pharmacists 

who still put “poison” on an opioid prescription:

“I give a couple of lectures to pharmacists. It’s fascinating to talk to them because they have their own perspec-
Chapter 6 Palliative Care in Israel

National Cancer Institute 59 MECC Palliative Care Monograph 

tive, and stories. I can give them a call and say, ‘Look... 

please help us with this,’ and it’s usually fine. They’ve 

got their own laws and rules; they’re not allowed to be 

flexible—you can’t give this, and this has to be written 

down—and still when a patient gets a script of MCR, 

they put on the back sometimes a notice saying ‘poison’ 

on it. We’re working on them to try and convince them 

it’s not really clever to put ‘poison.’ But there’s still this 

thing about narcotics in Israel. But it is changing. Some 

of the old pharmacists keep putting, just out of habit, I 

think, ‘poison’ and during my talks, I have these slides 

showing them the obstacles to the perception of opioids 

and then I show them, and I say to them, ‘Who wants to 

take a drug which is poisonous?’ ” (42)

At Hadassah, Director Ruth Gassner and Social Worker 

Malka Yehezhel discuss the difficulties they find where 

patients ask for sedation, although the family may be 

afraid to see their relative sedated: 

“That’s a dilemma that we have: the whole issue of sedating, when the patient is awake and asks us to sedate him 

and it comes from the patient.... When we deal with the 

dilemma, first we have to feel we know what we feel and 

what we think we are ready to start to do, and then we 

come to the family, because we don’t want to let them feel 

the responsibility is [just theirs] or the patients—we want 

to help, we want to be there really as helpers.” (10)

History and development of

palliative care

Narrative history of palliative care

There has been a long history of hospice care in this region dating back to the Middle Ages with the Christian 

and Jewish tradition of hospices along the crusader and 

pilgrims’ paths providing care for the needy, sick and 

dying. One or two of these ancient institutions are still 

remembered in old names and buildings in Jerusalem 

(8). In the late 1970s a group of concerned nurses, led by 

Aliza Yaffe and her other colleagues based at the Israel 

Cancer Association (ICA), started to develop postgraduate 

specialist oncology nurse training, which was established 

in 1978 and included a component of palliative care and 

symptom management. As more nurses took up specialist 

nurse training there were greater opportunities for patients 

at the end of life to be cared for at home by specialist 

nurses, first as part of the family physician system and 

later as part of community health teams, where currently 

over 500 trained oncology nurses with palliative care 

skills continue to play a vital role in providing care at 

the end of life. Aliza Yaffe, head nurse at ICA, describes 

the first ICA initiative to develop the community-based 

palliative care nursing service:

“It started in1978, more or less at that time a few nurses 

of the American Oncology Nursing Society came here 

and presented a seminar on pain management. It was a 

good place to start thinking about some other things, 

not only the care of the patients in the hospital, but also 

to see what you can do to take care of persons in the 

community. And after we were finished that course—it 

was not a very long one, 80 hours that first postgraduate 

education—I came to the Manager and I said, ‘I think 

that we need to develop oncology nursing services in the 

community. The patient is staying in the hospital for a 

short time, and when he goes home then somebody has 

to go on taking care of him.’ The hospital experience is 

very short, and most of the time he will spend at his own 

home. It started with two nurses in Tel Aviv and Ramat 

Gan; their job was to get information from the hospital 

about who was going to be discharged and go and visit 

him at home and make an assessment of his needs, and 

try to take care of those needs. The theoretical model 

said that we are going to do that from prevention, early 

detection ’til bereavement, but it very soon became obvious that that couldn’t be done, because the patient was 

suffering a lot of symptoms, mostly pain. The nurses 

were working half-time; [they] had to go and see what 

the patients needed and to learn the needs of the nurses 

that are taking care of him. So it was a lot and then we 

said, well we will postpone the prevention, early detection for a little later, and we will try and do as good as 

possible symptom management. Very few [nurses] had 

access to a physician that would come with her to see 

the patient and help him. There were community nurses 

but they had no specific cancer nursing education: no 

palliative care, no cancer nursing. They came and they 

were very nice and they were very good at the heart but 

not so good at the other things.” (34)

By the early 1980s, this concern by the ICA to develop 

the skills and knowledge of nurses in end-of-life care for 

patients at home, and the needs of patients to have access 

to skilled care, facilitated the emergence of the modern 

hospice movement in Israel, which has overseen the development of freestanding hospice units and specialist 

home care services throughout the country (Table 6.6). 

Since the 1990s, in spite of ongoing financial and political challenges, significant and steady development has 

continued in hospice and palliative care services, policy, 

professional education and public awareness. 

The current situation from the perspective of positive and 

negative aspects of palliative care service development 
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National Cancer Institute 60 MECC Palliative Care Monograph 

is summarized by Nathan Cherny, Oncologist and Director of the Cancer Pain and Palliative Medicine Service, 

Sha’are Zedek Medical Center, Jerusalem:

“The things that are strong are now our very wide network of palliative care home care services, which are 

being provided in multiple different frameworks, many 

of them by the HMOs who are the payers, which go under 

different titles of home admission and oncology home 

admission or sometimes home hospice care. There are 

also several free-standing hospice services which don’t 

belong to any HMO but which the various HMOs can 

buy services from.

“And there are different patterns of service delivery in 

different parts of the country. Most of the country, and 

this is talking about Israel as distinct from Palestinian 

territory has an increasing availability of some sort of 

home care. The quality of care is various and the training of manpower is very variable, and if one can make a 

generalization, the nursing element of the teams generally 

have some modicum of training in palliative care. The 

physician part of the team is very variable; from people 

who have got diplomas in advanced training in palliative care to people who really have no training, but who 

hopefully have some degree of supervision.

“I think that the last 10 years has seen a dramatic change 

in terms of the awareness of analgesics and the number 

of people involved in this endeavor is very large. Just 

at a local meeting of palliative care they get somewhere 

between 400 and 600 people. For a little country that’s 

a very impressive number, it would be an impressive 

number in a big country. That’s the positive side.

“The negatives; the downside is that the level of funding is very small and thus the amount of service you can 

obviously bring into people’s houses is very limited. With 

very sick people, where you’re going to be dependent 

largely upon family caregivers with really a relatively 

small amount of professional support, there are limitations as to how successful home care can be and how 

far it can go. The number of services available outside 

of the home: there are a small number of freestanding 

hospices, and to date there is only one inpatient palliative care unit in a general hospital which is the unit 

here. Overwhelmingly the rest of the hospitals in the 

country not only don’t have dedicated palliative care 

beds but the palliative care services within the hospitals 

are generally limited to maybe a part-time nurse. There 

is no widespread recognition that this is an important 

service to bring in to hospitals. A commission was called 

by the Ministry of Health to get advice about improving 

palliative care services and a palliative working paper 

has been presented to them, and one of the things that’s 

been emphasized in that is the importance of developing 

palliative care inside general hospitals. Certainly given 

that most of the cancer services are in general hospitals 

we need to make sure that these are amply supported 

with adequate manpower.” (13)

Aliza Yaffe details more of the current challenges:

“When we look at the little map of Israel, if you will 

look at the whole area, we have so many different services and our problem is how people communicate with 

each other. If we do not have an inpatient hospice in 

Beersheba then we need one because not everybody can 

take care of a person in his own home all the time. You 

need a possibility, even for respite, even for a few days; 

let the family rest a little bit, to have a place where the 

patient knows the people that will be taking care of him 

and...and even if they want to open one more door and 

they’re going to build something in his home to make 

it more comfortable. That’s one of the things that I am 

sorry that is happening, that we are not really linked. 

The problem of inpatient hospices is that patients are not 

referred, not because they don’t need to be, but because 

the health care system is reluctant to pay the price that 

the hospital management is taking for the service. That’s 

very complicated and we should do more.

“The new service that we have developed is in the hospital 

palliative care, it should be a team but it’s really [often 

just] a hospital palliative care nurse. This is something 

that we started about five years ago. One of the nurses, the 

head nurse of the hospice, developed it in Haifa in Meyer 

Hospital. The nurse is giving the service to the oncology 

department and patients that are suffering the symptoms 

are getting the treatment. She makes a whole assessment, 

and refers to the specific physician. Dr. Waller is doing 

that in Tel Hashomer; he goes to the oncology department 

once a week and has a clinic there. The nurse [refers] the 

patients that need his expertise, especially if they have a 

number of symptoms. Usually they are referred to their 

oncology nurse in the community if they are not [already 

an] inpatient. But if they are in the hospital then the staff 

are given [information] about what to continue, what to 

stop, and how to change treatment.” (34)

Individual service development since the opening of the 

first freestanding hospice in Israel is described below: 

Tel Hashomer Hospice

In 1982 Dr. Marian Rabinovitch, who was chair of geriatrics at Chaim Sheba Medical Center in Tel Aviv, and 

other colleagues in the Israel Cancer Association, decided 
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National Cancer Institute 61 MECC Palliative Care Monograph 

Table 6.6 Chronology of the establishment of palliative care services in Israel

Year services

established

Organization Type of Service Provision

Pre-1970s Charitable religious hospitals; 

French Hospital, St. Louis Mission, 

Jerusalem and the Italian Hospital, 

Haifa

These charitable institutions have a history, throughout the 20th

century, of care for the dying. The Italian Hospital had specifically 

cared for dying cancer patients since the 1950s. Since the 1980s 

specialist palliative care units were developed within both these 

hospitals as the modern hospice movement evolved in Israel.

1970 - 1980 Israel Cancer Association (ICA) Recognition and awareness of palliative care needs led to the start 

of opportunities for initiating palliative care training within a new 

specialist branch of oncology nursing that was developed from 1978 

onwards. This led to the first community home care service run by 

nurses trained and funded by ICA in Tel Aviv.

1983 Israel Cancer Association at the Tel 

Hashomer Hospice, Chaim Sheba 

Medical Centre, Tel Aviv

First inpatient hospice for adult cancer patients.

1984 Home Hospice of Kiryat Tivon First home care hospice service for adult cancer patients run by 

volunteers.

1986 Ina and Jack Kay Hospice, 

Hadassah Mt. Scopus, Jerusalem

Inpatient hospice unit for adult cancer patients.

1989 Tel Hashomer, Chaim Sheba 

Medical Centre, Tel Aviv

Ina and Jack Kay Hospice, 

Hadassah Mt. Scopus, Jerusalem

Home care service for adult cancer patients within 25 mile radius of Tel 

Hashomer Hospice. 

Home care service for adult cancer patients.

1991 Jerusalem Home Hospital

Negev Palliative Care Services, 

Beersheva 

Home care service to include palliative care for adults and children 

with all kinds of illnesses.

Home care service and hospital consultation for adult cancer patients.

1992 Hannah Eshed Hospice, Nof Hadar 

Hospital, Haifa

Inpatient private (fee paying) hospice unit for adult cancer patients.

1994 Hospice of the Upper Galilee (HUG) 

(now the Nancy Caroline Hospice)

Cancer Pain and Palliative Medicine 

Service, Sha’are Zedek Medical 

Centre, Jerusalem

Negev Palliative Care Services, 

Beersheva 

Home care service primarily for adult cancer patients - children also 

cared for if requested.

Hospital-based day care, outpatient and inpatient consultation, now 

includes inpatient palliative care unit for adult cancer patients.

Extended home care service for adult cancer patients to cover wide 

geographic area managed from a single base.

1999 Milton and Lois Shiffman Home 

Hospice in the Valleys 

Negev Palliative Care Services, 

Beersheva 

Home care hospice for adult cancer patients. 

Pediatric inpatient hospital consultation developed.

2004 Cancer Pain and Palliative Medicine 

Service, Sha’are Zedek Medical 

Centre, Jerusalem

Negev Palliative Care Services, 

Beersheva 

Spiritual counselling service developed. 

Mobile desert home care unit for adult cancer patients in remote 

geographic areas established.

2005 Ina and Jack Kay Hospice, 

Hadassah Mt. Scopus, Jerusalem

Counselling service provided by hospice team for hospice patients 

transferred to hospital.
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National Cancer Institute 62 MECC Palliative Care Monograph 

to address the end of life needs of their patients. Dr. 

Rabinovitch explored hospice care in other countries, 

first in Germany and then England, where he visited St. 

Christopher’s Hospice and was inspired by the work and 

teaching of Dr. Cicely Saunders. Returning to Israel he 

set up a multi-professional team with the support of Head 

Nurse Dvora Goren, and in 1983 they opened the first 

freestanding inpatient 25-bed hospice, Tel Hashomer, in 

the grounds of Chaim Sheba Medical Center. The care 

provided was based on the British hospice model pioneered by Dr. Cicely Saunders. 

At Tel Hashomer, Dr. Rabinovitch was joined by other 

physicians, most of whom worked on placements from 

the Geriatric Department at Chaim Sheba. Physician Alexander Waller, who became Medical Director in 1989, 

took on Dr. Rabinowitz’s work and with other colleagues 

developed the multi-professional team (physicians, nurses, 

physiotherapist, social workers, and clinical psychologist). The team was joined in 1991 by hospice physician 

Michaela Bercovitch; since 1998 she has taken on the 

post of Research and Information Coordinator (72). Tel 

Hashomer pioneered the hospice movement and was influential in supporting the development of other services, 

coordinating the establishment of professional training 

and education, and encouraging research. In 1989 the 

hospice set up a home care service for patients living 

within a 25-mile radius of Tel Hashomer. This service 

is now well-established and the nursing team can care 

for up to 25 patients at any one time (73).

Home Hospice of Kiryat Tivon

In 1984, the following year after Tel Hashomer opened, a 

small home hospice was established in the little town of 

Kiryat Tivon in northern Israel. As the founder, sociologist 

and gerontologist Dr. Ilene Ora Cibulski, explains:

“I had the privilege of joining a wonderful group of people 

who were the first group who tried to create palliative 

home care, at the same time in Tel Hashomer, I heard 

Dr. Rabinovitz who was a geriatrician, he was actually 

the first [doctor in palliative care], talking about doing 

[palliative care] in a hospital setting. I said ninety per cent 

of the people, are ninety per cent of the time at home, the 

future solutions have to be in the community, and I had 

the privilege of having a physician, Dr. Miriam Boaz, who 

was the head of the outpatient clinic at Afula Hospital, 

and Professor Schaeffer Scharf who was the head of the 

rheumatology clinic in Haifa, Ramban Hospital, and Ruth 

Givon who became our head nurse, she was a public health 

nurse and she had developed community programs for 

infants who came out of the Holocaust. All of us together 

felt that we had to do something about what was happening...and we began immediately as an interdisciplinary 

team. ...For example, Professor Scharf, he would go to 

visit a patient, he would let the local physician know, this 

was a physician who never visited a patient, especially 

when [the patient] became homebound, and [physicians] 

never went to visit. The only people who did home visits 

at the time were nurses, physicians just didn’t do it. ...

We started a training course, and within a year we had 

about twelve volunteers, plus another twelve who were 

professionals and they were wonderful.” (46)

Ina and Jack Kay Hospice, Hadassah, Mt. 

Scopus, Jerusalem

In 1986, the second inpatient hospice in Israel based at 

Hadassah, Mt. Scopus, supported by a combination of 

funds from independent benefactors and the HMO, was 

opened by physician Dr. Reuvan Fink, Social Worker 

Roni Gertel, and Pediatric Oncology Nurse Ruth Gassner, 

who describes the early years:

“The hospice was opened in ’86. I came one year before 

to think what we need, what we want, how to develop, 

how to start...the only place that we knew in Israel was 

Tel Hashomer, they opened in ’83, so we went to Tel 

Hashomer, we visited to get some ideas. And in ’86 we 

started the hospice with only one patient at the beginning. Before that I was in pediatrics, a head nurse in a 

pediatric department.

In ’85 they decided to open, there was a big donation from 

the States coming from a Jewish family that donated a lot 

of funds and this went to reopen the renovation because 

the house was deserted [since the previous occupant, 

the Hadassah hospital director, had been killed during 

military action in 1967]. I started to recruit some staff, 

and I did it on my own intuition. I didn’t know what I 

wanted; I just knew that I wanted good people. Most of 

the staff working here in the hospice [now] are people 

that started with me in ’86.”

In 1989, supported by donations from independent benefactors (the Crown Fund) the hospice opened a home care 

service, as Ruth Gassner explains:

“Dr. Fink saw the need, he was very aware of the need of 

some of the patients that came here, who said that they 

want to go back home, and if they had support at home 

they wouldn’t come to the hospice. It came from the 

patients. And he had a dream and he talked about that, I 

must say home care is not my part, but he insisted and he 

raised the money for home care with Professor Penchas 

who was the General Director of Hadassah.” (74)
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National Cancer Institute 63 MECC Palliative Care Monograph 

Helen Englesberg, one of the first nurses in the hospice 

who later joined the home care service, and Judy Yoran, 

the home care social worker note that the home care was 

set up to offer a 24-hour on-call service for patients and 

their families. Helen Englesberg explains:

“They can call...each family has a specific nurse that’s their 

nurse, but the other nurses will come to them, be there on 

a day when the nurse is not there, and then they’re also 

on-call at night and on the weekend. So any time of the 

day and night they can call to get an answer [like] you 

know, ‘should we give more pain medication?’” 

The hospice worked to create a place of empathy and trust, 

with staff keen to explore different therapeutic approaches 

to improve support for patients and their families. Social 

Worker Malka Yehezkel describes some of the very successful initiatives tried over the years for adults and for 

bereaved children, some of whom later as adults, report 

great benefits:

“We’ve tried all kind of things during the years, like 

group work here: we had an art therapist working with 

us and we tried to do groups with the families here, and 

it didn’t succeed very well. It was an open group; every 

week different people came. But I felt that families prefer the one-to-one. Sometimes...the family sit there so 

I join them and we sit together, so it’s like a group. ...

But group work after the death of the patient, maybe I 

would like to do more support groups? A few years ago 

we did group work in Tel Aviv. Ruthie [Gassner] and me, 

a nurse and a social worker, and the group was of one 

nurse and one social worker from hospices and the home 

care, and we opened a group here for children: nine to 

twelve, children of patients, a support group for after the 

death of the parent. And it was a small group but a very 

good experience for us.” (75)

Nancy Caroline Hospice of the Upper Galilee 

(HUG), Rosh Pina

Founder of HUG, physician Professor Nancy Caroline 

became interested in palliative care in the course of her 

pioneering work training emergency paramedics. In the 

late 1980s she went to Tel Hashomer Hospice to train in 

palliative medicine with Alexander Waller, and to gain 

practical experience. She left Tel Hashomer in the early 

1990s to establish her own home hospice which opened 

as the Hospice of the Upper Galilee (HUG) in 1994. She 

died in 2002. The multi-professional team has been led 

by Medical Director Dr. Jim Shalom since 2001, with 

the emphasis on offering a range of therapeutic skills 

to cancer patients and their families, The team includes 

physician and homeopath Dr. Eyal Goldberger, Dr. Marianna Zrobliov, Dr. Ehud Barav, specialist oncology and 

palliative care nurse Yael Bleich, nurses Mazal Nitoker, 

Liora Aloni and Meira Gerlick, and social worker and 

family therapist Yaniv Ben-Shoshan. The team also calls 

on volunteer psychologist Niva, art therapist, Leila and 

music thanatologist Adira. Some key aspects of the ethos 

that have, and continue to be, developed in this hospice 

are explained by Jim Shalom:

“As a policy, almost always house calls are made by 

two staff members. Usually it’s a doctor and a nurse, but 

it can be the nurse and the social worker, occasionally 

there’ll be even three. This was something that Nancy 

set up from the beginning. It’s logistically complicated 

because we’re often coming from different geographic 

directions. There are two separate reasons for this policy, 

one in order to improve patient care, and the second to 

provide support for the staff itself. When you have a 

very complex case that has different technical and emotional components and you’re alone you tend to deal with 

the technical aspects. You will be better equipped to go 

into the more painful, less quickly available solutions 

if there’s another person there. In that respect a visit of 

two facilitates comprehensive and intimate care. A visit 

by two staff members, especially if it is a difficult visit 

is easier on the staff and helps prevent burn out, rather 

than a single staff member going to the visit alone. So this 

policy both works to the benefit of the family, and I think 

it also works to the benefit of the staff. It also usually 

necessitates less frequent visits. Furthermore, I suspect 

often when it’s a physician and a nurse there’s an element of psychological balance, a parenting model, where 

one person can deal with the more, the drier, technical, 

fatherly-type stuff, and somebody can sort of be more of 

the hugger. ...I think another thing that has become important, something that was very important for Nancy, and I 

think we’ve tried to maintain right from the beginning, is 

aggressive symptom control. We’re striving—we’re not 

quite there—to be able to evaluate in our charts too so 

that one can take a symptom, score it and then see what 

happens over time.”

The hospice also aims to provide reliable and varied 

sources of information by which to support patients 

through treatment and at the end of life, and in 2005 

started creating a small library, as part of this process, 

explained in more detail by Jim Shalom:

“What happens all over the world, and also here in Israel, 

is that when people are dying with cancer, they try, they 

are looking everywhere for hope. So besides taking the 

orthodox treatment of chemotherapy or radiation, they 

go to all kind of healers, serious and charlatans and they 

spend a lot of money for these things and traveling very 
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National Cancer Institute 64 MECC Palliative Care Monograph 

big distances for this. So Nancy’s dream, which we share, 

is that we should be also a center for information of this, 

not just treating the dying patient, which is the main field 

of the hospice, but also supporting, giving advice in all 

the fields related to palliative care. So we have many 

dreams also of having a place, a center, not just going 

out there in the field but having a place that will be a 

center for these kind of services. We are far away from 

that possibility but that’s the general direction. At present 

in order to help patients who are looking for support, we 

are in the process of setting up a small library to give 

books on the field that could help someone deal with this 

stage of life.” (37)

Negev Palliative Care Services

The service was established in 1991 by Professor Pesach 

Shvartzman, a family medicine specialist, originally as a 

home care service for adults in the city of Beersheba. In 

1994, Dr. Yoram Singer, also a family medicine specialist, 

joined the service and developed an extensive home-based 

service and a hospital consultation service for adults. He 

describes the development of the service:

“The home hospice team was started by two physicians 

and a nurse—and they built it according to [the US] 

model; in order to get home palliative care, you have to 

sign a consent form by which you really do sign the fact 

(a) that you realize the fact that you have a life-limiting 

disease and (b) that you are not going to get any kind 

of active treatment. Now nobody in this culture in the 

Middle East anywhere was willing to sign that kind of 

consent form, so there were about three patients, all of 

whom were American or British people, and that’s how the 

thing worked. After a year and a half the staff resigned and 

Pesach [Shvartzman], who had just come to Beersheba, 

asked me to take over this and I said to him, ‘No way,’ 

you know, I was just setting up this very difficult initiative, trying to set up a teaching clinic against all odds 

and it was enough for me to do that, and I said to him, 

‘I’m sorry, there’s a limit,’ and he said, ‘No, it’s good 

for you and it’ll be nice and interesting and we’ll do it 

together,’ really tried to convince me but I said no way. 

And so they took somebody else and it was a complete 

failure, it really almost disintegrated then. Pesach came 

to me again, he said, ‘Listen, we’ve tried it and it doesn’t 

work. Why don’t you give it a try? Try it for three months, 

if you don’t like it we’ll find somebody,’ and after two 

weeks I was completely sucked in and that was that, and 

since then we’ve been really doing it together. 

“The service has really grown quite a bit now. It began 

against all odds because it’s not part of the basket of services and there’s no initiative, no reason why to develop 

this kind of service because it doesn’t even save money 

because of the way the health system works. We were 

really having a very, very difficult struggle. We started 

off and now we have a service consisting of three home 

care units and one mobile unit. The home care unit, one 

is in Beersheba, which is the main one and it’s the biggest one, and we have 24 patients ongoing at all times. 

We have the meetings at the [community health] center 

where Pesach works. [The service] is a joint initiative 

of the University, the Division of Health in the Community in the Faculty of Health Sciences, and the HMO, 

and actually we get a little bit of funding from the Israel 

Cancer Association as well. Part of our post, well one 

half of our nursing posts and a half of our doctor posts 

are financed through this.” 

The hospice has developed working criteria, and has an 

ethos of maintaining personal contact with the patient 

as Yoram Singer explains:

“One criteria for working in our service is either you 

must have a position in the service or you must be a 

resident—we don’t have any doctors who are not part of 

the service doing calls, because the physician or anybody 

who does any kind of call duty must be at that Thursday afternoon meeting to get input, and we don’t want 

somebody to sort of go to the patient and start saying, 

‘Well, there’s nothing for me to do, go to the hospital.’ 

That’s not what we’re about. We have our patients, we 

have this personal contact which is absolutely essential; 

otherwise it won’t work.” (15)

Cancer Pain and Palliative Medicine Service, 

Sha’are Zedek Medical Center, Jerusalem

In 1994, the Sha’are Zedek Medical Center called on 

oncologists Dr. Nathan Cherny and Professor Rafael 

Catane to set up a service for cancer patients, to include 

a program of integrated oncology and palliative care. 

Nathan Cherny takes up the history:

“Professor [Rafael] Catane was the first Chair of Palliative Care and he is now Chair of Oncology at the Sheba 

Medical Center [in Tel Aviv]. Initially the service was 

an outpatient consultative service and over the years the 

program has grown. Two of us are both oncologists and 

palliative care physician; one of them is Dr. Ora Rosengarten, who also coordinates the Jerusalem Home Hospital 

(the home care program for the largest of the HMOs in 

Jerusalem). In terms of the palliative care team since 

1995 we‘ve had a palliative care nurse; she was initially 

funded by a philanthropic grant, and since 1997 she’s 

been on staff and we’ve had funding. We also have a 

research and education coordinator whose name is Rama 
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National Cancer Institute 65 MECC Palliative Care Monograph 

Sapir. Her background is that she’s a clinical pharmacologist and together she’s been a key player in research 

and in terms of developing educational publications in 

Hebrew but also translated into Russian and now Arabic; 

the management of pain, the management of symptoms, 

the management of post-operative pain which have been 

very widely disseminated.” 

An important aspect of the service has been the dedication of the team to address the need for the relief of 

suffering in patients at the end of life. The team works 

to improve pain relief and symptom control, conducting 

ongoing research and thereby constantly refining good 

practice, and also by developing psychosocial support. 

The initiation of spiritual counseling is part of the overall 

ethos of the service. Nathan Cherny explains:

“When I started in Israel, although there was a rabbi in the 

hospital, there was no tradition of chaplaincy organized 

spiritual care and this was clearly missing from the program. We had a limited, a couple of volunteer chaplains 

who’d come and gone but not very successfully. Partly 

because of cultural issues, and there was some degree 

of skepticism as to whether Israeli patients had a lot of 

spirituality. In 2002 Jonathan Rudnick approached me; 

he was a young rabbinic student who was interested in 

chaplaincy, and I said we were interested in taking him 

on but only after he got formal training. And he went 

to the States and did the thing called Pastoral Care Program and came back and started working on a voluntary 

basis, initially once a week. We introduced the service 

with a degree of skepticism on the part of some of my 

colleagues but from the outset it’s been an enormous 

success. Partly because of his specific skills, not only 

interpersonal skills and religious skills but he is also 

multi-lingual, speaking Hebrew, English and Russian, 

remembering that there are a million Russian immigrants 

in Israel. What we saw through that experience was that 

there was a huge need, a huge yearning for it and that we 

found we were able to spiritually engage patients across 

the entire sociological spectrum, from the ultra-orthodox 

to modern orthodox, through secular, Christian, Moslem 

in a very productive and rich way, and it’s really been one 

of the turning points in the development of the program. 

There is good cooperation between his work, the social 

worker and the psychologist without competition over 

patients. There are different issues being addressed and 

good communication between the services. Based on 

that initial experience on a volunteer basis we applied for 

funding from the New York Jewish Federation, and they 

gave us a grant to make Jonathan’s position a full-time 

position and to start an internship program and this is what 

Jonathon has described to you. And besides the clinical 

program here he’s put in a lot of his energies teaching 

about the concept across the country, and the next stage 

of our program is to get funding to take on interns who 

will see it into other institutions. Not only to train interns 

but you need to train staff and to socialize them into the 

concept of this aspect of care, which we strongly believe 

is an important part of care.” (13)

Rabbi Jonathan Rudnick describes the ways in which 

the spiritual counseling supports not just the patient but 

also the staff:

“We’re trying to learn about how [this kind of approach] 

happens here, in order to try to help that happen in other 

hospitals, and part of it is clearly how the staff related to 

it. The whole other issue, in terms of the staff benefiting 

from this for themselves, for the spiritual care that the 

staff need, is a bit more difficult conceptually but I think 

that in general not just in spiritual care many people kind 

of feel like the whole issue of self care, like everyone 

says, ‘Yeah, we need to take care of ourselves but lots 

of us don’t do it so well.’ But seeing this as something 

that is an important resource and something they can help 

in terms of the care for patients and families; the whole 

staff went along with this. And slowly and slowly [staff] 

started referring patients, in a sense of it being very slow 

and organic which is one of the important issues that Nathan emphasizes in terms of changing and developing the 

culture in the hospital setting in Israel where this is seen 

as OK, positive and something that the staff will want to 

support because it helps them as well.” (14)

Milton and Lois Shiffman Home Hospice in the 

Valleys 

The hospice is one of the few services owned by HMO Kupat Holim Clalit. Founded in 1999 by nurse Mali Szlaifer, 

the hospice took over the work of the (now closed) Afula 

Hospital Home Care, on the retirement of the Medical 

Director Isaac Kersz. Mali Szlaifer explains the aims and 

ways the service has developed since 1999: 

“For terminal patients I really felt that we can not do too 

much, and the needs were very large. The problem was 

that nobody was really in charge of that and the community send them to the hospital because they already 

paid for it, and they don’t know how to manage their 

symptoms and things like this. The hospital sent them 

back home and the people were very miserable—really.... 

Sometimes they give them something, or here or there, 

but didn’t help a lot, and then they sent them back to 

the hospital and the hospital sent them back home. The 

vision of our hospice when we were establishing, is to 

provide excellence—not good but excellent palliative 

care for patients and family, and also to be one of the 
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National Cancer Institute 66 MECC Palliative Care Monograph 

leaders in palliative care in Israel, and to ensure that 

high-quality standards of palliative care services will 

be accessible to all patients suffering from progressive 

diseases—see that I’m not using the word ‘cancer’...in 

our hospice we will see other diseases...but we see very 

few referrals [for other illnesses]. In the beginning, the 

American partners (the Jewish Federation of Detroit) 

agreed to pay for three years. We are in the sixth year, so 

they decided that they will give for another three years 

but smaller amounts of money, and maybe I’ll have to 

close some of those regions.

“Staff satisfaction [is important], because one of my concerns at the beginning was that nobody works for the 

hospice a full-time job, everybody works very part-time, 

so I was afraid that, OK, this is not important and so on. 

But what happened over time [although they said] ‘it’s 

very bad time’ but they ‘see this as the quality work,’ 

as the nurses say: this is where they can magnify their 

profession. Because the district is very spread, one of the 

options was that I would take a nurse, for example, and 

she would be traveling most of the time because she must 

go from here to there to there to there—so I decided to 

take nurses or physicians who live in the region, a very 

small region, but that they can cover this region in 10-15 

minutes of driving, and for example a nurse can have 

between one and four patients. [She is on call] 24 hours 

a day, all year. If she is not able to go to the patient, in 

every region there are two nurses, and then she will refer 

the patients for the other nurse, and sometimes today what 

happens is, if the nurse goes on vacation the doctor is 

on call for the patient because they build a very strong 

relationship in their team.

“In Israel, as I told you, in the beginning the Jewish Federation of Detroit gave us money to make a partnership, but 

in the Arab city they have no partnership, and I felt very 

bad because I felt like it’s some kind of discrimination, 

and I ask them that it doesn’t look good that we only give 

treatment for Jewish people. And they think about it and 

in Detroit they also have a very large Arab community and 

they want to improve the relationship between the Arabs 

and Jews so this also met some agenda of theirs. They 

give me the money to open the hospice in the Arab city 

of Nazareth, and then I was in the United States with an 

Arab social worker but she was working for the hospice 

of us here, and we made some projects together with the 

community of Israel and the United States. OK? So this 

is what I was writing about, you see, that sometimes when 

you are talking about mutual issues that are important for 

both communities and you are not talking about peace

but those things that improve peace and understanding 

because, you see, we are people the same.

“So the goals were to provide high-quality culturally and 

religiously tolerant palliative care and train professionals 

from the various religious groups emphasizing the ethnic 

diversity of patients. And patients and families stated in 

this satisfaction questionnaire that the spiritual and cultural differences were appreciated and respected, you see 

that and this unique project demonstrated the feasibility 

of multi-religious collaboration in palliative care is a 

potential to promote understanding and peace.” (22)

Jerusalem Home Hospital

Founded in 1991 as an HMO-run service, the Home Hospital was established to provide “hospital”-type care at 

home for patients with a range of acute and chronic illnesses, including palliative care at the end of life. The 

service is unusual because from the start palliative care 

has been offered to patients with a range of illnesses, 

not just cancer, and also the service provides palliative 

care for children at home. Medical Director Dr. Jeremy 

Jacobs explains:

“We’ve got, we have about 25-30 patients, full-time ventilated patients at home... with tracheotomies, and home 

ventilators the size of a shoe box. They’re at home, most 

of them are in home hospital; the minority manage to do 

without us.”

The service was also encouraged by work with heart failure patients at the end of life to ensure an effective home 

care service that would benefit both the health service 

and patients by preventing recurring hospital admission. 

Jeremy Jacobs continues:

“We discharged a lot of patients at one stage and we found 

that the heart failure patients went back to the hospital 

very significantly, so that we persuaded our bosses to 

reallocate funding in order to open up the service again. 

We have started a pilot service that’s focused on heart 

failure patients. Whereas in the past we have always 

waited for patients to be referred to home hospital, with 

the heart failure patients who are home bound/bed bound 

with recurrent readmissions to hospital we are actively 

seeking out patients to admit to home hospital. We’re going to take them in and give them the service for as long 

as they remain at the level of heart failure. We’ll keep 

them for a long period of time, with a nurse practitioner 

going in and a doctor going in, and see if that really keeps 

them out of hospital or not.”

The service continues to emphasize the importance of 

palliative care provision and employs a part-time palliative care consultant Dr. Ora Rosengarten and a specialist 

palliative care oncology nurse, Yonat Lamed. The Home 
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National Cancer Institute 67 MECC Palliative Care Monograph 

Hospital, as a concept and in practice, has proved both 

efficient and well-regarded and the nature of the team 

and the way they work have changed since the hospice 

was established, as Ora Rosengarten explains:

“Some 20 physicians work today in the Home Hospitalization service and provide the best possible care to the 

patients. Most of the physicians have been working with 

us for a long period; they have acquired good experience 

in palliative care, and they do their best to respond to 

patients’ needs 24 hours a day. Along with the nurses, 

we provide all services for end-of-life care—as much as 

can be done in the hospital setting, allowing the patient 

to enjoy the home without compromising the quality of 

care. The work done by the team of the home hospitalization is very difficult and only those really devoted 

persist in this work.”

An important part of the service has been to develop the 

supportive role of nurses for families in the home care 

setting. As Yonat Lemed, specialist nurse explains:

“A big part of the nursing work actually is supervising 

nurses, and the nurses themselves, to guide the family, 

it’s a big part of our role. If they get infusions they are 

taught how to change the bags, sometimes even with the 

sores the families are taught how to treat and change the 

bandages and everything; pain medication, of course. 

And we have to prepare the family what’s going to be, I 

mean, if we know already what is the deterioration of the 

patient, we have to start to prepare the woman, the wife, 

what she can expect to see, and what are convulsions and 

what are etc, and not just using those high words. Then 

it’s like we prepare her for what she will meet, will see, 

and then what to do if there’s something else, what will 

happen. This is really a big part of our role to do, the 

nurses.” (24)

By 2002 the Jerusalem Home Hospital had built its capacity to provide care for 450 patients at any one time. 

However, funding is always precarious, and the service 

was severely tested in 2002 when over two months, due 

to unexpected funding cuts by the health insurer, the 

service was forced to reduce the number of patients 

to 150, prioritizing cancer patients needing palliative 

care. A consequent sharp increase in hospital admissions 

prompted the insurer to acknowledge the cost effectiveness of home care and to restore some of its funding. By 

2005 the service had managed to increase capacity back 

up to 300 patients. 

Bereavement services 

Formal bereavement counseling is being developed in 

some services: the Ina and Jack Kay Hospice, and from 

2005 at Tel Hashomer (76). In 2005 Negev Palliative 

Care Services started to develop bereavement counseling through Ma’agan House, Beersheba. However, most 

services offer some element of bereavement counseling 

that builds on well-established informal support already 

provided by the service prior to a patient’s death. Bereavement support may, as for instance at HUG, include 

one or more members of the whole team, or in other 

services tend to be taken up mainly by social workers 

or psycho-oncologists. Malka Yehezkel, the inpatient social worker at the Ina and Jack Kay Hospice, Hadassah, 

describes how she supports the family in the first stages 

of bereavement: 

“After the death of the patient I sometimes go: first I go 

to the visit of the ‘shiva’; the Jewish have the ‘shiva’ 

[seven-day mourning period immediately following the 

burial] (77), the Moslem have three days, so I go to visit 

at this stage...I open the door to continue this follow-up if 

they want. Sometimes they are ready to come back here 

[at the hospice] and meet me regularly. At the beginning 

when the patient is here it’s not a regular meeting, every 

day I go up, I see them here or we meet. Afterwards, with 

the follow-up, it’s regular meetings, like in a clinic, it’s 

very different, that part. And I’m ready to go to their 

home if they feel it’s too difficult to come to the hospice 

again.” (75)

Other services will usually try to offer some bereavement 

support but may depend on volunteers being available. For 

example in Kiryat Tivon as Ilene Ora Cibulski explains 

immediately following the patient’s death: 

“We do very little. [But] we always go to the seven-day 

mourning period [shiva]. We’re always there immediately after the patient dies. We call up or make contact 

[for] 30 days—30 days is usually, it’s a sort of type of 

mourning period [sheloshim]—and then whoever was in 

direct contact with the particular family calls about once 

a month until six months. Sometimes there are visits—it 

very much depends upon the particular volunteer (46).

Pediatric services

Palliative care services for children have developed slowly 

since the 1990s. For a few years there was one dedicated, 

though small, inpatient unit at Chaim Sheba—The Marion 

and Elie Wiesel Children’s Pavilion—but a change in 

staff in the 2000s meant that this unit developed a greater 

emphasis on curative care. There are two home care hos-
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National Cancer Institute 68 MECC Palliative Care Monograph 

pice services able to care for children (Jerusalem Home 

Hospital and HUG). However, as pediatric oncology nurse 

Ruth Gassner notes:

“In oncology pediatrics, mainly when children die they 

stay in the hospital. From my experience I don’t believe 

that you can open an inpatient hospice for children, I don’t 

think that. Not even one parent would give up treating 

here, I mean treating, giving chemotherapy, etc to the 

children, I don’t think so. Usually they give it until the 

end. Very rare that they take the child home and he dies 

at home. It’s not so often.” (78)

Professor Pesach Shvartzman, who has helped to develop 

the pediatric palliative care consultation service at the Soroka Medical Center, Beersheba agrees and continues:

“Children are another issue, you know. [For] children, 

what we lack, what we don’t have is inpatient care, and 

we are doing our best to get a contribution to have an 

inpatient department. Now our children, you know, we 

have some children at our palliative care unit, usually 

children culturally—and it might be a Jewish culture—

although we have many of the children who are Bedouins, 

usually children die in the hospital. It’s very difficult for 

parents to go home and let the child die because it might 

be obvious that the old people die, it’s not obvious that 

children have to die, so I can tell you that there are not 

many families in whom we could take the child out and 

take care of him at home. ...We have about four or five 

children dying each year and of course, just having...I 

usually work with the social workers of the pediatric oncology department, so there is not...what I did I just first 

of all trained the department themselves to do something 

by themselves and just give them the support and usually 

I used the resources of the pediatric oncology department because, you know, just to have a few people—five 

children a year—it’s problematic when you talk about 

cost-effectiveness.” (16)

Because families rarely request home hospice care for 

children, since the late 1990s in response to these very 

different needs of dying children and their families, pediatric services have tended to develop hospital-based 

services rather than home or specific hospice services. 

For instance, there are currently hospital consultation 

teams and hospital-based support groups for families 

within pediatric oncology units at several large medical 

centers.

Drop-in center

The only drop-in center in Israel was established in the 

early 2000s, Ma’agan House, in Beersheba, run by Negev 

Palliative Care Services as a charitable venture funded by 

an independent, overseas benefactor. Dr. Yoram Singer 

explains: 

“Ma’agan House is a community house whose function 

is to support cancer patients and their families. It’s like 

a club, where they have all kinds of activities for cancer 

patients and their families. There are also group therapy 

sessions, and there’s an art therapist and a music therapist 

who come. They have lectures on all kinds of, not medical 

issues but sort of bringing together cancer patients—not 

only terminal cancer but cancer patients and their families 

under one roof.” (15)

The center is organized by a social worker with a group 

of trained volunteers able to offer a range of supportive 

and creative therapies.

Changes in service provision

Since the late 1990s, financial and staffing difficulties have 

resulted in closure of some home hospice services such as 

the Haifa Home Care Hospice in 2003, the reduction in 

provision of services as at the Jerusalem Home Hospital 

in 2002, and the shift of emphasis from palliative care 

to more curative-based pediatric care at the Marion and 

Elie Wiesel Children’s Pavilion when dedicated palliative 

care staff moved to other locations (79). 

Established in January 2006 by Kassim Baddarni, a registered nurse, the Al-Taj for Health and Heritage Association 

is a charitable, volunteer-run home hospice service in 

Galilee, north Israel (80). A multi-disciplinary team of two 

full-time and 10 part-time volunteer health professionals 

and lay support staff are able to undertake home visits to 

over 20 cancer patients a year. The service works with 

patients of all ages and at different stages of illness.

Various other new services have also been set up in the 

last few years within existing organizations; for example, 

the mobile desert unit started in May 2004 at the NegevPalliative Care Services, the inpatient unit and the spiritual 

counseling service at the Cancer Pain and Palliative Care 

Unit at Sha’are Zedek,the current expansion of services 

at the Hospice of Upper Galilee, and the development 

of palliative care services at the new Davidoff Oncology 

Unit, which now incorporates the Beilinson Unit at the 

Rabin Medical Center.

Since the 1980s, with the support of the Israel Cancer 

Association (ICA) and the Israeli Association of Palliative 

Care (IAPC), dedicated services have been developed in 

many areas of the country, including an extensive community nursing service and regular training programs.
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National Cancer Institute 69 MECC Palliative Care Monograph 

can add to your successes starting to educate the rest of 

the hospital about what palliative care is. They’re called 

in by nurses in the internal medicine department, the 

nurses are sometimes in the middle of the night consulted 

about how to help someone with pain, and the doctors 

are educating other doctors.” (10)

Cancer Pain and Palliative Medicine Service, 

Sha’are Zedek Medical Center, Jerusalem

Nathan Cherny, oncologist and director, identifies some 

key developments as markedly successful, and includes 

research (among many other strengths in the service) 

and the dissemination of this work through ESMO to 

the wider community as a particular important part of 

the service:

“Since 1994 the key things have been, the four biggest 

things have been getting the position for a dedicated 

palliative care nurse, the second was getting the nurse 

and research assistant, secondly getting more staff, having more help, then the development of the inpatient 

service and finally the development of the chaplaincy 

service. In terms of research and education we’ve had 

a long history of involvement, looking back at issues, 

looking at attitudes and practices and also issues of specific interventions. When Professor Catane was head 

of the department here, at the time he was the national 

representative for Israel on the board of the European 

Society for Medical Oncology, and he suggested to them 

that they form a task force to approve the integration of 

oncology and palliative medicine all across Europe and 

this was approved by the Board. Since that time I have 

run this task force which has had a very strong ripple 

effect in the organization. ESMO have adopted a series 

of policy statements on the role of the oncologist, and 

minimal standards for cancer centers in the delivery of 

palliative care. It surveyed its entire membership on 

their practices and that’s been published and it has set 

up an incentive program to award centers of excellence 

in the integration of oncology and palliative care and 

this is to try to encourage centers across Europe to really 

look at this issue and it’s been a very successful program 

in ESMO and is widely publicized the organization on 

the front page of their website and it’s early to say but 

there’s definitely a ripple effect and an awareness that’s 

been generated through this intervention and this whole 

program has come out of this department.”

Negev Palliative Care Services 

Dr. Yoram Singer describes the successful developments 

as providing a vital service for patients as well as providing opportunities to train physicians:

Hospice success stories

Tel Hashomer Hospice 

Alexander Waller, Medical Director, writes:

“Tel Hashomer Hospice has not only provided good and 

appropriate treatment to patients in the terminal stages of 

cancer, but has also strengthened the awareness of their 

particular needs—among the Israeli medical community 

and Israeli society at large. By its successful example the 

Tel Hashomer Hospice has stimulated the establishment 

of additional hospices throughout Israel. Ours was a truly 

international effort, for since our very first days we enjoyed the friendship, advice, and support of colleagues 

abroad, most notably our English friends and especially 

those from St. Christopher’s Hospice.” (8)

Ina and Jack Kay Hospice 

Ruth Gassner, Director, highlights one important aspect 

of the success at the hospice at Hadassah:

“Avoiding burnout and keeping your good staff. I read 

in the literature that in hospices every two or three 

years nurses are rotating, that’s exactly what I wanted 

to avoid, so how do I avoid it? [Harriet Copperman] said 

that burnout comes only from hard conditions, not from 

hard work, and, you know, during the years, now I can 

say because now I’m almost twenty years here, that she 

was so right. Look at the nurses, they are still with me, 

most of them—some left because they left Israel, some 

left for the north—but most of the nurses are with me.”

Malka Yehezhel, inpatient social worker agrees and also 

notes that:

“This multi-disciplinary work is, I think, one of the keys 

of doing the best job here, and I know it’s not everywhere, 

we appreciate it very much.” 

Judy Yoran, home care social worker describes success 

at the patient level:

“When you help them when you see a patient that suffers, 

the day after he has a very tiny smile, small, a smile; that 

is a huge success....I think we have to, we have to see 

our little steps as our successes because there are a lot 

of battles to fight, I think, around the, what society sees 

as a hospice, you know, we still, people see us as a place 

where you come to die and you don’t leave, and so we 

are all fighting that when you try to explain to someone, 

you’re trying to give them quality of life, not only end of 

life, that’s a very big change of mind. But I think also you 
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National Cancer Institute 70 MECC Palliative Care Monograph 

“Many of the people, by the time we come on, they’ve 

been so disillusioned and they’re so angry at the health 

system that it may take a week or two for us to regain 

their confidence in any kind of health, any kind of system 

which has to do with health, because they’ve, you know, 

had a recurrence and another recurrence, and finally the 

oncologist has called them together and said, ‘Listen, 

there’s nothing more we can do.’ Then they send them 

home, and there’s nothing more horrendous for a family 

than to sit at home and feel that there’s nothing more can 

be done. And then we come and we say, ‘Well, we have, 

there’s lots we can do.’ ‘How’s that possible? I mean, in 

the hospital the Professor said there’s nothing, how is it 

possible that you think you have [something]?’ And then 

we say, and we start doing, and suddenly the patient feels 

better. Wow, it works, and it makes a whole difference 

because then the patient suddenly has enough energy to 

be able to do all these things that he has to do, you know, 

closing, forgiving, asking for forgiveness, the whole thing. 

The important point in all this is how to teach? We have 

to convert the non-converted. I can tell you that ninety 

per cent of the [family medicine trainee] residents when 

they start are absolutely petrified. ‘What is...how are we 

going to get...?’ I mean, you know, residency is not a 

very easy thing anyway, but ‘How are we going to deal 

with this issue? I don’t know; this is too much.’ And very 

often they come up with most amazing excuses why they 

just can’t possibly do this kind of thing, but by the end 

of the nine months [training] they’re pretty good at it, I 

must say. So I think it’s absolutely important and you can 

see if somebody’s been through this program, they will 

call up and ask for advice because they know that there’s 

something—they can’t always remember or whatever, but 

they call up and they know where to look for advice, they 

know that it’s possible to, and you can tell the difference, 

I mean, there’s no doubt whatever.” (15)

Milton and Lois Shiffman Home Hospice in the 

Valleys 

Mali Szlaifer, Director, explains some of the success is 

due to the way the team is trained and works together:

“I think what is the special thing in our hospice here is that 

all the education we are doing is on a multi-disciplinary 

basis. It means that even the social worker learns about 

medication, and the Edmonton [pain assessment scale] 

and everything. So she supports also if she goes there 

and the patient is in pain. She’s not supposed to treat the 

pain but to call the doctor, she doesn’t have to treat, but 

assess, yes.” (22)

As Mali Szlaifer notes this has resulted in everybody in 

the team being involved in assessments and then responding according to what is required. Dr. Amitai Oberman, 

Medical Director, highlights the staff commitment:

“They don’t do it just for the salary; I mean you have to 

like what you do. So there’ve been rotations and some 

people came and some people left, and we basically ask 

people, ‘Are you interested, there’s money, but are you 

interested in coming to work with us?’ Because there 

have been rotations, although we didn’t plan it this way, 

many of the nurses within the Nazareth region have been 

exposed to palliative care. So we all know one another 

and I feel at home here. It’s less...it’s more complicated 

with the physicians because I don’t really see them too 

often—I talk to them in conferences, I talk to them over the 

phone—but with the nurses and the social workers there 

is wonderful liaison; I can tell [the social worker] Shauki, 

‘Tell the physician to do this,’ and it’s done.” (42)

Jerusalem Home Hospital 

Medical Director Dr. Jeremy Jacobs reports two important 

elements in the success of the service:

“Everyone’s very pleased with our service here, which 

is not a surprise. As regards the quality, what’s important is the communication, that’s what makes or breaks 

the service; in addition to the medical or nursing or the 

professional side of it, probably what makes it successful and ensures the patients stay at home is the level of 

communication. And the more communication the better 

the service is. And it’s good for our bosses because supposedly it costs much less than being in hospital and we 

consistently show that it reduces hospitalization rates. 

So it is financially viable.” (24)

Nancy Caroline Hospice of the Upper Galilee 

Hospice of the Valleys

Medical Director Dr. Jim Shalom describes some aspects 

of the hospice’s success:

“We have quite a good connection with the pain clinics 

in all the main, big hospitals in Israel, and we have one 

patient which we are going to present next week, in a 

seminar, that he is with us for more than three years, he 

has a spinal pump, and we do all the...all the refilling 

of the pump, we do it by servicing at home, so we try 

to do, that’s one of the things that hospice is doing extraordinary things, many different examples, so I think 

we are quite good at it, at trying to treat each case as, 

each case individually, seeing the needs and trying to 

improvise sometimes.”
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National Cancer Institute 71 MECC Palliative Care Monograph 

Yaniv Ben-Shoshan, Social Worker, explains the success 

of the patient/staff approaches:

“I think that, I think all of us receive a lot of, from our 

work. For me it’s a lot of life, of a sense of life, and a 

love of life, I find in the family and the person, not in 

all the person, not all the patients and their families, but 

the process that I go with a person and with them to find 

some [meaning] in their time of life, in this time of life, 

and I with them, it’s a lot.” (37)

Home Care Hospice of Kiryat Tivon, Northern 

Israel

Dr. Ilene Ora Cibulski describes the greatest success from 

her perspective in Tivon:

“In Tivon, we always had our training of professionals 

and nonprofessionals together, and we always used the 

professionals to teach their particular thing. I met the 

most wonderful people in the world. Not one, not two, I’m 

talking about dozens of very, very special people, dedicated people, knowledgeable people, responsible people, 

people who would crawl on their knees in order to get to 

a patient. It wouldn’t make any difference if it was two 

o’clock in the morning or on Yom Kippur, it wouldn’t 

make a difference: if the patient needed them they would 

be there. And that’s a privilege, you know, how many of 

us have chance to meet people like that?” (46) 

Life/oral histories

Aliza Yaffe, Head Nurse, Israel Cancer 

Association: interviewed by Amanda Bingley, 13 

May 2005. Length of interview: 1 hour 20 minutes

In this interview Aliza Yaffe describes her work with the 

Israel Cancer Association, developing specialist nurse 

training and community home care:

“When I came to the Israel Cancer Association I was working in a general hospital in Tel Aviv and I was teaching at 

nursing school and I already had experience of treating 

the patient with stoma but I didn’t have the formal education in stoma care. And later on I went to the United 

States in order to have specific education. And that was 

my job description. But stoma care is not the only thing 

that they should need, and not everybody has a stoma, so 

gradually we developed in the Israel Cancer Association 

some nursing services and some nursing education. I think 

it was kind of bolting things together. I went to the first 

Cancer Nursing Conference in London in 1978 when 

Mr. Bob Tiffany from the Royal Marsden, he said, ‘We 

need an international conference.’ When I returned from 

there, I went to the General Director of the Israel Cancer 

Association, Miriam Boaz. She said, ‘OK, what do you 

think we need here?’ Then I said, ‘we need some education for nurses in cancer, nursing not only the general, 

the general nursing education that we get.’ There were 

specific courses on midwifery—not like in England, the 

nurses study differently, but postgraduate courses, midwife courses. Then we said we need also something like 

that in cancer nursing, and that was the first step doing 

something different from stoma care, starting a course 

in cancer nursing.”

Dr. Nathan Cherny, co-founder and Director, 

Cancer Pain and Palliative Medicine Service, 

Sha’are Zedek Medical Center, Jerusalem: 

interviewed by Amanda Bingley, 4 May 2005. 

Length of interview: 1 hour 19 minutes

Nathan Cherny describes his early interest in medicine 

and his eventual training as a physician. He explains 

that he was made powerfully aware of the needs of cancer patients and palliative care partly through his own 

experience of illness and partly through the impact of 

seeing two documentaries on St. Christopher’s Hospice and another on the work of Elisabeth Kübler-Ross, 

whom he later met, and then caring for a young patient 

who was dying. These influences led to his training 

in medical oncology where he was struck by the lack 

of awareness in other oncologists of palliative care:

“When I started my training in medical oncology one of 

the things that struck me was that the residents around 

the hospital really knew nothing about palliative care and 

this was a problem in terms of care round the wards and I 

approached the medical school to see if they would allow 

me to teach palliative care to the students on the internal 

medicine rotation and this is now 1988/89, and that was 

supported and I wrote part of the palliative care training 

program for Monash University and I taught that through 

the rest of my fellowship in oncology and you know the 

preparatory work that went into preparing that material 

gave me a lot of background into palliative care and the 

clinical skills of palliative care and led me to the next 

decision point which was in seeking a fellowship, to seek 

out a fellowship in palliative care. I went to talk with 

Kathy Foley. So you can see there have been multiple 

steps along this way, and when people ask me who inspired 

me, no single person inspired me, there was the very brief 

exposure to the work of Elisabeth Kübler-Ross and then 

these trigger experiences with patients as a young medical 

student. As I have gone along the path there are people 

who I’ve found wonderful inspirational people along the 

way, certainly Kathy Foley and Russell Portenoy were 
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National Cancer Institute 72 MECC Palliative Care Monograph 

wonderful mentors to me when I was at the Memorial 

Sloan-Kettering Cancer Center. While I was there I was 

exposed to a couple of other people who had a disproportionate impression on me to the amount of contact, 

one was Derek Doyle and the other one is Ned Casson. 

Kathy and Russell in particular created opportunities for 

me to develop professionally to develop an interest in 

policy beyond just service delivery.”

In 1993 he arrived in Israel at the invitation of the Director of Sha’are Zedek to establish, with Professor Rafael 

Catane, the service at the center, which has proved to be 

a highly successful unit. He notes that in the course of 

his work in palliative medicine he has instigated research 

into pain and symptom control and the relief of suffering 

at the end of life. 

Jonathan Rudnick, rabbi, spiritual counselor, 

Cancer Pain and Palliative Medicine Service, 

Sha’are Zedek Medical Center, Jerusalem: 

interviewed by Amanda Bingley, 4 May 2005. 

Length of interview: 35 minutes

Jonathan Rudnick talks about how spiritual counseling 

was initiated into the service and is currently being developed. He explains that his interest in bringing spiritual 

counseling into palliative care was supported by Nathan 

Cherny and other colleagues. He speaks about his specialist training in the USA, and how the service is now 

supporting the course he is teaching for others to train in 

this work. He describes how successful the counseling is 

proving to be for patients, families and staff.

Dr. Amitai Oberman, Medical Director, Milton 

and Lois Shiffman Home Hospice in the 

Valleys: interviewed by Amanda Bingley, 10 May 

2005. Length of interview: 58 minutes

Amitai Oberman describes how his interest in palliative 

medicine developed out of his work in geriatrics. He 

explains how after his training in internal medicine in 

1996 he went to the United States to do a Fellowship in 

Geriatric Medicine at Harvard. After two years of clinical training and a year of research, he was increasingly 

fascinated by the USA approach to end-of-life issues and 

treatment, such as the advanced directives and patient 

autonomy. This led to a two months palliative care training 

in an inpatient hospital-based hospice unit. On his return 

to Israel he continued, as a geriatrician, to be involved in 

palliative care, both in the nursing home system and in 

his work in internal medicine in one of the hospitals: 

“Mali [Szlaifer] approached me and said, would I like 

to come and help out, because she knew of my interest 

in setting up the home hospice unit? Then I joined the 

Israeli Palliative Care Association and from there things 

began rolling very quickly and I became very involved, 

both on a local level setting up the services here, a lot of 

education, and on a national level meeting people, getting 

to know the system. Over the last few years we’ve been 

working in parallel lanes: one is the local hospice here 

and the other on a national level. I have to devote much 

of my time to the national level, setting up, getting to 

know people, bringing people together, setting up these 

big annual conferences, and also working on a regional 

level. When I went to work in Poria at the Geriatrics 

Department, originally there was an inpatient unit there 

which was a more skilled nursing facility, but I managed 

to get education for the nurses there, so until it was closed 

down a year ago all the terminally ill patients at Poria 

were moved over to my department, and we’ve got good 

staff over there. I’ve been involved with the EAPC from 

2001 or so, we’ve had the poster, then I had some more 

posters; in The Hague I gave a lecture on palliative care 

and dementia. A lot of the work is devoted to the national 

level kind of stuff in order to promote palliative care on 

a national level. I’m very active in the Education Committee and the Health Services Committee, teach a lot, 

but also try to get involved as much as I can in doing 

true clinical care. In the kibbutz which I live in we had 

a couple of patients die at home. I wish I could have 

more time and devote more of my time to palliative care, 

which I don’t do enough. I could do more but these are 

the limits which I have.”

Mali Szlaifer, Chair of IAPC and Hospice, 

Director, Milton and Lois Shiffman Home 

Hospice in the Valleys: interviewed by Amanda 

Bingley, 9 May 2005. Length of interview: 2 hrs 

20 minutes

Mali Szlaifer talks about the history of her involvement 

in the Israeli Association of Palliative Care (IAPC) and 

her election as chair of the association. She describes 

her work in the largest of Israel’s health insurers, Clalit 

Health Services, where as a trained nurse and regional 

nurse manager she organizes the provision of nursing 

services for patients at home with chronic illness. She 

relates how in the course of this work she became acutely 

aware of the needs of patients at the end of life and decided in 1999 to set up a palliative home care service. 

Drawing on her considerable management experience 

she negotiated with Clalit to fund the service and called 

on another IAPC board member and local geriatrician 

Dr. Amitai Oberman to join her in establishing the home 
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National Cancer Institute 73 MECC Palliative Care Monograph 

hospice. She talks about her determination to create opportunities in developing her own and her colleagues’ 

knowledge and skills in palliative care through links with 

health care professionals in organizations in Israel and 

overseas. She describes her research and evaluation work 

in home care and her enthusiasm in developing the IAPC 

educational programs. 

Hospice team interviews:

Ina and Jack Kay Hospice, Hadassah, Mt. 

Scopus, Jerusalem: team interviewed by Amanda 

Bingley, 4 May 2005. Length of interview: 2 

hours 7 minutes

Ruth Gassner, co-founder and Director

Ruth talks about her long history with the hospice, as cofounder and Director since the start in 1986. She trained 

in pediatric nursing specializing in pediatric oncology 

before she became involved in establishing the hospice. 

She describes how the renovation of the building and 

the setting up of the hospice was funded by American 

benefactors as well as the Kay family, and then she had 

to find staff to work there:

“I started to recruit some staff, and I did it on my own 

intuition. I didn’t know what I wanted; I just knew that I 

wanted good people. What is good I don’t know—now I 

know, then I didn’t know. I made a few mistakes: I don’t 

think too many, but a few mistakes I made. Those that 

weren’t so good left, but very small number of people. 

Most of the staff which is working here in the hospice 

are people that started with me in ’86.”

She talks about how the team has developed ways to 

best support patients and families and relates some of 

the challenges they have faced in their work within the 

inpatient hospice and in the community.

Dr. Daniel Azoulay, physician

Daniel Azoulay describes his work at the hospice, the 

ethos of the care, and how he came to work there. He 

explains that he was practicing general medicine in France 

and came to Israel to train in internal medicine. He began 

to work in geriatric medicine which started his interest 

in palliative care. Around 10 years ago he was asked to 

take the position as hospice physician in addition to his 

geriatric work at Mt. Scopus hospital. He discusses his 

dedication to working in palliative care, his enthusiasm 

for teaching and training other health professionals and 

his involvement in seminars and conferences nationally 

and internationally.

Malka Yehezkel, social worker

Malka explains that she has worked at the hospice for 

around 16 years, following community social work. She 

relates the story of her introduction to the hospice:

“I was working in the community. I had a patient that I 

felt maybe should be in hospice and I asked the family 

and they were interested; her son was a doctor, and her 

daughter was a social worker. We got in touch. It was a 

good relationship with the patient... it was the first time I 

talked to someone about death and hospice—and I asked 

her what she thinks about it, and she said, ‘I feel I need 

it.’ And then I talked to the family and I called Ruthie 

[Ruth Gassner] and the patient was hospitalized here. I 

came to visit once... she was only here a few days; I came 

to visit only once. It was a time that I thought I need a 

change, a different kind of work in my profession, and it 

was the first convention of the hospice, three years after 

the hospice was opened, and you invited me to come. 

The first social worker, she said in front of everyone that 

the hospice is looking for a social worker to the home 

care, and I came to talk to her and I said I feel I want to 

be in the inpatient unit at the beginning, and that’s how 

it started.”

She talks about the importance of how the team support 

each other and how much she loves her work.

Judy Yoran, home care social worker

Judy talks about her work in home care and the family 

support offered by the service. She explains how the 

work changes and presents different challenges, which 

reflect the ways communities and cultural groups have 

had to change in the face of the conflict.

Helen Englesberg, home care nurse

Helen talks about how she came to be one of the first 

nurses recruited to the hospice when it opened. She started 

nursing in London and was working in oncology before 

she was unexpectedly introduced to palliative care:

“I’d met Cicely Saunders many years ago when I was 

in London. I went to the Royal Free Hospital to visit a 

friend, and I’m looking at the noticeboard. I was working in oncology, and I see [there was a] Cicely Saunders’ 

lecture; [I thought] that sounds interesting. I went to 

the lecture and I just fell in love with this whole idea. I 

said this is wonderful, this is what we need, this was in 
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National Cancer Institute 74 MECC Palliative Care Monograph 

1975, something like that. And then [Cicely Saunders] 

came to Israel and she came to Hadassah, she gave a 

lecture and I went to the lecture, and again I said this 

is wonderful and I was full of it all. And the years went 

by and I’m not in oncology any more, and I’m reading 

the Jerusalem Post one day and I suddenly see ‘Hadassah Medical Organization...opening a hospice... contact 

Ruth Gassner,’ so immediately I called Ruth Gassner. 

We arranged a meeting, she said ‘I’ll meet you, come 

to the hospice,’ and she told me how to get to here, and 

she met me at the door. The place was empty, there was 

no furniture, I think there were a few chairs in here, and 

we sat. I remember exactly, we sat over here on those 

brown chairs, just a few chairs. We sat together and we 

talked and I told Ruthie about my history, she told me her 

history and I think I was one of the first nurses probably 

to be employed here actually.”

Jerusalem Home Hospital - team interviewed 

by Amanda Bingley, 3 May 2005. Length of 

interview: 1 hour 9 minutes.

Dr. Jeremy Jacobs, geriatrician and Medical 

Director; Dr. Ora Rosengarten, consultant in 

palliative medicine; Yonat Lamed, specialist 

oncology palliative nurse supervisor; Timna 

Zistling, head nurse

Jeremy Jacobs leads the team discussion about the work 

of the Home Hospital and how the service is managed 

and organized. He describes the flexible approach they 

have developed in order to be able to care for patients 

with a range of complex illnesses. He explains some of 

the history of the service and how, because the service is 

run by the HMO Clalit, they have had to pay particular 

attention to balancing economics with providing good 

care for a large number of patients. Ora Rosengarten, 

Yonat Lamed and Timna Zistling describe some of the 

situations and challenges of bringing hospital-type care 

into the home with a wide range of patients. They talk 

about the importance of helping to reduce the physical, 

mental and emotional suffering for people at the end of 

life and how they try to do everything needed for the 

patient; offering such a wide-ranging home care service 

enables them to support many people to stay at home 

who would otherwise die in hospital. They sometimes 

have to deal with difficult ethical dilemmas but have 

proved the service to be both efficient and welcomed by 

patients and families.

Yonat Lamed explains:

“I started to work here something like nine years ago 

and today it seems so different from since I started. You 

know, at the beginning when I called a doctor and I said, 

‘Well maybe we do that,’ and he was shocked, I mean, 

‘Who you are? A nurse?’ and today we just work together, 

it’s really a team and we advise each other and the doctors know that I know palliative care maybe more than 

many of them and they are willing to hear advice, etc 

and we just work as a team. You do need an oncology 

nurse who is palliative care oriented, you know, to be 

able to do it.”

Dr. Ora Rosengarten confirms the importance of the commitment of those dedicated to palliative care:

‘If you look at the doctors, really it’s something that’s 

very special, I think; like we have a surgeon in the service 

that’s giving palliative care today. I think you can take a 

lot of oncologists who could learn from him how to deal 

with patients with their last days of life, really. They’re 

really dedicated and devoted, they’re devoted, it’s more 

than dedicated, they’re devoted.”

Nancy Caroline Hospice of the Upper Galilee 

(HUG): team interviewed by Amanda Bingley, 9 

May 2005. Length: 2 hrs 3 minutes

Dr. Jim Shalom, Medical Director

Jim Shalom talks about his involvement in palliative care 

and he also relates the story of Nancy Caroline, in whose 

memory the hospice is named; she was an influential 

physician in palliative care before her untimely death in 

December 2002: 

“Nancy grew up in Boston, USA and from a very young 

age she knew that she wanted to be a physician, studying 

at Harvard. She got involved early on in her career in 

emergency medicine, and set up an educational program 

for paramedics and wrote a handbook called Emergency 

Care in the Streets. The paramedic program became nationwide and then was basically exported, certainly Israel 

uses paramedics and Canada uses [them] and other places. 

She came to Israel and started working with the Israeli 

Red Cross. At some point a physician friend of hers had 

terminal cancer, she was working during the last month 

and she found herself helpless not being able to help him. 

And that sort of caused her to change: she declared that 

she would never let that happen again, and she started 

going down to Tel Hashomer which is one of Israel’s 

big hospitals and studied oncology. Then she met Alex 

Waller (head of the Tel Hashomer Hospice) and started 

studying, going down to the hospice there. She got very 

interested and learnt the subject well and she co-wrote 
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National Cancer Institute 75 MECC Palliative Care Monograph 

a textbook of palliative of care with Alex Waller, based 

on their experience.

“Then she decided to set up a hospice and that’s where I 

met her. She tried to persuade me that the Upper Galilee 

needed a hospice. I said, ‘Nancy, you know, I’ve worked 

in palliative care in semi-rural Canada, and when I came 

here I was surprised at how antiquated things were; their 

hesitation about using opiates, the idea of not treating 

people at home or, if they’re treated in hospital all the 

very basic stuff, but that’s just the way it is here. Because 

when I was working that’s not only how the hospital

practiced but the families, that’s what they expected: 

‘They’re gonna give my father narcotics! I mean, he’ll 

become addicted to it.’ He’s gonna die in three days. 

So I said [to Nancy], ‘You don’t have to persuade me, 

I just don’t think that you’ll be able to get through the 

red tape.’ Well she did and she set things up and she had 

this way of getting people to agree with her. You could 

argue with her but it didn’t help because she always had 

the arguments to justify. But when I took over as the administrator it was a little bit intimidating and she didn’t 

interfere at all, nothing, absolutely nothing. There was 

a period of about, I took over in October 2001 and she 

died December 2002—never once did she have a word 

of criticism. She was just helpful and supportive in any 

way that she could be. And then we took care of her.”

Yael Bleich, specialist oncology nurse

Yael Bleich describes how she became involved in this 

work at HUG nine years ago: 

“I met Nancy Caroline in 1996. I first went on the oncology nursing course, a postgraduate course for one year. 

Then Nancy invited me to meet her and to see if I would 

work with her. She was the hospice [at that time], she did 

everything there; doctor, nursing, secretary, driver. She 

treated about, say, five, six patients at a time. I started 

to work with her and it was only two days a week, but 

more and more I left everything else and I did this work. 

Between all this more and more families and physicians 

and nurses, started to ask us to come to see the patient: 

and it grew and grew, and one more doctor came, Dr. 

Marianne, and then one more nurse, another American 

doctor, and then Nanny got sick and Dr. Shalom started 

work. Now we are about ten or eleven people.”

Yael discusses the way the team works to resolve pain 

relief and symptom control in collaboration with the 

oncology department, always with the aim to connect 

sensitively to a patient’s individual needs. Where appropriate, Yael will bring in the expertise of the team 

art and music therapists (Leila and Adira) to support a 

person’s journey at the end of life. 

Dr. Eyal Goldberger, physician and homeopath

Eyal Goldberger describes how his interest developed in 

homeopathy and palliative care:

“After I finished my internship, I was interested in oncology and especially as a student I was always seeing 

the old patients, if nobody wanted to see them myself, I 

was not afraid of the real people. So when we had the opportunity to do the one-year course I went to the hospice 

in Tel Hashomer for one month and then after the course 

for one year I was mainly in charge of the home hospice, 

but also working in the department. They asked what 

was a young doctor at the beginning of his career doing 

with people at the end of their career. But it was a very, 

very important experience for me. Then I did an officer 

course as a medical doctor with the army, and then the 

Gulf War began. Afterwards I went to England to study 

homeopathy at the Royal Homeopathic Hospital. Even 

in the army I was interested in complementary medicine. 

For almost ten years I left the palliative field and was 

doing mainly homeopathy, teaching and working here [in 

a hospital]. Then my father-in-law had cancer; at the end 

of his life I arranged for him to go to Tel Hashomer, and I 

spent the last two weeks of his life with him there. I met 

people that I knew ten years ago. I said, ‘When I go back 

I must check what’s happening in palliative medicine in 

the north.’ A week later I had a message on my answering machine from Niva—she’s the psychologist—that 

I should call her urgently connected to Hospice of the 

Upper Galilee, which I never heard before. I said what a 

coincidence. Then I was in a kind of a turning point, I had 

to decide to start a new job in somewhere else...and I was 

ready to go into it. Very quickly it became the main thing 

that I am doing so basically I cut down my homeopathy 

but in this last two years I had to see how homeopathy 

is going in the world, I attend lots of seminars here in 

Israel, so it was a good time to do some kind of change. 

I enjoy the work. At first I was not religious and going 

to homeopathy from orthodox medicine, I also, through 

a long process of spiritual searching which were all over 

many other fields so I became religious here. I enjoy very 

much seeing the patient in their home, not in a clinic, 

and the team is very, very excellent.

Yaniv Ben-Shoshan, social worker and family 

therapist

Yaniv Ben-Shoshan talks about how he became involved 

in palliative care and how this experience enriches his 

work at HUG: 
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National Cancer Institute 76 MECC Palliative Care Monograph 

“When my daughter was six years old she was sick of 

cancer for one year, and received chemotherapy in Haifa 

Hospital. Ten years after, when I work with our hospice 

patients, I bring with me not only my experience of my 

work, but also the family, own family experience.”

He explains the importance of the way the team works, 

where each member is an integral part and can refer to 

the other in any way that best supports the patient and 

the family.

Negev Palliative Care Services, Beersheba

Professor Pesach Shvartzman, pediatric oncologist 

and Head of Division: interviewed with Dr. Yoram 

Singer by Amanda Bingley, 5 May 2005. Length of 

interview: 45 minutes

Professor Shvartzman talks about his palliative medicine 

research work, specializing in pediatrics and his role in 

setting up the first hospice services in Beersheba. He is 

trained in family medicine and this led to his interest in 

palliative care:

“When you look at palliative care and it’s actually very 

close to the way that family medicine works and actually 

I think if you look at the UK, a lot of GPs are involved 

in palliative care. It’s not just by chance, I think that 

the way of thinking, the way of looking at patients and 

not at diseases, the way of looking at the context of 

families, the way of not seeing the fact that you cannot 

cure everything as our own failure, but just as a fact that 

medicine cannot cure everything and just to recognize 

the fact that people die, and they will die. So I think that 

the way of thinking is not far off and actually I felt that 

probably it is actually pretty neglected in—not in the 

UK, but the UK is an exception I think—UK, Australia, 

Canada, the States, and probably that’s it, New Zealand 

maybe—but if you look at our country we have still a 

far way to go.”

He explains that he did some training in Canada with 

Balfour Mount at McGill University and conducts a research program as part of his own work as a Professor in 

the Faculty of Medical Science at Ben-Gurion University 

of the Negev. He is also involved in training in pediatric 

palliative care. 

Dr. Yoram Singer, Medical Director: interviewed 

with Professor Pesach Shvartzman by Amanda 

Bingley, 5 May 2005. Length of interview: 45 

minutes. Dr. Yoram Singer interviewed individually: 

1 hour 10 minutes

Yoram Singer describes his commitment to palliative 

medicine and his diverse experience in Africa, where he 

was involved in setting up effective community medicine projects, and in Israel as a community and family 

practitioner before he became involved in developing 

the service at Negev. He talks about how the service is 

organized and some of the extraordinary generosity of 

benefactors and the ways in which he has managed to 

raise the profile of palliative care by working sensitively 

with multi-cultural communities in remote parts of the 

country. He explains how his previous work has both 

enriched and inspired the ways he and his colleagues are 

developing the service.

Tel Hashomer Hospice, Chaim Sheba Medical 

Center, Tel Aviv (team interviewed individually)

Dr. Alexander Waller, Medical Director: 

interviewed by Amanda Bingley, 8 May 2005. Length 

of interview: 45 minutes

Alex Waller discusses the ways in which Israel has developed a hospice and palliative care service that is on a 

par with Europe. He talks about the early history of Tel 

Hashomer and the importance of the hospice in starting to 

raise awareness of palliative care and in encouraging the 

education of health professionals. He describes how Tel 

Hashomer influenced others, stimulating the opening of 

new hospices around the country. He explains his interest in education and the importance of exploring ways to 

improve the practice of palliative care; for example, the 

development of a multi-disciplinary hospice team that 

aims to address needs of the patient. 

Dr. Michaela Bercovitch, physician and 

researcher: interviewed by Amanda Bingley, 1 May 

2005. Length of interview: 35 minutes

Michaela Bercovitch describes how she joined the hospice 

in 1991 having arrived from Romania in 1987. From a 

background of great personal tragedy she was at first unsure that she could work in palliative medicine. However, 

during her work in the Rehabilitation Geriatric Department 

at Chaim Sheba she completed a six-month residency at 

Tel Hashomer Hospice and was subsequently inspired 

to take up a permanent post in the hospice as inpatient 

physician. She describes how much she learns about palliative care from the many patients she has cared for as a 
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National Cancer Institute 77 MECC Palliative Care Monograph 

physician. She talks about how the hospice is organized 

and her role as researcher, physician and palliative care 

consultant in the department of gyneoncology. She has 

seen the hospice through many changes, most recently 

the move to the new purpose-built unit, and she talks 

about some of the challenges they face as a unit and in 

the hospice movement. She writes about her involvement 

in developing and teaching palliative care training, and 

her work with the Israel Palliative Medical Society.

Tamie Goan, nurse, Home Care Service: 

interviewed by Amanda Bingley, 1 May 2005. Length 

of interview: 25 minutes

Tamie Goan explains how she became interested in palliative care when she was a dietician in a dialysis unit 

and went on to train in nursing, specializing in oncology 

nursing. She now organizes the nursing in the home care 

service. 

Sarah Rimer, social worker: interviewed by Amanda 

Bingley, 1 May 2005. Length of interview: 20 

minutes

Sarah Rimer joined the hospice as a part-time social 

worker for the inpatient unit. She talks about her interest in palliative care and her commitment to work with 

patients and families.

Shulamith Werner, physiotherapist: interviewed by 

Amanda Bingley, 1 May 2005. Length of interview: 

20 minutes

Shulamith Werner is a retired university tutor in physiotherapy. She talks about her lifetime of experience as a 

physiotherapist and how she enjoys her part-time work 

at the inpatient hospice. She describes her dedication in 

supporting patients at the end of life and the ways she 

can help to improve their quality of life.

Kiryat Tivon Home Hospice

Dr. Ilene Ora Cibulski, sociologist and 

gerontologist, co-founder of the hospice and cofounder and retired chair of the Israel Association 

of Palliative Care: interviewed by Amanda Bingley, 

12 May 2005. Length of interview: 1 hour 13 

minutes

Ilene Ora Cibulski describes her involvement and motivation in setting up the home hospice at Tivon. She was 

born in the USA and had trained as a sociologist and 

became increasingly interested in gerontology. She was 

inspired to work in some way in palliative care following 

the experience of watching a close friend and also family 

members die from cancer and realizing that there was no 

real support for them. Gathering other interested people: 

physicians, nurses, social workers, she set out to establish 

the home care service in 1984 and also in 1993 to set up 

the Israel Association of Palliative Care, of which she 

was the first chair, retiring in 2002:

“In order to build the organization I went to the library, 

I looked for all the research on palliative care. By training I am a sociologist/anthropologist and then I went 

into gerontology and so today I call myself a gerontologist. OK? And I’m used to doing research because that’s 

what we do. There were four or five books altogether on 

hospice at the time, or anything to do with hospice, and 

there were journal articles. An important book for me 

described how these people wanted to introduce palliative 

care into their hospital in the United States. They made 

this wonderful plan to change the whole hospital and put 

palliative care in every department. They worked for a 

year but in the planning they had not included the people 

who were supposed to use the service, and they were 

completely ignored and thrown out of the departments. 

Well that told me something. It meant that everything 

we did, every step of the way, we had to explain to the 

people who would have to provide services and include 

in the planned provision. The initial reaction of local 

physicians, the Ministry of Health and the Ministry of 

Social Services was that we were slightly mad; palliative 

care was neither medicine nor social services. However 

we were very persuasive. 

“I’m always talking in the plural for the very simple 

reason that we were four or five people who did this 

work consistently. We added a young psychiatrist; we 

thought the psychiatrist would be for the patients, in the 

end he was actually for the team. Because for all of us 

this was something new, dealing with death, immediate 

death, how do we handle it? ...I’m not a physician, I’m 

not a social worker, I’m not a nurse, and I’m not any of 

the direct disciplines of palliative care. I always was in 

the position of learning the material. What I would do is 

I’d learn it, and I’d ask the nurse or physician, ‘Would 

you say this was this way?’ and they would correct me, 

‘Would you say this was that way?’ So it turned out that 

I could develop a general plan for developing training 

programs and palliative care services in Israel. I wasn’t 

being paid by anyone. OK? So that was my great advantage, that I could say exactly what I think and without 

anyone feeling attacked or competing or anything of that 

sort, and very long time ago I learned anything that had 

to do with a patient, I just put aside my ego.”
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National Cancer Institute 78 MECC Palliative Care Monograph 

Dr. Netta Bentur, sociologist, Academic Health 

Research, Myers–JDC, Brookdale Institute, 

Jerusalem: interviewed by Amanda Bingley, 3 May 

2005. Length of interview: 1 hour 4 minutes

Netta Bentur talks about her work in academic health 

research and how she has specialized in research in palliative care: mapping services and exploring patient and 

caregiver experiences of care, pain relief and symptom 

control. She co-authored a report on service provision in 

Israel in 2004, which included looking at different models 

and systems by which palliative care is provided.

Miryam Morganstern, homeopath and trainee 

spiritual counselor, Cancer Pain and Palliative 

Medicine Service, Sha’are Zedek Medical Center, 

Jerusalem: interviewed by Amanda Bingley, 7 May 

2005. Length of interview: 1 hour 10 minutes

Miryam Morganstern is currently training in spiritual 

counseling. She talks about her background in education 

and psychology, going on to train and for the last 13 

years to practice as a professional homeopath. She discusses how important palliative care work is for her, and 

the extraordinary lessons in compassion she has learned 

in the course of her professional work as a homeopath 

emphasized in her current work as a trainee spiritual 

counselor at Sha’are Zedek. 

Dr. Shlomith Perry, social worker, Beilinson 

Oncology Unit, Rabin Medical Center, Tel Aviv, 

Head of the Psycho-Oncology Society, Israel: 

interviewed by Amanda Bingley, 1 May 2005. Length 

of interview: 55 minutes

Shlomith Perry talks about her supportive and palliative 

care work as a social worker with patients in the oncology 

unit. She completed her doctorate in genetic counseling 

for women with breast cancer and has a particular interest 

in work which addresses these kinds of ethical dilemmas 

for cancer patients, especially those patients who have 

a poor prognosis:

“At the beginning, I thought that we should stop all the 

DNA testing.

At the end, I’ve realized that people can manage it, and 

we have to be with them all the way and they can decide 

very good decisions, but the medical system has to be 

with them, not to make the tests and go back, but to be 

involved in the decision. So after I finished the Ph.D. 

we opened clinics for high-risk women, this was the fruit 

of my Ph.D. We opened [clinics] here in the hospital 

for follow-up.”

She explains that her work in palliative care is due to 

increase as the new Davidoff Center opens and they plan 

to have a dedicated palliative care consultant and team. 

She is head of the psycho-oncology society in Israel and 

actively involved in developing support for children at the 

end of life and their bereaved parents, and also in encouraging psycho-social support and education for patients. 

Professor Michael Silbermann, Director of 

the Middle East Cancer Consortium (MECC):

interviewed by Amanda Bingley at Haifa, Israel, 10 

May 2005. Length of interview: 1 hour 3 minutes

Professor Silbermann talks about his role in developing 

the work of MECC and the original aims and objectives 

of the organization to promote a standardized cancer 

registry in member countries in order to develop effective cancer control programs. He describes how, since 

2004, MECC has started to address the palliative care 

needs in member countries, funding health professionals to attend training seminars and setting up “train the 

trainer” courses nationally and internationally. Professor 

Silbermann explains that he is a surgeon and served as 

the Chief Scientist for the Ministry of Health in Israel. 

He talks about his own increasing interest in palliative 

care, and his involvement at the Italian Hospital, Haifa 

which has developed a palliative care service and runs a 

hospital-based unit, where the patient is cared for physically and emotionally:

“What impresses me most there is really the attitude of 

the staff—most of them are nursing sisters, nuns—to 

the patient; that is just amazing. I’m so impressed, you 

know, they sit with the patients on their own initiative, 

the patient doesn’t have to ring and ring and ‘Please 

come and do...’—they come and they say ‘How are you 

doing? Can we do something for you?’ I mean, many of 

the cancer patients, many are lonely, so being alone and 

being a patient that is close to death, that’s a very, very 

unpleasant situation. So if somebody bothers to come 

and sit with you and puts his hand on you and asks ‘How 

are you feeling today? Can I do something for you?’ and 

this...this is I think a big, big thing. And I was there and 

I visit there quite often, just to see what’s going on. And 

I think this will be one of the topics that we are going to 

really emphasize...and palliative care would eventually 

become one of the very most important issues that MECC 

will be involved in.”
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National Cancer Institute 79 MECC Palliative Care Monograph 

Professor Abraham Steinberg, Center for Medical 

Ethics, The Hebrew University-Hadassah Medical 

School, Jerusalem: interviewed by Amanda Bingley, 

4 May 2005. Length of interview: 47 minutes

Rabbi Steinberg discusses his work in medical ethics as 

chair of the Steinberg Committee which debated the formulation of a law for the dying patient for which legislation 

was passed in December 2005. The law addresses endof-life issues, including instituting statutory provision of 

palliative care, and legislation on euthanasia and assisted 

suicide. He describes the political, religious, medical and 

humanitarian aspects of the debate and concludes that 

the law must adhere to moral principles, and although 

this may not be perfect for everyone, for example those 

in extreme, intractable situations, the important point 

is that the law proves workable and acceptable for the 

greatest number of people.

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ENDNOTES

1. World Factbook: www.cia.gov/publications/factbook/geosis.

html.

2. World Factbook July 2004 est. www.cia.gov/publications/

factbook/geosis.html. In August 2005, the Israeli government 

withdrew its settlers from the Gaza Strip.

3. For history and discussion see Rennert G. Considerations in 

planning a national cancer control program – the case of 

Israel, Public Health Review, 1990-1991:18:117-128.

4. Israel’s National Cancer Control Program (NCCP) policy 

guidelines follow WHO recommendations. See WHO (2002) 

National Cancer Control Programmes: policies and managerial guidelines, World Health Organization: Geneva. www.

who.int/cancer/media/en/408.pdf .

5. For example of early discussion of developing AIDS policy 

see: Ben-Ishai Z. National AIDS Policy of Israel, In I. Schenker et al. (eds.) AIDS Education, New York: Plenum Press, 

1996, pp. 81-85,

6. Robinson, E. (2002) The Israel National Cancer Control Program. www.asco.org/ac.

7. IOELC interview: Dr. Alexander Waller -Tel Hashomer - 7 

May 2005.

8. Waller A. (1997) ‘Hospice and palliative care services in Israel,’ In Dame C. Saunders and R. Kastenbaum, Hospice care 

on the international scene. New York: Springer Publishing, 

1997, pp. 235-241.
Chapter 6 Palliative Care in Israel

National Cancer Institute 80 MECC Palliative Care Monograph 

9. IOELC interview: Dr. Michaela Bercovitch - Tel Hashomer– 1 

May 2005.

10. IOELC interview: Ruth Gassner, Dr. Azoulay Daniel, Malka 

Yehezkel, Helen Englesberg and Judy Yoran – 4 May 2005.

11. IOELC questionnaire: Ruth Gassner – 8 March 2005.

12. Levin M. It takes a dream: the story of Hadassah, Jerusalem: 

The Women’s Zionist Organization of America, 1997.

13. IOELC interview: Dr. Nathan Cherny - Sha’are Zedek– 4 

May 2005.

14. IOELC interview: Jonathan Rudnick – Sha’are Zedek – 4 

May 2005.

15. IOELC interview: Dr. Yoram Singer – Negev Palliative Care 

Services - 5 May 2005.

16. IOELC interview: Professor Pesach Shvartzman, Negev Palliative Care Services - 5 May 2005.

17, Delbar V. (1999) From the desert: transcultural aspects of 

cancer nursing care in Israel, Cancer Nursing 1999;22:45-51.

18. Beersheba – hospitals information: Soroka Medical Center; 

www.soroka.org. This is the site of the medical school for 

Ben-Gurion University of the Negev, Faculty of Health Sciences.

19. Shibli J, Oberman A, Szlaifer M. a) Dying, death and 

bereavement: rituals of Islam b) End of life ethics in Islam,

Poster presentations EAPC 2003 The Hague.

20. Nechustan G, Oberman A, Szlaifer M. a) A volunteer? Yes, 

but only a good one b) Is volunteer pre-selection process 

required? Poster presentations EAPC 2003 The Hague

21. Szlaifer M. Making a difference: palliative care in Israel

Presentation at the Cancer Nursing conference, Wembley, 

London, UK, 2002.

22. IOELC interview: Mali Szlaifer – Nazareth - 8 May 2005

23. Clalit Health Services (Kupat Holim Clalit) was one of 

the original, and largest, nongovernmental, not-for-profit, 

voluntary health plan insurance schemes. A health plan insurer is also referred to generically as a Health Maintenance 

Organization (HMO). Clalit used to be known as the General 

Sick Fund or “Kupat Holim” (which literally translates as 

“health plan”).

24. IOELC interview: Dr. Jeremy Jacobs, Dr. Ora Rosengarten, 

Yonat Lamed, Timna Zistling, Jerusalem Home Hospital – 3 

May 2005.

25. Brandon N. (1999) The hospice volunteer Support: Bulletin 

of the Israel Association of Palliative Care 1999;12. (See 

also IOELC interview: Dr. Ora Cibulski, - 13 May 2005.)

26. French Hospital, St. Louis Mission, information posted Rev 

R. Adam Forno. www.al-bushra.org/Truth/living.htm 26 June 

1997.

27. IOELC questionnaire and email communication: Kassim 

Baddarni – 21 September 2005.

28. IOELC interview: Professor Michael Silbermann, Executive 

Director MECC – Haifa - 10 May 2005.

29. The Embassy of Italy Italy in Israel – Special Issue, June 2 

2005 www.ambtelaviv.esteri.it/NR/rdonlyres. 

30. IOELC Field notes: conversation with Reiki healer - 8 May 

2005.

31. Information provided by Dr. Amitai Oberman – 21 July 2005.

32. IOELC interview: Dr. Shlomith Perry, psycho-oncologist, 

Beilinson Oncology Unit, Rabin Medical Center, Tel Aviv – 1 

May 2005.

33. IOELC interview: Dr. Netta Bentur – 3 May 2005. See also 

Bentur N. & Resnitsky S. An Overview of Palliative Care 

Services in Israel, presentation from Myers-JDC, Brookdale 

Institute, Jerusalem, 2004.

34. IOELC interview: Aliza Yaffe, Head Nurse, Israeli Cancer 

Association – 13 May 2005.

35. For more details of the history of the Israeli health system 

see Rosen et al. (2003). 

36. Rosen B, Goldwag R in Thomson S & Mossialos E, eds. 

Health Care Systems in Transition: Israel, Copenhagen: European Observatory on Health Care Systems, 2003;5.

37. IOELC interview: Dr. Jim Shalom, Dr. Eyal Goldberger, Yael 

Bleich and Yaniv Ben-Shoshan, HUG – 9 May 2005.

38. IOELC interviews: Dr. Michaela Bercovitch at Tel Hashomer 

– 1 May 2005; Dr. Jeremy Jacobs, Jerusalem Home Hospital 

– 3 May 2005; Dr. Yoram Singer, Negev Palliative Care Services – 5 May 2005; Mali Szlaifer, Milton & Lois Shiffman 

Home Hospice of the Valleys – 9 May 2005

39. IOELC interviews: Ruth Gassner, Ina & Jack Kay Hospice 

– 4 May 2005; Dr. Yoram Singer, Negev Palliative Care 

Services – 5 May 2005; Dr. Jim Shalom, HUG – 9 May 2005

40. IOELC interview: Dr. Nathan Cherny, Sha’are Zedek, Jerusalem – 4 May 2005; Dr. Amitai Oberman, Home Hospice in 

the Valleys, Nazareth – 10 May 2005.

41. IOELC interviews: Dr. Yoram Singer, Negev Palliative Care 

Services – 5 May 2005; IOELC interview: Ruth Gassner, Dr. 

Azoulay Daniel, Malka Yehezkel, Helen Englesberg and Judy 

Yoran – 4 May 2005. 

42. IOELC interview: Dr. Amitai Oberman, Home Hospice in the 

Valleys, Nazareth – 10 May 2005.

43. See for example Azoulay et al. for discussion of the dilemmas faced by palliative care teams when there is conflict 

between the team and the patient’s family about opioid 

prescriptions: Azoulay, D., Brajtman, S., Yehezkel, M., 

Shahal-Gassner, R., Cohen, A. When the family demands the 

discontinuation of morphine, European Journal of Palliative 

Care, 2000;7:138-140.

44. Dr. Jim Shalom in IOELC interview: Dr. Jim Shalom, Dr. 

Eyal Goldberger, Yael Bleich and Yaniv Ben-Shoshan, HUG 

– 9 May 2005.

45. Population figures www.citypopulation.de/Israel.html.

46. IOELC interview: Dr. Ilene Ora Cibulski, Home Care Hospice of Kiryat Tivon – 13 May 2005.

47. www1.haifa.muni.il/spru/doc/YB/Dmgrp/Y2003/Download/

DemographyDL.pdf.
Chapter 6 Palliative Care in Israel

National Cancer Institute 81 MECC Palliative Care Monograph 

48. IOELC interview: Dr. Netta Bentur – 3 May 2005. See also 

Bentur N & Resnitsky S. An Overview of Palliative Care 

Services in Israel, presentation from Myers-JDC, Brookdale 

Institute, 2004.

49. IOELC interview: Dr. Alexander Waller, Tel Hashomer, Tel 

Aviv – 8 May 2005. See also Waller A, Hospice and palliative care services in Israel. In Saunders, DC. and Kastenbaum R. Hospice care on the international scene. New York: 

Springer Publishing, 1997, pp.235-241.

50. IOELC interview: Shulamith Werner, physiotherapist Tel 

Hashomer, Tel Aviv – 1 May 2005.

51. Cibulski, O. Israel Association of Palliative Care Definitions 

and Objectives Support: Bulletin of the Israel Association of 

Palliative Care 1999;12. (See also IOELC interview: Mali 

Szlaifer - 8 May 2005.)

52. Email communication Amitai Oberman and Mali Szlaifer, 

Home Hospice of the Valleys, Nazareth - 10 November 2005.

53. Israel Cancer Association web page www.cancer.org.il.

54. IAPHC website www.hospicecare.com/yp/. 

55. Dr. Nathan Cherny: discussion at the MECC meeting 2-3 

February 2004, Larnaca Cyprus.

56. Singer Y & Shvartzman P. The feasibility and advisability of 

administering home blood transfusions to the terminally ill 

patient, Journal of Palliative Care 1998;14:46-48.

57. The Middle East Cancer Consortium (MECC) was established in 1996 with the aim of setting up population-based 

cancer registries for member countries in order to monitor 

cancer incidence, mortality and epidemiology, promote preventative health policy and encourage research and educational links. (See also Silbermann M. Perspectives for cancer 

epidemiology research in the Middle East Gastrointestinal 

Oncology, 2001;4,181-181.)

58. See for example sociological study by Rubin S, Malkinson 

R, Witztum E. Trauma and bereavement: conceptual and 

clinical issues revolving around relationships, Death Studies 

2003;27:667 – 690. Also for clinical/sociological research 

studies see Loven D, Goldberg E, Hart Y, Klein B. Place of 

death of cancer patients in Israel: the experience of a ‘homecare programme,’ Palliative Medicine 4, 1990;299–304. 

Yaniv H. Sexuality of cancer patients: a palliative approach, 

European Journal of Palliative Care, 1995;2:69-72.

59. Cherny, NI. The problem of suffering. In Doyle D, Hanks G, 

Cherny N, Calman K. (eds.) Oxford Textbook of Palliative 

Medicine. Oxford: Oxford University Press, 2003, pp. 7-14. 

Cherny NI. Israel, status of cancer pain and palliative care. 

Journal of Pain and Symptom Management 1996;12:116-117. 

Also see extensive references listed on the Research website 

for the Cancer Pain and Palliative Medicine Unit, Sha’are 

Zedek Hospital, Jerusalem www.szmc.org.il.

60. Bercovitch M, Waller A. Transcutaneous electrical nerve 

stimulation (TENS). In Doyle D, Hanks G, Cherny N, Calman K. (eds.) Oxford Textbook of Palliative Medicine. Oxford: 

Oxford University Press, 2003, pp. 405-410.

61. Waller A. Enigma of terminal dehydration, American Journal 

of Hospice and Palliative Care 1999;16:442.

62. Bercovitch M & Adunsky A. Patterns of high-dose morphine 

use in a home-care hospice service: should we be afraid of it? 

Cancer 2004;101:1473–7.

63. Bercovitch M, Waller A, Adunsky A. High dose morphine 

use in the hospice setting: A database survey of patient 

characteristics and effect on life expectancy, Cancer

1996;86:871–7.

64. Livneh J, Garber A, Shaevich E. Assessment and documentation of pain in oncology patients, International Journal 

of Palliative Nursing 1998;4:169-175. Sapir R, Catane R, 

Strauss-Liviatan N, Cherny NI. Cancer pain: knowledge and 

attitudes of physicians in Israel, Journal of pain and symptom 

management, 1999;17:266-272.

65 Delbar V. From the desert: transcultural aspects of cancer 

nursing care in Israel, Cancer Nursing, 1999;22:45-51.

66. See Shibli J, Oberman A, Szlaifer M. a) Dying, death and 

bereavement: rituals of Islam b) End of life ethics in Islam 

Poster presentations EAPC 2003 The Hague.

67. Gilbar I. Length of cancer patients’ stay at a hospice: does 

it affect psychological adjustment to the loss of the spouse, 

Journal of Palliative Care, 1999;14:16-20.

68. Kapp MB Living and dying in the Jewish way: secular rights 

and religious duties, Death Studies, 1993;17:267-276.

69. Sonnenblick M. Advanced medical directives, Harefuah

2002;141:181-188. Also see Gross M, Treating competent 

patients by force: the limits and lessons of Israel’s Patient’s 

Rights Act, Journal of Medical Ethics, 2002. www.jmedethics.com.

70. IOELC interview: Professor Abraham Steinberg, Sha’are 

Zedek Medical Center, Jerusalem – 4 May 2005.

71. Azoulay D, Brajtman S, Yehezkel M, Shahal-Gassner R, Cohen A. When the family demands the discontinuation of morphine, European Journal of Palliative Care, 2000;7:138-140.

72. Waller, A. Hospice and palliative care services in Israel. 

In Saunders DC, & Kastenbaum R. Hospice care on the 

international scene. New York: Springer Publishing, 1997, 

pp. 235-241. IOELC interview: Dr. Alexander Waller, Tel 

Hashomer, Tel Aviv – 8 May 2005. IOELC interview: Dr. 

Michaela Bercovitch, Tel Hashomer, Tel Aviv – 1 May 2005.

73. IOELC interview: Tamie Goan, hospice home care nurse, Tel 

Hashomer, Tel Aviv – 1 May 2005.

74. Ruth Gassner in IOELC interview: Ruth Gassner, Dr. 

Azoulay Daniel, Malka Yehezkel, Helen Englesberg and Judy 

Yoran, Hadassah, Mt. Scopus – 4 May 2005.

75. Malka Yehezhel in IOELC interview: Ruth Gassner, Dr. 

Azoulay Daniel, Malka Yehezkel, Helen Englesberg and Judy 

Yoran, Hadassah, Mt. Scopus – 4 May 2005.

76. IOELC interview: Sarah Rimer, social worker, Tel Hashomer, 

Tel Aviv – 1 May 2005.

77. Musgrave, C. “Rituals of death and dying in Israeli Jewish 

culture,” European Journal of Palliative Care 1995;2:83-86.
Chapter 6 Palliative Care in Israel

National Cancer Institute 82 MECC Palliative Care Monograph 

78. Ruth Gassner in IOELC interview: Ruth Gassner, Dr. Azoulay 

Daniel, Malka Yehezkel, Helen Englesberg and Judy Yoran, 

Hadassah, Mt. Scopus – 4 May 2005.

79. Email communication: Dr. Amitai Oberman – 18 August 2005.

80. Email communication: Kassim Baddarni – 9 January 2008.
National Cancer Institute 83 MECC Palliative Care Monograph 

Jordan (population 5,329,000) (1) is a country in the 

Middle East northwest of Saudi Arabia. It covers an area 

of 92,300 square kilometers. Mostly landlocked (apart 

from 26 km bordering the Gulf of Aqaba), its boundaries 

border Iraq, Israel, Saudi Arabia, Syria, and the Palestinian West Bank.

Palliative care service provision

Current services

In Jordan, four palliative care services are offered by two 

organizations: the Al Malath Foundation for Humanistic 

Care and the King Hussein Cancer Center. Supportive care 

is offered at Al Basheer Hospital (Table 7.1). 

These services are based in the capital city, Amman, and 

include a home hospice team for adults and children, a 

hospital and home hospice team for adults, and hospitalbased supportive care for adults. Pain and symptom relief 

for cancer patients is also provided in some oncology units 

in other general hospitals in Amman and Irbid.

The Al Malath Foundation for Humanistic Care runs one 

service in Amman: the home hospice team Al Malath Hospice. The team supports four volunteer nurses who work 

alone, on their own schedule, in other areas of Jordan. 

Since 1994 (the year following the establishment of the 

hospice) admissions have averaged around 30-40 patients 

per year (Table 7.2).

In 2004, around 63% of patients admitted to the home 

hospice were supported to die in their own home. Some 

families request that their relative be admitted to hospital 

in the 24 hours before death, and 20-30% of home hospice 

patients die in hospital having been admitted weeks or 

some days prior to death. 

The majority of patients have cancer, but the hospice will 

occasionally care for patients with other illnesses at the 

end of life. In the early years, nurses were most likely to 

refer to the hospice. Increasingly physicians are encouraged to refer patients (2). A proportion of patients are 

self-referring, through family or friends. 

The hospice provides a 24-hour on-call service and the 

home care team will continue to support their patients 

if requested after admission to hospital. The Foundation 

has an equipment loan service providing, for example, 

hospital beds, wheelchairs, bathing and toilet aids, and 

oxygen cylinders free of charge,with an option to make a 

donation. Financial help is offered from a special fund in 

cases of hardship and there is also a “special last wishes” 

fund which can provide for a personal request by the patient 

towards the end of their life. Examples include funding the 

cost of a special trip, and the making of a commemorative 

video of the patient for their children.

The King Hussein Cancer Center (KHCC) is a government hospital dedicated to treatment of adults and children with cancer. Patients are referred for treatment from 

Chapter 7

Palliative Care in Jordan

 Jordan
Chapter 7 Palliative Care in Jordan

National Cancer Institute 84 MECC Palliative Care Monograph 

all over Jordan. Since October 2004, the hospital has 

offered two key palliative care services—hospital support and home care for adults with cancer—delivered by 

the multi-professional hospice team including director, 

physicians, nurses, psychologists, physiotherapist, social 

worker and nutritionist. The team cares for patients in the 

following settings:

patients admitted onto the wards;

patients attending the outpatients department;

patients at home if they reside in the western areas 

of Amman within a 6 km range of the hospital.

Telephone support is available for KHCC patients and 

their families living in other areas of the country. There 

are plans to extend home care services into other areas of 

the country via the recently reformed community health 

care system. An eight-bed inpatient unit at KHCC was 

opened in 2005 (Table 7.3). 

Referrals are made by either the patient’s primary physician or via the oncology unit based at KHCC (3). The 

criterion for admission—for either palliative support at 

hospital or hospice care at home—is based on the patient’s 

decision about resuscitation:

“Do not resuscitate” (DNR): Home care palliative 

services are offered to all those patients at the end 

of life who have decided they do not want resuscitation, even if they are re-admitted to hospital.

“Resuscitate” (non-DNR): Palliative support is offered to patients at the end of life 

who choose to stay in hospital and in spite of a 

poor prognosis wish to be resuscitated, for example, in the event of sudden collapse.

In May 2005, there were six patients in home care (DNR) 

and 10 being offered hospital palliative support (non DNR). 

Around 17-20 patients are admitted to the palliative care 

service per month; it has a capacity to admit 30 patients 

per month (4).

Hospital oncology units 

There are three major oncology units in government-funded 

hospitals in Amman, which offer pain and symptom relief 

Table 7.1 Palliative care provision in Jordan 2005

Adult and Pediatric* Services Freestanding unit Hospital unit Hospital support team

Home care

Day care 

Clinic/Drop-in center

Grand Total

Al Malath Foundation * 1 1

King Hussein Cancer Center 1 1 2

Al Basheer Hospital 1 1

Total 2 4

Table 7.2 Al Malath Foundation – change in admissions and 

home visits over years 1994, 2000, 2004 

1994 2000 2004

Hospice home care admissions 11 34 43

Home visits 120 782 576

Source: Al Malath Foundation annual statistics – with kind permission Rana Hammad, Director:

Al Malath, May 2005
Chapter 7 Palliative Care in Jordan

National Cancer Institute 85 MECC Palliative Care Monograph 

to cancer patients at the end of life. Civilian patients can 

access supportive care, and, since 2004, specialist pain 

and symptom management in the oncology unit at the 

government Al Basheer Hospital. The Jordan University 

Hospital offers pain and symptom relief. Army patients 

can access relief through the Royal Medical Services at 

the military hospital King Hussein Medical Center. Other 

hospitals able to provide pain and symptom relief at end 

of life include:

In Amman: the Islamic Hospital (run by the 

Islamic Center Charity Society) (5); the privately funded Speciality Hospital; 

In Irbid, the King Abdullah University Hospital (KAUH) and (by referral) from KAUH 

at the Health Center of Jordan University of Science and Technology (JUST). 

These units and hospitals are part of the Jordan Pain 

Relief and Palliative Care Initiative, which is supported 

by the World Health Organization (WHO) and the Center 

for Palliative Care Studies at San Diego Hospice, California, USA (6). 

Patients may ask to be referred or may self-refer to the 

specialist palliative care services at Al Malath or KHCC. 

Patients at the end of life residing outside Amman, who 

have left the major oncology units to return to their homes, 

can access basic pain and symptom relief either from their 

primary physician or in local hospitals.

There are no reports of any government-funded specific 

palliative care services for patients at the end of life with 

other illnesses, including HIV/AIDS. There are plans by 

government to provide insurance for patients to receive 

end-of-life care if they have neurological illnesses, such as 

Alzheimer’s disease. As of 2005 patients and their families 

pay private nursing agencies to provide “aid nurses” for 

patients with other illnesses at the end of life.

Reimbursement and funding for services

Patients needing palliative care in Jordan can access free 

services from the charitable non-governmental organization (NGO) Al Malath Foundation if they live in Amman 

or have access to one of the four volunteer Al Malath 

nurses in their locality. Al Malath Hospice receives a 

small payment of up to 1000 Jordanian Dinar (JD) (7) per 

year from the General Union, the Philanthropic Societies, and the Ministry of Social Development. Al Malath 

offers all services, including equipment, free of charge. 

There are plans to institute a “sliding scale” of fees, but 

care will continue to be free to all those who cannot afford to pay (8).

King Hussein Cancer Center is an NGO providing services to patients either with government-subsidized insurance or for private fees. Since 2004, the government 

provides subsidized services for all cancer patients if they 

are Jordanian citizens. Patients with cancer can join the 

government Royal Court insurance scheme (regardless 

of previous health insurance status), and—providing they 

renew their insurance at six monthly intervals—need only 

pay a minimum of 10% of all health care fees. Private 

sector insurance, which provides coverage for around 

59% of the population, does not include palliative care 

services (9). 

All cancer patients have to pay for their medications. 

However, they can choose either to obtain a 90% discount 

on prescriptions through Royal Court insurance (dispensed 

via pharmacies at KHCC or Al Basheer Hospital) or to 

have the prescriptions dispensed through a private pharmacy and pay the full cost. Since 2004, new government 

legislation allows all children under five to be entitled to 

free health care (10). 

Opioid availability and consumption

The International Narcotics Control Board (11,12) has 

published the following figures for the annual consumption 

Table 7.3 Key palliative care services in development, and currently offered by the home hospice team to King Hussein Cancer Center 

patients

Current service (report 2005) Service in development

Hospital-based ‘Palliative Support Service’ (adults)

~ inpatient 

~ outpatient 

KHCC-based 8-bed inpatient hospice unit

Home care support (adults)

~ home visits in Amman

~ telephone support in other areas of Jordan

Community-based home care throughout Jordan

Pediatric palliative care
Chapter 7 Palliative Care in Jordan

National Cancer Institute 86 MECC Palliative Care Monograph 

of narcotic drugs in Jordan: codeine 35 kg (down from 

79 kg in 1998); morphine 3 kg (up from 1 kg in 1999); 

pethidine 24 kg (up from 17 kg in 1998).

For the years 2000-2002, the average defined daily dose 

consumption of morphine for statistical purposes (S-DDD) 

(13) in Jordan was 11 (14). Opioids and other related 

medications are available in Jordan, although the range 

of suitable preparations can be limited. 

Since 2003, the Ministry of Health has been developing a 

National Palliative Care Programme with the support of 

WHO. An important aspect of the program is to facilitate 

appropriate policy on opioid prescription.

Dr. Jan Stjernswärd of WHO writes: “The Jordan Pain 

Relief and Palliative Care Initiative (JPRPCI) is a World 

Health Organization (WHO) Demonstration Project for 

the Middle East Region. Following negotiations with the 

Ministry of Health (MOH) and WHO, a public health approach was established, introducing the WHO foundation 

measures of education, drug availability and supporting 

policies. In August 2003, a MOH/WHO workshop was 

attended by leading national policy makers and clinicians who agreed to establish a National Programme 

Initiative. Dr. Samir Khleif, Director of King Hussein 

Cancer Center, has since been addressing policies, drug 

availability and educational issues. Already there have 

been changes in opioid prescribing policies and nationally produced, inexpensive generic immediate release 

morphine and slow release morphine tablets are about 

to come on the market, with a policy that over 80 per 

cent of the estimated increase in morphine use will be 

covered by these drugs.” (15) 

Dr. Bassam Hijawi, Director of Health Promotion and 

Protection in the Ministry of Health explains that, as of 

May 2005, improved legislation on opioid production 

and prescription policy is imminent, although there are 

still some issues to be resolved: “We face a problem 

of legislation, prescription [and production] of drugs. 

Sometimes the manufacturers of the drugs are asked for 

a big amount of morphine, and they say that it is costly...

more than 20,000 JD and we cannot supply this amount. 

So [the supply] expires and nobody [can] use it. Sometimes the hospitals ask for extra amounts, and nobody 

knows the exact amount. So the system is sometimes 

[a problem]. I hope now we are on the correct way and 

that we are now at the end [ready] to sign [and complete 

the policy]. His Excellency the Minister of Health [has] 

said, ‘I am ready to send these issues to parliament to 

change, to update the legislation that is suitable for our 

current position.’ ” (10)

Since the early 1990s, at the inception of the first palliative care service, difficulties around the provision of 

opioids, and the different modes of prescription that are 

suitable in palliative care, have been eased with support 

from the Royal Court, which recognized the specialized 

needs. For instance, as Rana Hammad, Director of Al 

Malath, explains: ‘We have three morphine pumps now 

and they are the only three in Jordan. We’ve changed the 

regulations when it comes to narcotics. We were fortunate that Crown Prince Hassan, at that time [in the early 

1990s] helped us with one phone call. It became easier 

and we started having more ampoules, more pills, and 

for three years we managed to get the immediate release 

[morphine]. The first time I took the pump to Al Basheer 

Hospital, which was the Center for giving the morphine to 

patients, and I said, ‘I want 100 ampoule,’ and they said, 

‘What!?’ I said, ‘Okay, 50, and they said maximum five.’ 

So ‘but five cannot prime the [pump].’ So it changed--it 

changed quickly.” (16)

However, since the government committee on opioid 

regulations has been facilitating the policy on opioids, 

there is a wider range of opioid preparations available. As 

Nisreen Al Alfi, a nurse in the KHCC hospice team, describes, the team is now able to use: “... mostly morphine, 

MST, for pain relief...also adjuncts to medications, like 

paracetamol, tramadol, dexamethasone. We use fentanyl 

[transdermal patches] sometimes. We keep them as a last 

resort, because not all our patients feel comfortable about 

that and sometimes symptoms of nausea and drowsiness are more prominent with the patches more than the 

morphine. Sometimes if we have to keep going up, up, 

up on the morphine, we use a fentanyl patch, or if the 

patient cannot swallow we might just use the patch as an 

alternative. Sometimes it won’t work because the patient 

is really lacking subcutaneous tissue so there’s no absorption, so they’re not going to benefit on the patch.”

Al Malath home hospice also uses MST, and as Rana 

Hammad explains: “Now we have the immediate release 

[morphine] that I fought for ten years to get--we have 

it now. We do the fentanyl patches. We use injectable 

morphine through the pumps, not through injections. We 

have also syrups for kids. And we have the weak opioids: tramadol, codeine, all the range of weak opioids 

we use them...and the non-steroidals for pain. And for 

nerve pains we use the tricyclic antidepressants, which 

we introduced--we were the first to use them or to apply 

them. Of course we have, for symptom management, our 

regular antifungals, antibiotics, antidiarrheals, all range of 

normal medications for symptoms. And of course we have 

the colloids for bedsores, and skin care products.” 
Chapter 7 Palliative Care in Jordan

National Cancer Institute 87 MECC Palliative Care Monograph 

WHO reports that from 2004 there has been a demonstrable 

change in opioid use as a result of the training programs 

and the change in opioid legislation. For instance, in 2004 

KHCC was using 2.7 kg morphine, but by 2005 usage 

had increased to 4.8 kg morphine. By 2005 Al Basheer 

Hospital reported increased levels of opioid use, 13,000 

mg prescribed as morphine sulphate 10 mg tablets (17). 

Palliative care coverage

Currently there are two organizations offering three specialist palliative care services to adult cancer patients, 

one of which also admits children and will admit adults 

with other illnesses at the end of life. These services are 

based in Amman. Specialist palliative care services are 

not currently available in any governmental hospitals for 

adults or children. New services are in process of being 

developed in Irbid, and in Amman from 2004 as a result 

of training initiatives in the oncology unit of the government hospital. Two other oncology clinics provide pain 

and symptom relief to cancer patients at the end of life, 

all of which are based in the capital city Amman.

As of May 2005, the two organizations offering specialist 

hospice and palliative care services reported caring for, 

between them, a total of around 22 patients at any one 

time, although the total capacity between both organizations is around 45 patients at any time (Table 7.4).

Three oncology clinics provide pain and symptom relief to 

cancer patients at the end of life, all of which are based in 

the capital city Amman. Services in other regions of Jordan are limited; the King Hussein Cancer Center (KHCC) 

hospice team offers telephone support to their patients 

being cared for at home outside their Amman catchment 

area. If a patient needs urgent pain or symptom relief, 

unless or until they can travel back to KHCC the team 

will advise contacting the family physician or attending a 

local emergency department. Al Malath Hospice supports 

four volunteer nurses working independently in other 

regions outside Amman. 

Palliative care workforce

­capacity

Al Malath Foundation

The home hospice has six full-time team members: a 

hospice director (a specialist nurse), a physician, and 

four nurses (of whom two are case managers). The team 

can call on an additional four part-time members: a pain 

specialist, a social worker, a dietician, and a religious 

cleric. Volunteers support the team. Families are supported 

to give care. Hospice physician Dr. Mazen Al Bashir 

describes how the caregivers in the family can be taught 

to manage infusions: “They know exactly whatever it 

[pump IV infusions] means, what it means when it’s up, 

when it’s in, and how to check that, and to check the 

rate; and they know how to use calculator to work out 

exactly how much to take. Of course, you cannot just 

put it in and turn your back, you need to make sure they 

are safe, we have nurses which can supervise this sort of 

thing and many of the people had nurses there looking 

after them.” (18)

The case managers are experienced hospice nurses who 

offer full support for the patient, from nursing procedures, 

personal care and social needs, including grief therapy 

for families. They will call on other members of the team 

as needed; for instance, medical, additional nursing or 

psycho-social support. The Director of Al Malath, Rana 

Hammad explains: “[The case manager] has her mobile, 

if she sees anything she will call me, she will call the 

physician, we act on things. She will train the family, she 

will look out for the family, she will deal with the patient, 

look at possible troubles to come, do all the adjustments 

at home, check the medications, check the symptoms, 

check the life signs, and check the body. If she needs a 

blood test she will order blood tests. She will follow the 

schedule for changing the dressings or the catheters, or 

it’s the time to check the hemoglobin or check the potassium. If there is a need, she will arrange with a physician 

and go with him.”

PHOTOGRAPHS for Chapter 7

Photographs were taken during field visits. 

Suggested placing of images is indicated in the 

manuscript – subject to editorial preference. 

Chapter 7

Illustration 7.1: Members of the King Hussein Cancer Center 

hospice team, Amman, Jordan [photograph: Amanda Bingley, May 

2005].
Chapter 7 Palliative Care in Jordan

National Cancer Institute 88 MECC Palliative Care Monograph 

King Hussein Cancer Center

The hospice team has a total of 30 full- and part-time 

members: a team director, a medical director, a hospice 

physician, a nurse manager, a home care coordinator nurse, 

a unit head nurse, a consultation team coordinator, 19 

nurses, a psychologist, a social worker, a physiotherapist, 

a nutritionist, and a team secretary.

The team is supported by other departments at KHCC 

if the patients or their families request admission for 

pain and symptom relief. Spiritual counseling is sought 

from outside clerics at the request of the family. Team 

members will offer whatever spiritual solace they feel 

is possible.

The new palliative care training schemes for physicians, 

nurses and pharmacists have resulted in palliative care 

knowledge disseminating into the workforce within large 

oncology units such as at Al Basheer Hospital and also 

within the new governmental family and community medical centers. In May 2005, there were as yet no records 

of the capacity of this workforce or the level of care 

offered.

National and professional 

organizations

Al Malath Foundation for Humanistic Care

This organization was founded in 1993 by Rana Hammad, 

a specialist palliative care nurse. The Foundation is the 

only non-profit, voluntary NGO in Jordan offering a home 

care hospice service. The service provides care for adults 

and children at the end of life who reside in the capital 

city Amman. Since its inception in 1993, the Foundation 

has developed a multi-professional home hospice team 

(Al Malath Hospice) including a physician, nurses, a pain 

specialist, a social worker, a rehabilitation therapist, and 

a dietician. Volunteers and religious clergy support the 

team (19). The home hospice team admits patients:

who live within the “Great Amman Municipality”;

who have life-threatening cancer or poor prognosis of life expectancy due to other illnesses;

who personally (or through their families) 

ask for palliation and understand the goals 

of palliative care (physicians or oncologists can refer or patients self-refer); or

who are homebound but have one or two caregivers willing to support them (20). 

Since the mid-1990s the Foundation has provided services 

for an average of 45 patients per year, of which 3-10% 

have been children and young people under 19 years of 

age. The home hospice team offers medical and nursing 

care, psychosocial and spiritual support to patients and 

their families. An important aspect of the Foundation’s 

ethos is to offer the option of continuous care and attendance, if requested by the family, in the patient’s last 

days or hours of life, including accompanying the patient 

into hospital in the event of the family asking that the 

patient be admitted.

King Hussein Cancer Center

The King Hussein Cancer Center (KHCC) was founded 

in 1997 as the Al-Amal Cancer Center and renamed in 

2002 in memory of the late King Hussein. The hospital 

is a specialized NGO cancer hospital treating adults and 

children. It has a capacity of 148 beds and currently treats 

more than 2300 new patients per year. KHCC is the only 

dedicated cancer center in Jordan. It also attracts 25% 

of its patients from neighboring countries in the Middle 

East. The Director, Dr. Samir Khlief, is an oncologist and 

internationally recognized cancer researcher, who supports 

palliative care services and has facilitated the development 

of the KHCC “hospice team.” (21) The KHCC hospice 

team was established in October 2004, offering palliative 

care—including medical, nursing, physiotherapy, nutritional, and psychosocial support—in the hospital or at 

Table 7.4 Patient activity and capacity in the two dedicated palliative care organizations (May 2005)

Organization Service Patient activity Maximum patient capacity 

Al Malath Foundation home hospice 7 15

KHCC ~ home hospice

~ hospital support

6

10 30 (in both services)

Total 3 22 45
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National Cancer Institute 89 MECC Palliative Care Monograph 

home to adult patients at the end of life. KHCC is working 

with WHO to develop a comprehensive palliative care 

training program and establish a regional training center 

within the hospital.

World Health Organization (WHO)

WHO is involved in supporting the development of palliative care services, in particular a review of opioidprescription policies, and the promotion of education 

and training. In August 2003, a Ministry of Health/WHO 

workshop was attended by leading national policy makers 

and clinicians; they agreed to establish a National Programme Initiative, “The Jordan Pain Relief and Palliative 

Care Initiative (JPRPCI).” This is a WHO Demonstration 

Project for the Middle East Region. Negotiations with the 

Ministry of Health and WHO have resulted in a public 

health approach being established, introducing the WHO 

foundation measures of education, drug availability, and 

supporting policies (22).

Education and training

Recommendations for palliative care training in Jordan 

were first proposed—in an unpublished report on assessing need for palliative care for cancer patients in Jordan 

completed in 1986—by two UK nurses from the charity Macmillan Cancer Support (23). In 1992, concerned 

health professionals began actively to develop the concept 

of palliative care services and training in Jordan. Most 

Jordanian health care professionals, who had completed 

post-graduate education in the USA or UK, were already 

aware of the concepts of palliation and end-of-life care. 

In 1993 the Al Malath Foundation was established, not 

only to set up the first home hospice service, but also with 

a commitment to education for people in the community 

and for health care professionals within Jordan (24). 

Al Malath Foundation

The Al Malath Foundation is committed to both public 

and professional education. The Director of Al Malath, 

Rana Hammad, explains: “We serve the community in 

three ways: patient care is one way, education and training 

is the other channel we work at. I went round the country 

giving courses, presentations, panel discussions, from 

sophisticated conferences down to sitting with lay women 

on the floor and talking about sadness and grief and the 

wisdom of God, for example. Also two structured courses 

at the University for medical students, nursing students, 

social workers. The third area is support groups and supporting the caregivers in the hospitals. They should be 

empowered. They should be trained on grief, loss, spiritualities, emotional well-being, understanding, empathy, 

communication, knowing the value of the work. 

“We got a hospice social worker who was a volunteer 

through the American Peace Corps. She stayed with us 

for two years, and the first year she got to understand the 

culture and the needs of the patient, the second year with 

us we together developed a manual, and she trained the 

nurses. They trained each other. So they interacted in 

a way which she knows the needs of those patients and 

they know the culture. Eventually people will get to know 

what palliative care is, it is not about skills because it’s 

there, we can study and we can learn those skills, we can 

learn how to calculate, we can learn how to assess, but it’s 

about attitude. So the majority of my training programs 

are about shaping the attitudes, empowering them, make 

them understand the value of this work, and then when 

it comes to knowledge, it’s there.

“I have a one-day program, and I have a two-day program 

for pain management, and I have a two-week program 

that I developed for the Ministry of Health; and I have 

some tailored programs, it depends on the needs, for example, the social workers when they come and they want 

to talk about the social-psychological emotional aspects 

of cancer care.”

World Health Organization (WHO)

The World Health Organization has been actively involved 

in supporting the development of services and promoting education and training at Al Basheer Hospital and 

at KHCC. In June 2004, Dr. Jan Stjernswärd of WHO 

announced:

“All medical and nursing schools are committed to introducing palliative care into their undergraduate education 

and six palliative care courses, supported by an international faculty and bedside practice, are budgeted for over 

the coming three years.”

In March 2004, an introductory training course in Amman 

ran with 32 participants (nine physicians and 23 nurses). 

In March 2005, introductory and advanced courses ran 

with 70 participants--physicians, nurses and pharmacists 

(including two Iraqi doctors), of which 22 participants had 

returned to complete the advanced course. The advanced 

group had some class-based training instruction and also 

did interactive bedside work in small groups discussing 

cases at two clinical sites, KHCC and Al Basheer Hospital; seeing a large number of patients, initially practicing 

assessments. In autumn 2005 the course following the 

training model “Education on Palliative and End of Life 

Care” (EPEC)—Train the Trainers—ran in collabora-
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National Cancer Institute 90 MECC Palliative Care Monograph 

tion with colleagues from San Diego Hospice and the 

Hospice of the National Capital Region, USA, and Dr. 

Stjernswärd (25). 

An important aspect of the training was addressing health 

professionals’ opioid phobia by the trainers teaching physicians how to write an opioid prescription, and then 

witnessing patients improving and wanting to go home. 

It has proved vital to train pharmacists; for example, Al 

Basheer pharmacists initially were horrified at the dosages proposed until the improvements in patients’ pain 

and well being was demonstrated. The training includes 

sessions on specific symptom management, how to disclose prognosis, how to avoid burnout and about other 

symptom management (e.g. dyspnoea) and withholding 

fluids and nutrition. The training hospitals and trainers have 

worked with the religious leaders, who have announced 

a new fatwa allowing the prescribing of opioids and the 

appropriate withholding of fluids and nutrition.

King Hussein Cancer Center (KHCC)

In 2004, the Ministry of Health, supported by WHO and 

with members of KHCC and other hospitals, formed an 

education committee. One of the aims of the committee has been to establish a palliative care education and 

training program for interested health professionals and 

training for medical and nursing students. 

The director of nurse training at KHCC and chairperson 

of the KHCC training committee, Ahmad Al Khateib, 

explains that KHCC was designated to be the training 

Center for palliative care and pain relief in Jordan, and 

later on to be a regional training Center. KHCC has been 

chosen because it is the pioneer hospital in the region offering palliative care services and has the facilities and 

resources to develop these services. KHCC is supported 

by WHO, which has donated funds to cover courses twice 

a year. With this collaboration, since March 2004, there 

have been introductory and advanced training courses at 

KHCC for physicians, nurses and pharmacists, supported 

by an international faculty, Dr. Frank Ferris and his team 

from San Diego Hospice (26). The idea is to help those 

who have attended the courses from the different institutions to establish palliative care teams in their institutions. Ahmad Al Khateib explains that these courses are 

expanding: “We have [a] second palliative care training 

program, conducted in our center; one introductory course 

for three weeks, and we have around 50 people now on 

this course who are physicians, pharmacists and nurses, 

from different institutions [in Jordan]. We have physicians 

coming from Iraq and the plan is to have physicians from 

Syria, from Palestine. I hope by this time we might have 

some of them coming because as I told you the plan was 

to become the regional training centrecenter. We have 

now five international faculty members here at this moment conducting the second part of training course, and 

the same time an advanced training course. We are going 

to have a three day workshop starting in March (2006), 

designed to provide some sort of education for the faculty; 

the teachers from school of medicine, school of nursing 

... helping them to orient about the concept of palliative 

care and helping them to integrate the concept of palliative care and pain relief in the undergraduate curriculum 

for school of medicine and school of nursing.”

Ahmad echoes the WHO observation that a major difficulty in developing palliative care is the “sensitivity of 

physicians towards prescribing narcotics... I think that 

we need to educate the health care providers and to try to 

change their perception about palliative care and morphine 

and to understand palliative care.”

As part of the development of the training programs, Dr. 

Amal Bandak, Director of the KHCC hospice team and 

her colleagues, have compiled a draft manual and guide 

for training and hospice team development (27). 

Since 2004, with the help of Carol El Jabari, director of 

the NGO Patient’s Friends Society based in Jerusalem, 

KHCC have developed education in the community by establishing a self-help group for women with breast cancer, 

which provides regular training sessions in preventative 

and supportive care. There are now around 13 women 

regularly attending the group at KHCC (28).

Ethical issues

There are three major ethical issues described by palliative 

care teams in Jordan. The first is the difficulties experienced at the end of life by patients, their families and 

members of a palliative care team in a medical system that 

is not yet fully attuned to the concepts of palliative care. 

Al Malath Medical Director Mazen Al Bashir explains: 

“There’s tension between our [hospice] regime of what 

needs to be done, or not what needs to be done, but what 

we want to achieve, and the other medical profession’s 

paradigm. We think of the human being, the whole person 

and the family, and those guys [oncologists] are really 

focusing on the size of one of the tumors in the brain 

for getting the drugs for it. But there’s a human being 

around that tumor. We want to do what we need to do, 

but they want to give them a drug or give them a shot of 

chemotherapy, or whatever, or somebody who they record 

the blood pressure and according to the doctor they are 

showing liver failure, renal failure, and [the patient] is 

on a respirator in the ICU studded with metastases everywhere, and they decide to do renal dialysis.”
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National Cancer Institute 91 MECC Palliative Care Monograph 

To some extent, it is hoped that this issue will recede 

as more health professionals—at undergraduate, postgraduate and professional development levels—receive 

training in the concepts and practice of palliative care, 

and as there is more public education around end-of-life 

care.

Closely linked to this ethical dilemma is the second problem that palliative care professionals report: distress in 

the families at withdrawal of active treatment, including 

food, drink, and infusions, in the last few days or hours 

of life. Both organizations, Al Malath and KHCC, found 

families were best supported by the hospice team ensuring 

the situation was fully explained and discussed with the 

caregivers before death became imminent. This discussion with families is a key element of hospice care and 

includes the general education and support offered to 

family caregivers throughout the end-of-life period.

Difficulties arise also around a third area--disclosure of 

diagnosis. Nisreen Al Alfi, nurse at KHCC explains: “I 

think another problem is problems of disclosure, this is 

not a problem for all [patients] but we have faced this 

quite a lot at the beginning. The best thing is if the patient 

and the family are informed and they decide for themselves. I think with training for the primary physician [in 

how] to talk about prognosis and so on will make our job 

easier. The team often can’t do anything with the patients, 

because we have been faced with rejection sometimes--

the patient is angry, ‘I want my primary physician, who 

are you to tell me, like what I am going to do, why I’m 

going to die.’ ... there were problems of disclosure and 

confidence patients have with us.”

However, both organizations report that where the team 

is sensitive to the needs of patients, families, and their 

physicians, and where there are more opportunities for 

training in communication and education of the patient 

and families, these issues of disclosure and acceptance 

at the end of life have shown signs of change.

History and development of 

palliative care

Narrative history of palliative care

Interest in palliative care in Jordan was initiated by Crown 

Prince Hassan in 1985. In 1986, through his office, two 

nurses from the UK charity Macmillan Cancer Support 

(then known as Cancer Relief Macmillan Fund) were 

commissioned to conduct an assessment of palliative care 

need in cancer patients in Jordan. Their study highlighted 

the need for pain relief and trained professionals. By 1992 

a group of concerned health professionals was discussing how to actively set up palliative care services. Rana 

Hammad, director of Al Malath Foundation, describes 

how, with the continuing support of Prince Hassan—who 

gave Al Malath an award for starting the first service—

the hospice was set up in 1993: “I wanted to start an inpatient service because I’m more in control, and because 

there was no home care, community home care program 

whatsoever in Jordan. Nothing, not even paid. Nobody 

goes to homes; all the patients have to go to hospital 

whatever their conditions. So I thought we will be talking 

about pain control, we started talking about morphine, 

and people are about to shoot us because of this. We are 

talking about empowering patients, quality of life--so we 

are pioneers in everything. I didn’t want to add another 

burden of being pioneers also in home care. So I wanted 

to be in the hospital--the majority wanted home care--and 

then we had this first phone call from Ann David, who 

was a lovely British lady, who was our first patient--her 

husband used to work in the United Nations--and when 

she became terminal, she decided to die here, at her home 

here. She said, ‘Why don’t you start and come and visit 

me.’ So she dragged us, and we started home care. So 

there has been a sequence of coincidences, of beautiful 

people who just put us on the right track. It was destined 

to become, to be. 

“A second decision that we had to make: should it be a 

program under the umbrella of Ministry of Health, or a 

private sector hospice, or a charity hospice? The toughest 

way was to be a charity organization, because in Jordan, 

the charity sector is hard to live in. We don’t have resources or income, so it was hard, but for me it was the 

most suitable thing because it was the only guarantee to 

eliminate the human bias when it comes to money. So 

if I want to deal with people, I’ll deal with them regardless of their ability to pay, regardless of, you know, the 

income they have or the donations they might give or 

money they might give. From 1993 till 2004, there was 

no other program in Jordan. 

“It started with primitive resources, but with huge will 

we’ve got professionals to help us; volunteers. It started 

from my home, with the space and one huge table as the 

office for one year; with wheelchairs, my kids playing 

on both wheelchairs; meetings of the part-time secretary, 

‘Come and help me while I cook and do some meeting.’ 

So I started home care using a taxi from my home. And 

the first year, we only took one patient, stayed with that 

patient, helped, tested the needs; saw what the Jordanian 

people wanted. And modifying, re-modifying again and 

again, coming back and forth to the basics again; till that 

patient dies then we take another patient--we haven’t 

duplicated two patients at the same time. In 1993-1994, 
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National Cancer Institute 92 MECC Palliative Care Monograph 

we rented this office, got a car, and added more equipment.”

By 1995 Al Malath had sufficient resources to care for 40 

patients – adults and children, over the year. The hospice 

continues to care for, annually, around this same number 

of patients. 

From the late 1990s WHO began actively to support the 

development of further palliative care services, encouraged 

by the establishment of KHCC as a dedicated oncology 

hospital. Director of nurse training, Ahmad Al Khateib 

describes the development of the first hospital-based palliative care service:

“August 2003 we started, there was a one day workshop, 

sponsored by WHO and the Ministry of Health, and KHCC 

participated in that workshop. One of the outcomes was 

a recommendation to have a National Palliative Care and 

Pain Relief Initiative Committee in Jordan, with his Excellency the Minister of Health as chairperson and Dr. 

Samir Khlief, Director of KHCC, and people who cover 

all health sectors in Jordan to sit in that committee. Here 

at King Hussein Cancer Center, two years ago we started 

the program of palliative care and pain management at 

home care. I have to say proudly that the only hospital 

setting palliative care program in Jordan is King Hussein 

Cancer Center. Now we’re going to have this hospice unit 

and we are going to extend it for more. And we have the 

home care program; we have trained nurses and trained 

physicians to run this service.”

The KHCC team was established in September 2004. 

Team director Dr. Amal Bandak, with the nurse manager 

and the team (including two nurses who trained in palliative care with Al-Malath), wrote the guidelines for 

the inpatient and home care services. The team started 

with four nurses, but has now expanded to a total of 

21 nurses in order to develop small teams able to work 

within the hospital--in the outpatient department and the 

new inpatient unit--and in the home care service. The 

team has a part-time psychologist and is recruiting more 

psychologists and social workers. Amal Bandak is keen 

to develop more educational opportunities for the team 

professionals; in particular she is setting up links with 

centers in the USA. 

At the Faculty of Nursing at Jordan University of Science and Technology (JUST) in Irbid, the largest city in 

the north of Jordan, Assistant Professor of Nursing, Dr. 

Suha Omran and her colleagues, are developing palliative 

care training workshops based at the medical and nursing schools. Currently, the Faculty is offering a unit in 

oncology nursing for undergraduate nurses included in the 

medical surgical course. There is also a Masters program 

offering a clinical nurse specialist in oncology nursing. 

The palliative care element is supported by opportunities 

for student placements at KHCC and Al Malath (29). 

Hospice success stories

Al Malath Foundation

Rana Hammad set up Al Malath in 1993, in response to 

a need to provide care and comfort to patients at the end 

of life. For Rana Hammad and hospice Medical Director 

Mazen Al Bashir, the success of Al Malath lies in the dedication to be totally committed and present for the patient 

and the family: attending to all aspects of the patient and 

family needs, medical, personal, social and spiritual. The 

team supports the patient and family throughout the final 

stages of life, staying with them through the last hours, 

however long, and after the patient dies will maintain 

support for the grieving family, wherever appropriate. 

Mazen Al Bashir suggests that the vital element of Al 

Malath is that “We think of the human being, the whole 

person and the family...”

There is anxiety that the over-medicalization of end-oflife care results in a loss of the holistic and humane approach, felt so essential by Al Malath. Thus, the team 

encourages the newer developing services to hold to the 

compassionate element of palliative care.

King Hussein Cancer Center

A combination of support from the existing expertise of 

Al Malath and WHO, together with the determination to 

develop a wide coverage of services, is proving successful in setting up several teams at KHCC. The Director 

of Nursing Education, Ahmad Al Khateib, is dedicated 

in his resolve to create a regional training center and 

encourage a wide uptake across Jordan, and the region, 

of the concepts and practice of palliative care.

Life/oral histories

Rana Hamad—Director: Al Malath Foundation for Humanistic Care, Amman: interviewed by 

Amanda Bingley, 12 May 2005--duration of interview: 76 minutes.

Rana Hammad talks about her early work in nursing and 

completing a Master’s in Nursing Research and her growing interest in caring for patients at the end of life. She 

describes how she was alerted to the need for palliative 
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National Cancer Institute 93 MECC Palliative Care Monograph 

care in Jordan by a TV appeal about cancer research. 

She explains: 

“When we started, we started on October 12th, 1992, there 

had been a telethon on TV, to raise funds for the King 

Hussein Cancer Center--at that time it was called the Amal 

Cancer Center and Amal in Arabic means hope, so it is 

the center for hope for cancer cure, and it was the first of 

its kind and I think it was the first, and the whole country 

were so enthusiastic to do something about cancer... When 

they started repeating the hope center for cancer cure--it 

was repeated for millions of times--it started hitting me. 

The majority of cases--eight out of ten--are diagnosed 

late, diagnosed terminal. So then a question hit me: this 

center will be for cancer, what if cancers cannot be cured, 

where will patients go? At that time I was finishing my 

Master’s degree in Nursing Education and Research, and 

I was working on my thesis on empathy, and I empathized 

really easily at that point. Next day I was talking to a 

friend of mine who has a Ph.D. in nursing, and we had the 

same questions. And then we started pulling interested 

people to ask this question--we just wanted an answer to 

this question. And we realized that we don’t see terminal patients at hospitals--where are they? They’re not in 

hospitals! So where are they?”

She began to understand that “in palliative care you do 

really care for a human being who is suffering. I don’t 

know why—maybe it’s the way the philosophy of palliative care makes it always easier to start at homes—it has 

started most of the places, the work, at homes, and it took 

a long time before it got integrated in hospitals.” 

An important aspect of her work is to develop attentive 

communication and cultural sensitivity. With the support 

of two or three hospice workers from the US and UK to 

whom she feels very grateful, she was encouraged to 

develop a Jordanian model of palliative care that was 

culturally appropriate. As she says, ”This is palliative 

care; it has spiritual and cultural issues.”

Mazen Al Bashir—Medical Director: Al Malath 

Foundation for Humanistic Care, Amman: interviewed by Amanda Bingley, 12 May 2005 – duration 

of interview: 35 minutes.

Mazen Al Bashir talks about his training as a general 

practitioner at the medical school in the University of 

Liverpool, UK and later his GP work in Liverpool. With 

Rana Hammad he discusses his dedication to providing 

holistic palliative care for the patients in the home hospice, 

describing how he often spends long hours with patients 

and their families. He talks of the importance of honoring 

the dying process as a valid and vital part of medicine, 

as important as the birth process. As he says:

“You know, if one of my patients died without me attending, or he died unexpectedly, without really having 

family around, giving all the rituals...if it doesn’t happen 

that way, I don’t have that--if one of them died when 

I’m not there, it’s not exactly losing one of your young, 

new mothers in labor--if it happened to a gynecologist 

that he loses a young lady in labor, I mean, it’s the most 

humiliating experience--but it’s the same for me. But 

that’s exactly the spirit you need in any cancer hospital 

or in patient facility. It’s the most important job to make 

sure that those hours worked and this time--because it’s 

a crucial time--the finale--the grand finale, and without 

having the family there continuing to help, their reaction 

and their grief response won’t be the same.”

Amal Bandak—Associate Director of Nursing & 

Patient Affairs at the King Hussein Cancer Center: 

interviewed by Amanda Bingley, 11 May 2005--duration of interview: 55 minutes.

Amal Bandak is leading the first hospital-based hospice 

team in Jordan. She is Palestinian, and has lived and 

worked in Jordan since the late 1980s.With a background 

in pediatric oncology nursing and nursing education, her 

PhD was in maternal and child nursing. As she describes: 

“I used to teach at Jordan University until last year and 

then I decided to give up teaching, I want something new! 

Rena (the specialist nurse on the KHCC team) is one of 

my students; most of them are my students.” She talks 

about her experience nursing patients at the end of life and 

setting up volunteer groups supporting cancer patients in 

three hospitals in Amman. She is a psychotherapist, and 

is committed to use these skills to build a strong team. 

She notes that: 

“In a short period of time we did a lot. And most important 

is that we are a group, a very committed group working 

together like one family. I’m very proud of them. We 

have a lot of problems but through this method [psychotherapy] we are able to solve many problems ... together 

we are able to build a very nice group.”

She is keen to promote training and has initiated positive 

links with palliative care courses with Frank Ferris at San 

Diego Hospice, US and in Canada.

Ahmad Al Khateib—Director of Nursing Education: King Hussein Cancer Center, Amman: interviewed by Amanda Bingley, 11 May 2005--duration 
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National Cancer Institute 94 MECC Palliative Care Monograph 

of interview: 45 minutes.

Ahmad Al Khateib talks about his work to promote education and training for the newly developing services in 

Jordan. He has a background in oncology nursing, with 

a Master’s in Nursing Oncology from Georgetown, US, 

and hospital training in palliative care and patient education. He is currently doing a Ph.D. He became involved 

in KHCC when he was asked to coordinate a course in 

palliative care and liaise for the Ministry of Health, WHO 

and KHCC. He was nominated to coordinate the training 

programs and developing projects. As he says: 

“I’m glad to do this... For me palliative care, I think it 

is part of symptom management, quality of life and not 

suffering. I think it is important from the belief that it 

is the patient’s right to be cared ... I might not be able 

to cure, but that becomes a secondary objective or goal, 

but sometimes at least we could help alleviate suffering. 

The concept of palliative care... in Jordan and maybe all 

over the world, but in Jordan particularly, still it’s a new 

concept. So it took us some time to help the physicians 

and nurses and health care providers to understand what 

you mean by palliative care and to emphasize that the 

patient it’s part of their lives to die in peace and dignity. 

So even until the last minute you have to take care of the 

patients. We found some people who are really interested, 

and we work with these people who now attended the 

courses, and train them, because I think these people will 

be very helpful, to also convince other people. So now 

we have a program and training, so things become clear; 

before there was nothing.”

ENDNOTES

1. 2002 population estimate Jordan Ministry of Health statistics – Al Kayed S and Al Hijawi B. Report of the National 

Cancer Registry, Incidence of Cancer in Jordan 2002, The 

Hashemite Kingdom of Jordan, Ministry of Health; 2005.

2. “Physicians’ guide to hospice care” Al Maath 

Foundation information leaflet, 2005.

3. IOELC interview: Nisreen Al Alfi – 11 May 2005.

4. IOELC interview: Amal Bandak – 11 May 2005.

5. Clark JA (2004) Islamic associations and the middle class, ISIM newsletter 14, June 2004; 51 www.

isim.nl/files/newsl_14/newsl_14-51.pdf.

6. Center for Palliative Care Studies at San Diego Hospice, CA is 

supporting the Jordan Pain Relief and Palliative Care Initiative. http://www.cpsonline.info/content/resources/jordan.html.

7. 1,000 JD are equivalent to around $1,411 (currency exchange 1 JD = $ 1.41 – 11 July 2005).

8. Al Malath Operating Model - information on website 

www.hospic.jubilee.edu.jo/operating_model.html.

9. IOELC interview: Ahmad Al Khateib – 11 May 2005.

10. IOELC interview: Bassam Hijawi – 11 May 2005 and 

IOELC interview: Rana Hammad – 12 May 2005.

11. International Narcotics Control Board. Narcotic Drugs: 

estimated world requirements for 2004. Statistics for 2002. 

New York: United Nations; 2004. International Narcotics Control Board. Report of the International Narcotics 

Control Board 2004, United Nations: New York; 2005. 

www.incb.org/incb/en/annual_report_2004.html.

12. Selva C. International control of opioids for medical use 

European Journal of Palliative Care 1997;4:194-198.

13. “The term defined daily doses for statistical purposes 

(S-DDD) replaces the term defined daily doses previously used by the Board. The S-DDDs are technical units 

of measurement for the purposes of statistical analysis and 

are not recommended prescription doses. Certain narcotic 

drugs may be used in certain countries for different treatments or in accordance with different medical practices, and 

therefore a different daily dose could be more appropriate.” 

International Narcotics Control Board. Narcotic Drugs: 

estimated world requirements for 2004. Statistics for 2002.

14. International Narcotics Control Board. Narcotic 

Drugs: Estimated World Requirements for 2004. Statistics for 2002. New York: United Nations; 2004.

15. Stjernswärd J. Jordan: National Palliative Care Programme. Hospice Information Bulletin June 2004. Worldwide Hospice and Palliative Care Online (WHPCO) - a 

free, electronic newsletter published every two months for 

people involved or interested in international palliative 

care. For a sample copy, or to subscribe mail to: anne@

hospiceinformation.info or avril@hospiceinformation.info.

16. IOELC interview: Rana Hammad – 12 May 2005.

17. Ferris F and Stjernswärd J: presentation at the 

Open Society Institute (OSI) seminar, Budapest, Hungary, 5 –7 September 2005.

18. IOELC interview: Mazen Al Bashir – 12 May 2005.

19. ‘The concept of hospice care’ Al Malath Hospice information leaflet, 2005.

20. Al Malath Operating Model--information on website 

www.hospic.jubilee.edu.jo/operating_model.html.

21. King Hussein Cancer Centre--information on 

website www.khcc.jo/KHCCCenter.asp.

22. Stjernswärd J. Jordan: National Palliative Care Programme Hospice Information Bulletin June 2004.

23. Brown A and Kay J. The continuing care of the patient 

with advanced cancer, Unpublished manuscript; 1986.

24. Hammad R. The hospice experience in Jordan: Al Malath Foundation for humanistic care, In Saunders DC and 

Kastenbaum R. Hospice care on the international scene. 

New York: Springer Publishing; 1997, pp. 242-254.

25. Stjernswärd J. Jordan: National Palliative Care Programme Hospice Information Bulletin June 2004.
Chapter 7 Palliative Care in Jordan

National Cancer Institute 95 MECC Palliative Care Monograph 

26. Ferris FD, Bower KA, Stjernswärd J. Integrating palliative care into an existing healthcare system: an 

international perspective. Paper presented at the 

AAHPM, New Orleans, LA, January 23 2005.

 27. King Hussein Cancer Center training manual and 

guide--draft--compiled by Amal Bandak and members of the KHCC hospice team, May 2005. 

 28. IOELC interview: Carol El Jabari – 10 March 2005.

 29. IOELC questionnaire: Suha Omran – 8 August 2005.

National Cancer Institute 97 MECC Palliative Care Monograph 

West Bank

Gaza Strip

Chapter 8

Palliative Care in the Palestinian Authority

The Palestinian Authority refers to two separate land 

areas in the Middle East. The Gaza Strip (population 

1,324,991) covers an area of 360 square kilometers bordering the Mediterranean Sea between Egypt and Israel. Its 

land boundaries border Egypt and Israel. The West Bank 

(population 2,311,204) covers an area of 5,860 square 

kilometers bordering the Dead Sea. Its land boundaries 

border Jordan and Israel. 

PALLIATIVE CARE SERVICE 

PROVISION

Current services

There are no specific palliative care services in the Palestinian Authority. The charitable non-governmental organization (NGO), the Patient’s Friends Society-Jerusalem 

(PFS) located inside the Augusta Victoria Hospital in 

East Jerusalem, offers psychosocial support, advice and 

education. 

There are six oncology units in general hospitals around 

the West Bank and the Gaza Strip, which provide pain 

and symptom relief for adults at the end of life. Two of 

the units in the Gaza Strip also care for children (Table 

8.1).

Hospital oncology units: There are six oncology units 

which offer pain and symptom control at the end of life. 

The Augusta Victoria Hospital in East Jerusalem, which 

has a government-funded oncology unit, treats around 

100 cancer patients per year. 

There are two government-funded units in the Palestinian Authority West Bank, Beit Jala Hospital and Nablus 

Hospital (no patient numbers available). There are three 

government-funded units in the Gaza Strip, which between 

them treat an estimated 700 patients per year; around 

55% of patients in the north of Gaza access services at 
Chapter 8 Palliative Care in the Palestinian Authority

National Cancer Institute 98 MECC Palliative Care Monograph 

the Shifa Hospital and a pediatric oncology unit at the 

Nasser Hospital, and around 45% of patients in the south 

of Gaza access services at the European Gaza Hospital, 

which also treats children. 

Palestinians may also access palliation via Israeli services 

if they live in East Jerusalem and have an Israeli identity 

card and health insurance. If patients have the means to 

pay, there are oncologists who run small private oncology 

clinics in the West Bank or patients are given referrals to 

services in Jordan, Egypt and other countries overseas. 

The Patient’s Friends Society, Jerusalem (PFS), focuses 

on women’s health and public health through health education and psychosocial support. Services include breast 

cancer and osteoporosis screening, lectures, advice about 

cancer via health education literature and a Helpline service, self-help groups for women with breast cancer in 

the West Bank, newsletters and seminars for physicians 

and other health professionals working in, for example, 

small clinics around the West Bank, some of which may be 

supported by other NGOs and UN organizations. Where 

possible, PFS offers psychosocial support to women with 

cancer at the end of life. 

There is no reported palliation or support for patients 

with other illnesses including heart disease and stroke. 

At the time of writing, the incidence of HIV/AIDS is 

reportedly still very low but supportive care is provided 

if needed. (2)

Reimbursement and funding for services

Augusta Victoria Hospital is part funded by government 

and part funded by charitable donations. The Oncology 

Department is government-funded. The hospital is resource 

poor and relies heavily on donations for equipment and 

development of existing services.

The Patient’s Friends Society is a registered charity nonprofit NGO. The PFS charges a nominal fee for breast 

PHOTOGRAPHS for Chapter 8

Photographs were taken during field visits. 

Suggested placing of images is indicated in the 

manuscript – subject to editorial preference. 

Chapter 8

Illustration 8.1: Augusta Victoria Hospital, East Jerusalem 

[photograph: Amanda Bingley, May 2005].

Table 8.1 Palliation and palliative support available to Palestinians 2005

Adult and Pediatric* Services Freestanding unit Hospital unit Hospital

support team

Home care

Day care 

 Drop-in /

Advice 

Center

Grand Total

Palestinian Authority-funded oncology units:

West Bank

~ Beit-Jala Hospital 

~ Nablus Hospital 

Gaza Strip

~ European Gaza Hospital*

~ Shifa Hospital

~ Nasser Hospital*

1

1

1

1

1

1

1

1

1

1

Charitable funded provision:

~ Augusta Victoria Hospital oncology unit

NGO

~ Patient’s Friends Society

1

1

1

1

6 1 7
Chapter 8 Palliative Care in the Palestinian Authority

National Cancer Institute 99 MECC Palliative Care Monograph 

and bone density screening services. All other services 

are provided free.

The Palestinian Authority funds hospital services in 

government hospitals in the West Bank and Gaza Strip. 

Oncology patients are eligible for free treatment via their 

government health insurance. There is a small charge for 

some medications during cancer treatment.

Opioid availability and consumption

The Palestinian Authority is not an independent sovereign 

state and thus not an acceded party to the conventions of 

the International Narcotics Control Board which therefore 

has no published figures for the consumption of narcotic 

drugs in the Palestinian Authority. The proportion of consumption via Israeli license--and thus accounted for in 

Israeli returns--is not defined. 

Oncologists report that the available range of drugs in 

2005 for pain at any stage of disease can include: 

morphine hydrochloride by injection 10 mg and 20 mg; 

MCR oral tablets--more commonly used than injectable 

morphine--(morphine sulphate as a controlled release 

system 10 mg and 30 mg)

Dolestine (pethidine hydrochloride) by injection 50 mg 

and 100 mg

Percodan oral tablets (a combination drug containing 

oxycodone and aspirin); these are widely used throughout 

Gaza and the West Bank. 

Opioids of choice when available at the end of life include 

injectable fentanyl 2 mg, 10 mg (ampoules), and pethidine 50 mg (ampoules). The opioid antagonist nalaxone 

is used if needed (2).

Opioids are available to patients at the Augusta Victoria 

Hospital, East Jerusalem. However, availability for outpatients is dependent on the authority of an Israeli license 

holder and is also compromised by the ability of the patient 

to pay, as one of the oncologists explains:

“The main problem that we have is the availability of pain 

medications, especially morphine. We are in a difficult 

situation, because here it’s a Palestinian hospital but it’s 

in Israeli territory, so we cannot get morphine, so I don’t 

have, let’s say, the authority to prescribe morphine. I can 

do it here inside the hospital, but if I want a patient to take 

morphine when he goes home, then officially I can’t do 

that, I have to wait for somebody with an Israeli license 

to come do a prescription. We do have somebody on the 

staff here who has an Israeli license, but he’s not available all the time. That’s not the only problem: another 

aspect is really most of our patients don’t have permits 

to go to West Jerusalem, and that’s where the pharmacy 

is. So even when we do get a prescription written, there 

are problems how to go and get it, and it’s kind of expensive because the average morphine prescription will 

cost a patient around probably 50 euros. Maybe that’s 

not expensive by your standards, but for our people here 

it’s really expensive. And of course there are restrictions, 

so sometimes people at the pharmacy will not give more 

than two weeks’ supplies, so the patient has to keep on 

going back and forth to the pharmacy. So that’s a big 

problem for us.” (1)

Palliative care coverage

Currently there are no dedicated palliative care services 

in any area of the Palestinian Authority. Palliation is supported in six oncology units. As one oncologist stated, 

there is acute need as “the majority of cases are at an 

advanced stage, requiring palliative care--but we have 

no palliative care services, or trained people.” 

Palliative care workforce capacity

There are no available figures for workforce capacity.

National and professional 

organizations

The Patient’s Friends Society, Jerusalem (PFS), is a Palestinian non-profit non-governmental organization (NGO) 

established in 1980 by Palestinian academics and health 

professionals to promote health care services. The PFS is 

the only health-related NGO that offers, among its other 

public health education and cancer support work, psychosocial support for women with cancer at the end of life. 

Since the early 1990s the focus of PFS-Jerusalem has been 

on women’s health and in particular supporting women 

with breast cancer in the West Bank and Gaza. (6)

Located in East Jerusalem at the Augusta Victoria Hospital, PFS offers a range of health education outreach 

services and literature to promote cancer prevention; a 

mammography screening service for early detection of 

breast cancer and bone density screening for osteoporosis. An important development since 2000 is the setting 

up of the “Sunrise” (Shuruq) breast cancer survivors’ 

support group for Palestinian women. In 2002, women 

in the Sunrise group set up a Helpline for information 

and advice, which by 2005 had been shown to be very 

successful. They have a current membership of 50 can-
Chapter 8 Palliative Care in the Palestinian Authority

National Cancer Institute 100 MECC Palliative Care Monograph 

cer patients including survivors. There is a “Reach for 

Recovery” program, where trained volunteer survivors 

offer support to breast cancer patients. PFS also offers 

low cost wigs and prostheses to breast cancer patients. 

(13) Director Carol El Jabari explains that PFS can only 

offer limited support at the end of life; in this situation 

PFS volunteers will offer psychosocial support and sometimes may be able to help access oncologists to prescribe 

pain relief. (15)

PFS is committed to training and professional development and research around cancer and women’s health, 

organizing occasional short seminars for health care professionals; and self-help workshops teaching first aid, 

Reiki healing and self care. Since 2002, representatives 

from PFS have regularly attended the conferences of the 

International Union against Cancer (UICC). For example 

in 2002, PFS participated in a presentation of findings of 

the “Project COPE” Israeli/Palestinian study, funded by 

MECC, “Coping with breast cancer among Palestinian 

and Israeli women” at the 18th conference of the UICC 

held in Oslo. In 2004, Carol El Jabari, the Director of 

the Society, presented at the UICC World Conference for 

Cancer Organizations in Dublin, Ireland with a workshop 

entitled “Cancer Patient Support Groups in Palestine and 

Jordan.” In 2005, PFS Director Carol El Jabari and Amy 

Avgar of the Israel Association for the Advancement of 

Women’s Health, sponsored by MECC, published an evaluation of the Project COPE study. PFS also distributes 

a twice yearly newsletter to members, volunteers, and 

health care professionals. 

Augusta Victoria Hospital, located in East Jerusalem, 

is a charitable hospital managed since 1950 by the Lutheran World Federation. Its history and development 

is described as:

“Built in 1907 as a pilgrims’ hospice by Kaiser Wilhelm 

II in honor of his wife the Empress Augusta Victoria, it 

was converted into a hospital for the British Army during 

WW2. In 1948, the International Committee of the Red 

Cross established it as a hospital for displaced Palestinian 

refugees. In 1950, the United Nations Relief and Works 

Administration (UNRWA) took over responsibility for 

Palestinian refugees. Today, 75% of the hospital’s referrals are made by UNRWA. Since 1993, Augusta Victoria has been providing services to the local and greater 

Palestinian community... In cooperation with UNRWA, 

and through an assessment of the needs of West Bank 

communities, Augusta Victoria Hospital is developing 

the first radiation oncology center available in all of the 

Palestinian territories, as part of the expansion of the 

hospital’s Oncology Department.” (18)

The Augusta Victoria is a general (medical and surgical) hospital with 100 beds. Facilities include a renal 

dialysis unit for children and an oncology department 

run by Medical Oncologist Dr. Fouad Sabatin, who treats 

around 100 cancer patients every year. He describes the 

current situation: 

“This number [of cancer patients] is supposed to double 

or treble very soon because we are going to be the only 

radiation oncology department in the West Bank, so we 

are expecting that most, if not all the patients will be 

referred to us. They will still go to [oncology units in 

the West Bank] for chemotherapy, it’s just these places 

don’t have radiation therapy; they have to come to us for 

that. We have a medical department; we admit patients 

with medical conditions and oncology conditions to that 

department, and it’s really variable, so sometimes these 

beds are 100 percent occupied by oncology patients and 

other times 20 percent, so it’s variable. In the next one or 

two months [from May 2005], we [will] make a specific 

requirement for oncology patients.”

Dr. Sabatin will provide palliation at the end of life in 

the hospital. He explains the difficulties of providing 

palliative support:

“If they have severe pain we keep them and get their pain 

under control, but eventually they will be discharged. But 

one of the problems here that is we don’t have hospice 

care, so there are a lot of patients who are candidates for 

that kind of care, but it’s not available. So I would say that 

towards the end of life, what happens is that these people, 

they tend to come frequently to the hospital because when 

they go home their pain’s no longer under control and 

because it’s unfortunate we cannot, 99 percent of our 

patients cannot afford to pay for the Fentanyl patches, 

for example. Sometimes they have side effects from the 

morphine and in that situation we are stuck. So these 

people come back into hospital because they don’t have 

a lot of choices. So that’s the main point--these people, 

instead of being in a good hospice program, they end up 

visiting the emergency room frequently. 

“I’m the only medical oncologist here at the Augusta 

Victoria Hospital, so it’s natural that I have to take care 

of, to palliate patients, not only give them chemotherapy 

but even after that, like during therapy if they have a pain, 

and after they’ve done the therapy, they can also have 

pain. Or even if they are not candidates for chemotherapy 

or aggressive therapies they still need to [have] palliative 

care. So it’s like [an] important part of my job here to do 

the palliative care for patients.” (1)
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National Cancer Institute 101 MECC Palliative Care Monograph 

There are considerable difficulties of access for staff to get 

to work at the hospital and for patients to get to services 

at the hospital if the checkpoints into East Jerusalem are 

closed. This is particularly serious if they are dialysis 

patients, as the hospital has the only dialysis center for 

children in the West Bank. But access poses a tremendous 

problem for cancer patients, especially those at the end 

of life who are not living near an oncology unit:

“People living in Ramallah are unlucky when it comes to 

having a diagnosis of cancer because there is no center 

in Ramallah with the facility to treat these patients, and 

typically, these patients need to be referred to Beit Jala 

hospital or to Nablus, and all of them are far away, and 

there are several checkpoints in between. So getting to the 

hospital is really difficult, and usually it takes several days 

for these patients to be sent in the right direction. Now, 

these patients have a choice to come to Augusta Victoria 

Hospital, but obviously not all of them will be sent to us 

because we’re not a government hospital. So most of the 

patients, I would say, will be sent to Beit Jala or to Nablus 

Hospital. And if you’re asking about how these patients 

will do and their management, if they have a pain crisis 

or something like that, it’s really very tough because, as 

I said, there is no place in Ramallah that’s really able to 

treat these patients. They end up being treated by general 

practitioners at government hospitals until they can be 

referred to another place. It’s a sad situation.” (1)

The Middle East Cancer Consortium (MECC), of which 

the Palestinian Authority has been a member since 1996, 

provides support in several different areas: establishing 

standardized cancer registries in member countries, as 

well as sponsoring and supporting training and development in cancer registry and cancer services. In February 

2004, MECC convened a two-day conference in Larnaca, 

Cyprus, specifically to discuss the concept of palliative 

care and to initiate assessment of palliative care services 

and needs in the member countries. 

Education and training

There is no formal program of palliative care training. 

The PFS has run occasional day seminars for doctors 

and nurses, a component of which includes psychosocial 

support for breast cancer patients. Oncologists travel to 

international conferences and seminars for training. The 

Middle East Cancer Consortium convenes conferences and 

seminars for training in cancer registry and other aspects 

of cancer diagnosis and treatment, including the conferences on palliative care in February 2004 and November 

2005, at Larnaca, Cyprus. 

Ethical issues

There are two major ethical issues described by health 

care professionals providing end-of-life support in the 

Palestinian Authority. The first is the problem of health 

service provision when working in an area riven by conflict, and with no home care support. The second is the 

problem of disclosure of the diagnosis and prognosis to 

cancer patients. Dr. Fouad Sabatin discusses these two 

ethical problems:

“Sometimes the families also can ask us not to tell the 

patient he or she has cancer and we end up having to deal 

with the situation because the patient doesn’t know if he 

has a tumor. Eventually they will know they have a terminal illness, but for the families the pressure is so hard 

not to tell the patient. So the families they take that role, 

they try to take decisions for the patient. I try my best to 

avoid that. I love it when I get to the patient first before 

a family member comes to me and says, ‘Oh please, don’t 

tell him that he has so-and-so.’ And in certain situations 

that has happened, so that’s number one. Number two, 

these families, most families they don’t have support; 

for example, although we have a social worker on the 

staff, but we don’t have enough support and resources 

for these people and because the insurance system is not 

great, once these patients go home they don’t have the 

luxury of having like a visiting nurse or sometimes having physiotherapy at home or home care or for example 

home equipment and so on. So sometimes the families 

get overwhelmed. But this is probably different from the 

Western countries, most of the families here are committed, so they really take care of the patients very well, but 

it’s a hard job.” (1)

Carol El Jabari suggests that much of the problem relating 

to disclosure is due to lack of training for doctors. She also 

feels that the lack of access to care is a major issue:

“A major ethical issue is that the doctors are not frank 

with the patient; they don’t tell them they have cancer. 

It is a major obstacle we as caregivers have to try and 

overcome when trying to give palliative care or any kind 

of care. Usually the family will know, and the family tells 

the doctor, ‘Please don’t tell them.’ Most of the patients 

know--won’t they figure out when they go for chemotherapy or radiotherapy? While most people don’t want 

to say or hear the word ‘cancer’ we have found in our 

experience it is best to tell the patients, so they can get 

on with the rest of their lives. Most of the doctors have 

never been trained to discuss such a major health issue 

so they need skills and sensitivity training to better deal 

with patients and families. We’ve had some workshops 

with nurses. The nurses we’ve been teaching are great, 
Chapter 8 Palliative Care in the Palestinian Authority

National Cancer Institute 102 MECC Palliative Care Monograph 

but they’re all very frustrated because they’re dealing 

with patients the doctors haven’t told.

“Another ethical problem is that the access to care, whether 

it be for diagnosis, chemotherapy, radiotherapy or psychosocial support, depends on the individual being well 

enough to go obtain a permit, have it accepted at the 

barriers and eventually get to their treatment. This is all 

very traumatic, disheartening and exhausting.” (6)

History and development of 

palliative care

Narrative history of palliative care

Palliative care remains an undeveloped and under-resourced area of health care in the Palestinian Authority. 

There are, however, several dedicated oncologists and 

also PFS volunteers who strive wherever possible, often 

against the odds, to provide some palliative and psychosocial support for cancer patients at the end of life.

There are concerns at the lack of palliative care training 

and the subsequent lack of awareness of needs. Senior 

Oncologist Dr. Abdel Rassaq Salhab has explained that 

he had to develop his palliation skills, in the form of pain 

relief and symptom control, by attending international 

seminars and short training courses abroad. As he noted 

there is a need for “a national program of palliative care 

and to have a dedicated society for hospice care.” 

Efforts by MECC and PFS since the early 2000s offer 

some opportunities for greater awareness of the need for 

specialist care and training at undergraduate and professional level. 

Dr. Fouad Sabatin describes his hopes for the future:

“What I would really want to see change is to have a team 

approach for cancer care, to have more resources. We 

have a lot of trouble giving chemotherapy so I hope that 

in the future we can give chemotherapy easier, and hope 

that the radiation and oncology unit starts running very 

soon. And when it comes to palliative care medicine, 

I really hope that we can come to an agreement with 

the Israeli people who can give me some authority to 

write prescriptions and I hope that somehow the price for 

morphine is not as high as it is now because I think it is 

one of the basic medicines and should not be expensive. 

And also I’d love for my patients to have all the options 

available for patients who are intolerant of morphine, 

to have the opportunity to resort to fentanyl patches, to 

oxycodone and sometimes methadone. Also I’d really 

love to witness the day when we would have a hospice 

program here. So as you see, we have a lot of things to 

look forward to.” (1)

Life/oral histories

Patient’s Friends Society

Carol El Jabari, Director, Patient’s Friends Society 

(PFS), Jerusalem: interviewed by Amanda Bingley--

10/03/05--duration of interview: 25 minutes

Carol El Jabari talks about her work with the PFS and 

how she became interested in psychosocial care. She 

explains:

“I’d started working with the Patient’s Friends Society 

in the late ‘80s, and in 1990 we started the first mammography center in Palestine. I identified women coming 

through being diagnosed with cancer and knew they had 

no psychosocial support, amongst other things, so it was 

a service I was really very keen to develop. It wasn’t until 

2000 that it became a reality because it was important 

to identify women that were as keen, or committed as 

me to make it happen. My educational background is 

nursing and psychology and public health, so it all came 

together.”

She describes the very successful model for support groups 

for women with breast cancer that she and other volunteers 

have developed based on the Reach to Recovery model 

and introduced by the Israel Cancer Association, noting 

what a tremendous difference the service has made for the 

Palestinian women involved: Importantly the program has 

been adapted to meet Palestinian needs and culture.

“The women who are part of the group are so happy. If I 

told them to come three times a week, they’d be here in 

a shot, because it’s made such a difference to their lives, 

you know, because it’s empowering. They participate in 

activities they never had the chance to do before such as 

fund-raising events, attending conferences, and workshops. 

For many of the women the diagnosis of cancer meant 

death. Now they are living productive, happy lives.”

Carol explains that she is now also able to teach this 

model of self-help at the King Hussein Cancer Center 

(KHCC) in Jordan. She has taught 11 women to be Reach 

to Recovery volunteers in addition to attracting over 30 

women to the SANAD support group.
Chapter 8 Palliative Care in the Palestinian Authority

National Cancer Institute 103 MECC Palliative Care Monograph 

REFERENCES

Avgar A & El Jabari C. The impact of an Empowerment Model 

on Palestinian and Israeli women coping with breast cancer: 

survey results and evaluation, MECC-sponsored study for 

Project COPE, 2005.

Rockoff Y, El Jabari C, Avgar A, Ziv M, Barnea T. Coping with 

breast cancer among Palestinian women and Israeli women: 

Project COPE, Final Report, Phase A, 2000-2003, 2004.

Stjernswärd J & Clark D. Palliative medicine – a global perspective. In: Doyle D, Hanks G, Cherny N, Calman K (eds.) 

Oxford Textbook of Palliative Medicine. Oxford: Oxford 

University Press, 2003.

www.who.int/cancer/palliative/en/

ENDNOTES

1. IOELC interview: Dr. Fouad Sabatin – 2 May 2005

2. Email communication: Dr. Khamis Najjar, European Gaza 

Hospital – 17 October 2005

3. Email communication Dr. Al Zakzuz – 21 July 2005

4. Bendel, M. The disengagement plan and its repercussions on 

the right to health in the Gaza Strip. 2005. 

www.phr.org.il/phr/files/articlefile_1123056289960.pdf

5. Information leaflet “Patient’s Friends Society Jerusalem” PFS. 

6. IOELC interview: Carol El Jabari, Director PFS--10 March 

2005

7. United Nations. Report of the International Narcotics Control 

Board 2004, New York: United Nations, 2005. 

www.incb.org/incb/en/annual_report_2004.html

8. International Narcotics Control Board. Narcotic Drugs: estimated world requirements for 2004. Statistics for 2002. New 

York: United Nations, 2004.

9. Selva C. International control of opioids for medical use European Journal of Palliative Care 1997;4(6),194-198.

10. Email communication Dr. Al-Zakzuz--21 July 2005--for 

details on the drug combinations referenced also see 

www.rxlist.com/cgi/generic/oxyasa.htm

11. For details on the list of accessible opioids see 

www.moh.gov.ps/index.asp

12. Dr. Al-Zakzuz in discussion MECC conference, Larnaca, 

Cyprus (February 2004)

13. Patient’s Friends Society website 8 February 2005 

www.pfsjer.org/home.htm

14. Patient’s Friends Society health education publications – all 

listed below are available on request from PFS 

www.pfsjer.org/publications.htm

Reports on studies conducted by PFS:

PFS Prevalence of breast disease among Palestinian women, 

1994-1996; 1999.

PFS The demographic characteristics and self reported symptoms 

and behaviors of mid life Palestinian women. 2000. (financed 

by the South African Representative Office, Ramallah).

Publications for healthcare professionals:

PFS National Guidelines for breast cancer screening, 1999.

PFS Breast cancer screening – a practical guide for primary 

health care physicians. 1999. 

PFS Mammography techniques for X-ray technologists. 1999.

Public health leaflets (in Arabic) (cancer-related information 

leaflets are sponsored by the National Cancer Institute, 

Bethesda): Exercises after breast surgery; Iron Deficiency 

anemia; Breast self-examination; Look after yourself; Food 

safety; Pain and breast lumps--more information; Adolescence; Midlife women; Osteoporosis; HIV/AIDS; You and 

your child; Your life after breast cancer; Me and my family--

living with cancer

15. IOELC field visit with Carol El Jabari, Director PFS – 

2 May 2005

16. El Jabari, C. (2005) Patient’s Friends Society Sunrise Group 

– Breaking the Silence, Bridges: Israeli-Palestinian Public 

Health Magazine 1(2), 26, February-March 

www.healthinforum.net/files/Bridges/bridges02.pdf

17. Project COPE is a joint Israeli-Palestinian initiative concern 

with the needs of breast cancer survivors and the professionals who care for them. “The project is supported by 

the JDC-International Development Programme (IDP), the 

Andrea and Charles Bronfman Philanthropies, Edythe Grodnick, Dr. Alfred and Isabel Bader and the British Consulate in 

Jerusalem and others.” See Rockoff et al., 2004; Rockoff Y, 

Project COPE: Coping with breast cancer among Palestinian 

and Israeli women, Bridges: Israeli-Palestinian Public Health 

Magazine 2005;1:26. www.healthinforum.net/files/Bridges/

bridges02.pdf

18. Rockoff Y, El Jabari C, Avgar A, Ziv M, Barnea T. (2004) 

Coping with breast cancer among Palestinian women and 

Israeli women: Project COPE, Final Report, Phase A, 

2000-2003

19. www.pfsjer.org/conferences.htm

20. Avgar A and El Jabari C. The impact of an Empowerment 

Model on Palestinian and Israeli women coping with breast 

cancer: survey results and evaluation. MECC-sponsored study 

for Project COPE; 2005.

21. Patient’s Friends Society (PFS) Jerusalem Newsletter 

January–June 2005. www.pfsjer.org/news/pfs_2005_june.doc

22. The Lutheran World Federation (LWF) has been running the 

AVH since 1950. The health institution is one of the projects 

of the LWF Department for World Service (DWS) program 

in Jerusalem. Around 75% of the Augusta Victoria Hospital 

patients come from the West Bank.

www.lutheranworld.org/news/lwi/en/1589.en.html

23. IOELC Questionnaire, February 2004 – MECC conference, 

Larnaca, Cyprus.

National Cancer Institute 105 MECC Palliative Care Monograph 

Turkey (population 68,893,918) is located largely in southwestern Asia, and also in southeastern Europe from west 

of the Bosporus. Turkey covers an area of 780,580 square 

kilometers bordering the Black Sea between Bulgaria and 

Georgia, and bordering the Aegean and Mediterranean Seas 

between Greece and Syria. Land boundaries border Bulgaria 

and Greece to the west; Georgia, Armenia and Iran to the 

north and west, and Iraq and Syria to the south.

Palliative care service provision

Current services

There are no specialist palliative care services in Turkey. 

Medical oncology units and departments of algology (pain) 

in major hospitals in the country provide pain control and 

symptom relief. Oncologists and pain specialists in seven 

hospitals report active working to establish the concepts 

of palliative care (Table 9.1). 

Development of palliative care tends to be focused around 

cancer patients in oncology units and algology (pain) departments and centers. The majority of cancer patients 

are treated in university hospitals that support units with 

pain specialists and medical oncologists. Pain centers 

and departments also offer palliation for patients at the 

end of life with other illnesses. Some specialist cancer 

state hospitals such as the Dr. Ahmet Andicen Oncology 

Hospital and Demetevler Oncology Hospital will provide 

pain relief and symptom management. No information, 

however, is currently available about the development 

of palliative care services in the state hospital system or 

the development of training in the 57 medical schools 

around the country (11). There are around 30 specialist 

“pain centers” and 20 medical faculties with departments 

Chapter 9

Palliative Care in Turkey
Chapter 9 Palliative Care in Turkey

National Cancer Institute 106 MECC Palliative Care Monograph 

of algology in Turkey. There are no reported activities 

for pediatric palliative care.

Individual physicians and their colleagues are actively 

involved in developing the concepts of palliative care 

within departments and units in three main areas of the 

country; in Ankara, a pain specialist at Hacettepe University Hospital, three oncologists, one at Başkent University 

Hospital, one at the Gulhane Military Academy (GATA), 

and one at Gazi University Hospital; in Istanbul, a pain 

specialist at the Istanbul University Medical Faculty 

and two oncologists at the Marmara University Medical 

Faculty; there is one pulmonary specialist developing 

concepts of palliative care at the Pamukkale University 

Medical School, Denizli. Medical and nursing professionals have also expressed interest in palliative care at 

Ankara University Faculty of Medicine.

Başkent University Hospital Faculty of 

Medicine, Ankara 

Başkent University, founded in 1993 through the cooperation of the Turkish Organ Transplant and Burns Treatment Foundation (established in 1980) and the Hasberal 

Education Foundation, runs a large university hospital 

in Ankara with several other sites around the country. 

A broad spectrum of up-to-date diagnosis and treatment 

in all fields of medicine is provided including oncology and algology. Medical oncologist Professor Özgür 

Özyilkan, chair of the Medical Oncology Department, is 

encouraging palliative care approaches in his unit. Professor Ozyilkan is also a founding member of the Turkish 

Oncology Group. 

Gulhane Military Academy (GATA), Ankara

Medical oncologist Dr. Seref Komurçu is providing palliation in the 33-bed oncology unit at GATA, a large (1500 

bed) military hospital in Ankara. The oncology unit has a 

staff of seven physicians and 18 nurses. They treat around 

1200 patients annually with around 100 inpatients every 

year requiring palliation at the end of life. Dr. Komurçu 

explains that at GATA: 

“We don’t have a separate unit for palliative care, but we 

need it. I’m mostly involved in palliative care, and I’m 

preparing a project to set up a separate unit, but it’s not 

easy. We need a separate floor and some other personnel, 

so I think it will take some time, a couple of years maybe. 

I do palliative care in that department and we follow the 

terminal patient also in the department. End-of-life care 

is done in the inpatient situation and most of the patients 

stay at home at their end-of-life period, and some patients 

prefer to stay at hospital in their terminal phase, and we 

apply terminal sedation sometimes. We don’t have a home 

care program; our insurance on each level doesn’t cover 

the home care program. But some new regulations are 

being [developed] and maybe after this year the general 

insurances will cover home care treatment.” 

Hacettepe University School of Medicine, 

Ankara 

Pain specialist and surgeon Dr. Osman Abbasoglu is involved in encouraging a palliative care approach in the 

Table 9.1 Palliation in Turkey 2005 (hospitals with some active development of palliative care concepts)

Adult Services Freestanding unit

Hospital unit

Hospital

support team

Home care

Day care 

Clinic/ Drop-in 

center

Grand Total

Başkent University Hospital, Ankara 1 1

Gazi University Hospital, Ankara 1 1

Gulhane Military Academy, Ankara 1 1

Hacettepe University Hospital, Ankara 1 1

Istanbul University Medical Faculty 1 1

Marmara University Medical Faculty , Istanbul 1 1

Pamukkale University Medical Faculty, Denizli 1 1

Total 7 7
Chapter 9 Palliative Care in Turkey

National Cancer Institute 107 MECC Palliative Care Monograph 

Department of Anesthesiology. The department offers a 

“pain relief service with one assistant professor in charge.” 

Dr. Abbasoglu explains that he works with adults, seeing around 400 patients each year, “about 80 percent 

are inpatients, 15 percent day care, and 5 to 10 percent 

home-based.” Patients are referred to the department for 

palliative pain relief by other physicians, “more than half 

have cancer, about 25 percent chronic diseases like COPD.” 

The physicians can call on a social worker to support a 

patient if they perceive a need. There are plans to build 

an inpatient hospice unit at the Hacettepe.

Gazi University Hospital, Ankara

Medical Oncologist Dr. Deniz Yamaç, based at the 20-bed 

oncology unit, specializes in head, neck, and breast cancer. 

While she offers pain relief and symptom control, she is 

also actively developing palliative care training for doctors, nurses and students. Dr. Yamaç reports that at this 

time there are no funds to develop the service in the way 

she hopes; for example, by employing a psychologist or 

setting up home care support. Working as part of a sixdoctor team, Dr. Yamaç sees up to 100 patients a week, 

around 10 of whom need end-of-life palliative care. 

Marmara University Medical School Hospital, 

Istanbul 

With 350 beds, Marmara Hospital’s services include a 

14-bed oncology outpatient unit, where medical oncologists Dr. Perran Fulden Yumuk and Dr. Nazim Turdal are 

actively developing the principles of palliative care. They 

are part of a team which includes three medical oncologists, two medical fellows, seven nurses, a psychologist, a 

pharmacist, a data manager and two secretaries. They see 

around 1000 new cancer patients a year and they write, 

“We are also following our patients who need palliative 

care and try to give them support for their pain management, nutritional status, etc. We try to be with our patients 

and relatives from the beginning of their disease till the 

end with all our team.” 

Istanbul University Faculty of Medicine, 

Istanbul

Pain specialist and Chairman of the Department of Algology Professor Serdar Erdine has developed pain relief, known in Turkey as algology, as a specialty. In 

his 14-bed unit they see around 3000 patients each year 

referred from other departments for pain relief. Around 

1000 are cancer patients, most of whom are at the end of 

life. The remainder are patients with chronic pain from 

other illnesses. He follows the WHO “analgesic ladder” 

when prescribing. His aim is to support patients to have 

sufficient pain relief at the end of life so they can be 

cared for at home (3).

Pamukkale University Hospital Medical School, 

Denizli

Pulmonary specialist Dr. Sevin Baser is keen to develop 

training for department staff, medical and nursing students 

in the concepts of palliative care. His enthusiasm follows 

his own specialist palliative care training in the US. The 

hospital sees a high number of patients with late stage lung 

cancer who need palliation. There is no medical oncologist 

and, as yet, no dedicated palliative care (2).

Reimbursement and funding for

services

Services currently providing palliation are largely based 

in university hospitals, which are government funded. 

Patients in university hospitals either have to pay for 

treatment and medication themselves privately or their 

costs may be partially (or completely) covered through 

one of three government health insurance schemes, by 

the Green Card scheme, or by private insurance. 

Free inpatient treatment and medication in university 

hospitals is available for people on low incomes if they 

have been issued a government Green Card. Outpatientprescribed medication has to be paid for by the patient, 

who may be covered by their health insurance. End-of-life 

medical support accessible in Ministry of Health hospitals 

is free for inpatients, if they are insured or have a Green 

Card. There are a few home care services run by private 

health companies who also offer palliative care, but these 

are not reimbursable by government insurance plans. 

The health system is highly complex in Turkey, with access 

to government health insurance schemes dependent on 

location and also on whether the patient is, or has been, a 

government employee. More government-funded services 

are found in the three largest cities. Where governmentfunded provision exists, there are more likely to be free 

or subsidized primary care and inpatient services. There 

are no reports of charitable palliative care non-government 

organizations (NGOs). In 2003, one cancer NGO, the Association of Patients with Cancer, was reportedly able to 

offer some financial help for cancer patients in need. 
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National Cancer Institute 108 MECC Palliative Care Monograph 

Opioid availability and

consumption

Opioid preparations are available for patients at the end 

of life. Turkey has a color-coded prescription system: 

red prescription sheets for opioids, green for sedatives 

and opioid derivatives like tramadol. White prescription 

sheets are used for all other drugs. There is a dosage 

limit of no higher than 400 mg morphine in any one 

dose. Supply is limited to no more than 10 ampoules of 

morphine per prescription, no more than 24 tablets of 

codeine 40 mg, and no more than three packs of drugs 

over 7–10 days (3).

Deniz Yamaç, medical oncologist at Gazi Hospital explains that they use a full range of medications including 

MST, morphine, and oral, injectable, and pumps as IV 

infusion, fentanyl (transdermal patches), sevredol, and 

oxycodone. The Department of Algology at Gazi uses 

intrathecal injections but the unit does not use subcutaneous infusions. 

Dr. Seref Komurçu, medical oncologist at Gulhane Military Academy, reports that in addition to oral opioids, 

they use epidural catheter in some patients. Professor 

Serdar Erdine explains that although they can prescribe 

fentanyl patches, slow release oral morphine and tramadol: 

“short-acting opioids are not available, like methadone.” 

In his Algology Department in the Medical Faculty of 

Istanbul, he reports: 

“We implant [morphine] pumps (intrathecal, epidural) 

for cancer. In our center [since the mid-1990s] we have 

performed more than 1000 [insertions of pumps] for 

cancer. Plus, we do all types of nerve blocks. In a year 

we see 1000 patients with cancer, but we do only 100 

[nerve blocks] for cancer. We obey the rules of the WHO 

step system. Not much use of the subcutaneous infusion 

because we see patients before the end of life, [although] 

the Oncology Departments are aware of our Pain Department and refer patients, and usually they are at a very 

late stage when diagnosed.” (3)

Professor Erdine has seen a change since the transdermal 

patches became available in Turkey. Before patches were 

available, he saw more patients for pain relief at an earlier 

stage in their treatment, but now the Oncology Department only refers to the Pain Department patients who, 

for example, are no longer having their pain relieved by 

the patches.

Palliative care coverage

Supportive care with pain relief is being developed mainly 

in university hospitals in Ankara and Istanbul—the two 

largest cities in the more populated western area of Turkey.

Palliative care workforce 

capacity

As of 2005, there are no specialist palliative care physicians, nurses, or related professionals in Turkey. Some 

individual medical oncologists and pain specialists are 

active in promoting the training of colleagues (doctors, 

nurses, psychologists, medical and nursing students) in 

the concepts of palliative care in their departments.

National and professional 

organizations

The Turkish Oncology Group (TOG) was established in 

1989. The Group works to encourage education about 

cancer and has several different sections which focus on 

different cancers. In the late 1990s the Group initiated 

a section on palliative care training and development. 

In October 2004 the Group dedicated a conference to 

the continuing development of palliative care in Turkey. 

The conference was co-sponsored and supported by the 

Multinational Association of Supportive Care in Cancer 

(MASCC) and co-chaired by Dr. Eoin Tiernan with Dr. 

Declan Welsh and TOG president Dr. Dincer Firat. As 

representative of MASCC, Dr. Eoin Tiernan explains: 

“This key conference coincided with the unveiling of 

architectural plans for Turkey’s first hospice unit, to be 

opened in Ankara. Though home care, hospice and palliative care are not yet well-developed in Turkey, the 

high attendance and obvious support from prominent 

members of the oncology community in Turkey for the 

meeting gave ample evidence of the clear determination 

of TOG to advance both palliative and supportive care 

issues. The very well-organized program covered a wide 

range of topics in supportive care, including both physical 

and psychological symptom management, with a distinguished faculty of speakers. Dr. Matti Aapro, President 

of MASCC, also contributed to the program presenting 

updates on current approaches to anemia and emesis. 

One of the main purposes of the meeting was to explore 

the challenges in organizing and developing home care 

and hospice programs in Turkey. In keeping with this, 

international perspectives on home care and hospice development were presented by Dr. Declan Walsh (US), 
Chapter 9 Palliative Care in Turkey

National Cancer Institute 109 MECC Palliative Care Monograph 

Dr. Eoin Tiernan (Ireland), and Julia Anne Walsh (US). 

Perspectives on organization of home care and hospice 

in Turkey were presented by a number of professionals 

working in innovative programs in Turkey, and the sessions were followed by lively debate and discussion, with 

a representative from the Ministry of Health contributing. 

The meeting was also supported by Ms. Guldal Aksit, a 

Turkish government minister, who made a formal address pledging government support for this very important 

initiative.” 

Education and training

There are a number of medical oncologists and pain specialists involved in developing palliative care education 

and training within existing hospital oncology and pain 

units. 

Gazi University Hospital, Ankara 

Dr. Deniz Yamaç, who was introduced to the concepts 

of palliative care while completing training in oncology at the Arkansas Cancer Institute (Arkansas, US), has 

been running short sessions and day workshops from her 

oncology unit since 2000. These are designed for other 

medical faculty members and resident physicians. There 

is a separate program for medical students. In 2005, Dr. 

Yamaç began workshops for nurses in the oncology unit. 

She is also involved in a project—starting in 2005, funded 

by private health insurance—to train nurses in home care 

for cancer patients. 

Istanbul University Faculty of Medicine, 

Istanbul 

Professor Serdar Erdine is actively involved in public and 

professional education, promoting the principles of palliative care and pain relief using opioids. Using his 25 years 

of experience and extensive knowledge of pain relief, he 

explains that he and other colleagues are trying to alleviate people’s fears of cancer by raising public awareness, 

through TV and articles in journals and newspapers, of 

the effectiveness of opioids in relieving cancer pain. He 

is also organizing a campaign to educate physicians about 

the safety and efficacy of using opioids. 

Gulhane Military Academy (GATA), Ankara 

Dr. Seref Komurçu, who trained as a fellow in palliative 

care at the Cleveland Clinic (Ohio, US), is now teaching 

palliative care to colleagues in his oncology unit. 

Ethical issues

There are three key ethical issues relating to palliative and 

end-of-life care in Turkey: difficulties around disclosure 

of prognosis that arise because the Turkish people tend to 

avoid openly discussing diagnosis and the progress of their 

illness; problems of communication with patients at the 

end of life and acceptance by the medical professionals; 

and fears about use of opioids, that can lead to low usage 

and potentially increased suffering at the end of life. 

In terms of issues around disclosure of diagnosis and 

problems of communication there is a strong ethos in 

Turkey of keeping a diagnosis from the patient, largely 

because a cancer diagnosis, in particular, is still regarded 

as a death sentence. Also, Turkish culture has tended 

towards a paternalistic attitude in the physician. There 

are signs that physicians’ and public attitudes are changing, along with changes in legal responsibility towards 

patients’ rights and autonomy; these changes are essential 

in order to encourage a greater openness. Deniz Yamaç, 

medical oncologist, explains: 

“Turkey is a little different from Europe, people know 

about end of life but they don’t say it, about half can talk 

about it, about cancer, but some don’t want [to hear] the 

name of cancer. You can act according to the patient which 

is in front of you. You must feel it; you must have the 

information before you and be open. I ask my patients, 

‘What do you know about your disease, your illness, what 

do you need?’ So I can see my way how to act, how to 

talk, but I don’t think that all Turkish doctors [who] are 

concerned with cancer know that, so I do the workshops 

in communication. Not to know—how to tell. They [the 

patients] should know. It’s their life. I try to tell it but 

not to break their heart. They must know their future. But 

doctors run away in order to prevent themselves from 

hurting. Doctors are afraid of palliative care and [often] 

don’t want to be involved.” (22)

Oguz et al. suggest that an important ethical issue is a 

lack of acceptance of the end of life by health care professionals, which requires the creation of a “treatment 

philosophy” that acknowledges and provides for the needs 

of people at the end of life: 

“To create this new treatment philosophy, Turkish physicians will have to accept death and dying patients as a 

natural life process for which medicine in its caring and 

comforting role has an important role.” (1)

There are ethical concerns about the continuing widespread 

fear of opioids, a fear which pervades the perceptions and 

practice of the public at the end of life and the health care 
Chapter 9 Palliative Care in Turkey

National Cancer Institute 110 MECC Palliative Care Monograph 

professionals who care for them. The problem about the 

practice of euthanasia and assisted suicide of people suffering severe under-treated pain has fuelled considerable 

debate in medical ethics since the mid-1970s. The point 

is made that improved training would result in better pain 

management and thus mean less suffering and consequently 

less call for euthanasia and assisted suicide. For example, 

in 2003 Turkish oncologists at Akdeniz University Hospital 

demonstrated a significant improvement in quality of life 

for cancer patients who were receiving opioids. There 

is a strong ethical dimension to the national campaign 

conducted by Serdar Erdine to educate both the public and 

health care professionals about the efficacy of appropriate 

opioid usage in alleviating cancer pain (3).

History and development of

palliative care

Narrative history of palliative care

Since the mid-1990s there has been a growing awareness 

for the need to develop a palliative care service in Turkey 

that would include not only pain relief and symptom control 

but also the psychosocial needs of the patients, and their 

families, at the end of life. Traditionally, Turkish people 

have tended to die at home cared for by their family. In 

less populated rural areas home is still the commonest 

place of death. Studies conducted in the late 1990s and 

early 2000s revealed a radical shift in the place of death 

for Turkish people, particularly those who have migrated 

to urban areas, where 75% of the population now live 

(1,27). With this change in socioeconomic patterns, fewer 

women are available to care for relatives in the home. 

Over 60% of urban deaths are now in hospitals, although, 

according to one national survey of people’s attitudes 

to dying in hospice or hospital, 47% of the 200 adults 

questioned would prefer to care for their dying relative 

at home; conversely, for themselves, 54% would prefer 

to die in hospital as they hoped to have better care. 

Given this socio-economic and cultural background, the 

concepts of palliative care have proved slow to disseminate, 

in contrast to the development of improved methods of pain 

relief. Professor Serdar Erdine, Chair of the Department 

of Algology at Istanbul Hospital Faculty of Medicine, 

explains that although “the real palliative care services are 

very weak here, pain management is very well-developed 

and is going to be a specialty very soon.” (3)

Political events, particularly in the 1990s, inadvertently 

raised awareness of the need to address adequate provision of care at the end of life, when separatist insurgency 

led to people fleeing from rural to urban areas (chiefly 

in regions such as Diyarbakir and Adana in southeastern Turkey). This caused an enormous burden for local 

hospitals that were unprepared for such a large increase 

in their patient populations and, most significantly, the 

consequent increase in the need for narcotic drugs for 

patients at the end of life. 

Several pain specialists and oncologists have recognized 

the need for specialist palliative care services since the 

mid-1990s, and a number have sought palliative medicine training overseas and returned to encourage training and development within their own units and faculty 

departments. There are, however, no national guidelines 

or government-financed support for palliative care services, 

although a cancer control policy is being prepared and 

there is now a public health policy for AIDS. Most of the 

interested oncologists and pain specialists are working 

in relatively few university hospitals (there are a total 

of 50 government-supported university hospitals in the 

country and 668 government-funded Ministry of Health 

hospitals). In 2003, Professor Yasemin Oguz, of the Unit 

of Deontology (Medical Ethics) in the Faculty of Medicine 

at Ankara University co-authored a paper with colleagues 

in which they report that end-of-life care services continue 

to be markedly inadequate. In particular, she and her colleagues highlight the lack of nursing or financial support 

for families who have to care for their older, terminally 

ill relatives at home, which increases the likelihood of 

hospital admission. Oguz et al. (1) note the issues around 

using opioids, points reiterated by Serdar Erdine in 2005, 

and suggest that too often the end of life is likely to be 

painful and lonely in the hospital. 

A needs assessment was due to be conducted by Professor 

Oguz in 2004 because as she describes, a major problem in 

meeting the palliative care needs of patients and educating 

health care professionals lies in the lack of data: 

“As the Director of the needs assessment project for palliative care in Turkey I may say that our main problem is 

the lack of national data on the subject. Without essential 

data it is not possible to convince the Turkish Ministry 

of Health and National Health Insurance Organizations 

about the importance of the subject. Palliative care and 

end-of-life issues are a kind of no man’s land in Turkey. 

Although many health care professionals encounter the 

problems and are aware of the need, they do not see the 

subject as their business. There are financial and legal 

restrictions. Our initial objective is to establish a continuous communication between interested professionals and 

patient advocacy groups. There are a couple of nongovernmental organizations which may support the efforts. 

One of them is the Association of Patients with Cancer. 

Their main concern is financial problems of cancer pa-
Chapter 9 Palliative Care in Turkey

National Cancer Institute 111 MECC Palliative Care Monograph 

tients. Another important group is the Turkish Oncology 

Group which is not a formal association, but a collection 

of interested professionals. It has a subgroup named Education, Research and Supportive Treatments.” (16)

Unfortunately, the palliative care needs assessment described here has been delayed for lack of funds (14). 

Although these economic difficulties are reported to act 

to slow the development of hospice home care, there are 

some recent initiatives, driven by members of the Turkish Oncology Group. For example, medical oncologists 

Dr. Perran Fulden Yumuk and Dr. Nazim Turdal at the 

Marmara University Medical School Hospital in Istanbul 

report: 

“We are planning to build a hospice and one fellow is 

being educated in USA for this purpose and she will finish her fellowship in three years. At this time there are 

no university- or government-based hospice programs in 

Istanbul. Most of the time patients are admitted to hospitals 

for palliative support, which is usually unnecessary use 

of beds, etc. This is why we decided to build a hospice 

in Istanbul.” (10)

There are also plans to build an inpatient hospice at the 

Hacettepe Hospital in Ankara. This is a project initiated 

and encouraged by Professor Dincar Firat, President of 

the Turkish Oncology Group. Members of the Turkish 

Oncology Group (TOG) have also been active in encouraging the development of palliative care training. As part 

of this initiative to raise awareness and address the need 

for palliative care, the TOG organized a conference in 

Istanbul during October 2004, dedicated to developing 

home-based palliative care programs. Dr. Seref Komurçu 

reported: 

“After that meeting we invited some people from government and from insurance companies, so they learned 

something about home care programs and the need for 

the programs. So I believe that meeting helped a lot, and 

there were some discussions about the new regulations 

on home care, and I think three weeks ago regulations 

were done. The government asks our Society about home 

care, how it can be controlled and to what standard. We 

gave some opinions, and the government also took some 

other ideas from some other organizations.” (6)

Although the Turkish Oncology Group has supported the 

concept of palliative medicine for medical oncologists 

and other interested health care professionals, professional 

oncology nursing organizations are not yet involved in 

developing specialist palliative care training. 

In June 2004, Turkey joined the Middle East Cancer 

Consortium (MECC). Funded by the National Cancer 

Institute (Bethesda, Maryland, USA), the organization is 

involved in helping its six member countries to develop 

a standardized cancer registry as part of its goal to raise 

cancer awareness and reduce the burden of cancer in 

the region. MECC organizes and offers free places at 

its seminars and conferences for its member countries’ 

health care professionals. From February 2004, MECC 

has been supporting initiatives to assess palliative care 

provision, needs and training. 

Life/oral histories

Dr. Seref Komurçu--Medical Oncologist, 

Gulhane Military Academy: interviewed by 

Amanda Bingley--18 April 2005--duration of 

interview: 35 minutes

Seref Komurçu talks about his education as a fellow in 

the US at the Cleveland Clinic and also in the Palliative 

Care Department. Since his return eight years ago he 

has been developing and teaching palliative care in his 

oncology unit.

Dr. Deniz Yamaç--Associate Professor of 

Internal Medicine and Medical Oncology, Gazi 

University Hospital: interviewed by Amanda 

Bingley, 6 July 2005--duration of interview: 45 

minutes 

Deniz Yamaç, who specializes in breast cancer and head 

and neck cancer, talks about her growing interest in palliative care, since 1995, following her training in medical 

oncology at Arkansas Cancer Institute (Arkansas, USA). 

She explains that after some years in oncology, she realized 

she had to know about palliative care and set about studying on her own. She offers palliation to her own patients 

at the end of life, and advises colleagues about palliation 

for their patients. She is actively developing palliative care 

training in the oncology unit, and with medical students 

in the university medical school. She is taking part in a 

project to train general nurses in home care.

Professor Serdar Erdine--Chair of Algology, 

Istanbul University Faculty of Medicine: 

interviewed by Amanda Bingley, 11 July 2005-- 

duration of interview: 36 minutes

Serdar Erdine talks about his work developing pain management and seeing a pain or algology specialty recognized. 
Chapter 9 Palliative Care in Turkey

National Cancer Institute 112 MECC Palliative Care Monograph 

He also describes the current attitudes towards palliation 

in Turkey, and his campaign to raise public awareness 

of the efficacy of cancer pain relief, to alleviate fears of 

opioids, and to educate physicians in opioid use.

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European Observatory on Health Care Systems, 2002;4. 

www.euro.who.int/document/E79838.pdf.

Stjernswärd J, Clark D. Palliative medicine--a global perspective. In: Doyle D, Hanks G, Cherny N, Calman K (eds.). 

Oxford Textbook of Palliative Medicine. Oxford: Oxford 

University Press, 2003.

Turdal NS, Efe B, Gumus M, Aliustaoglu M, Karamanoglu A, 

Sengov M. Patient satisfaction in the outpatients’ chemotherapy unit of Marmara University, Istanbul, Turkey: a 

staff survey BMC Cancer, 2002;2:30 www.biomedcentral.

com/1471-2407/2/30.

ENDNOTES

1. Oguz NY, Miles SH, Buken N, Civaner M. End of life care 

in Turkey, Cambridge Quarterly of Healthcare Ethics, 

2003;12,279-284.

2. Questionnaire from International Palliative Care Initiative, 

Open Society Institute, New York: respondent--Dr. Sevin 

Baser, Pulmonary Specialist and Assistant Professor, Pamukkale University Medical School--2 November 2004 

3. IOELC interview: Professor Serdar Erdine--11 July 2005

4. baskent-izm.edu.tr

5. Eoin Tiernan. Turkish Oncology Group website report on 

International Interim Meeting on Home Care and Hospice in 

Oncology, 7–9 October 2004, Istanbul, Turkey. www.mascc.

org/ktml2/images/uploads/Articles_ContentDocs/Report_

on%20Istanbul%5B1%5D.Tiernan11.04.doc

6. IOELC interview: Dr. Seref Komurçu--18 April 2005

7. COPD = Chronic Obstructive Pulmonary Disease

8. IOELC Questionnaire: Dr. Osman Abbasoglu--5 March 2005

9. Turdal NS, Efe B, Gamus M, Aliustaoglu M, Karamanoglu A, 

Sengov M. Patient satisfaction in the out patients’ chemotherapy unit of Marmara University, Istanbul, Turkey: a 

staff survey, BMC Cancer, 2002;2:30 www.biomedcentral.

com/1471-2407/2/30

10. IOELC questionnaire: Dr. Perran Fulden Yumuk and Dr. 

Nazim Serdar Turdal--20 July 2005

11. See Turkish Society of Algology www.algoloji.org.tr.

12. Erdine S. Turkey: status of cancer pain and palliative care, 

Journal of Pain and Symptom Management, 1996;12:139-40.

13. WHO Cancer pain relief and palliative care: report of a WHO 

Expert Committee, Geneva: World Health Organization Technical Report Series: 804, 1990.

14. Email communication: Professor Yasemin Oguz--18 September 2005

15. Savas BS, Karahan O, Saka RO. In: Thomson S & Mossialos E, eds. Health care systems in transition: Turkey. 

Copenhagen: European Observatory on Health Care Systems, 

2002;4. www.euro.who.int/document/E79838.pdf.

16. IOELC questionnaire: Professor Yasemin Oguz--31 December 2003

17. IOELC interview: Dr. Deniz Yamac--6 July 2005

18. IOELC interview: Dr. Seref Komurçu--18 April 2005

19. Savas BS, Karahan O, Saka RO. In: Thomson S. & Mossialos E, eds. Health care systems in transition: Turkey. 

Copenhagen: European Observatory on Health Care Systems, 

2002;4. www.euro.who.int/document/E79838.pdf.

20. MASCC “The Multinational Association of Supportive Care 

in Cancer is an international, multi-disciplinary organization with over 1000 members representing more than thirty 

countries and five continents. It operates in collaboration 

with the International Society for Oral Oncology. Founded in 

1990, this group is dedicated to research and education in all 

measures of supportive care for patients with cancer, regardless of the stage of the disease. MASCC aims to promote 

professional expertise of supportive care through research 

and international scientific exchange of ideas. Significant advances in cancer treatment in the last two decades have been 

made possible by the strides in supportive care.” For more 

details www.mascc.org/
Chapter 9 Palliative Care in Turkey

National Cancer Institute 113 MECC Palliative Care Monograph 

21. Eoin Tiernan. Turkish Oncology Group website report on 

International Interim Meeting on Home Care and Hospice in 

Oncology, 7-9 October, 2004, Istanbul, Turkey www.mascc.

org/ktml2/images/uploads/Articles_ContentDocs/Report_

on%20Istanbul%5B1%5D.Tiernan11.04.doc

22. IOELC interview: Dr. Deniz Yamac--6 July 2005

23. The Turkish Code of Medical Ethics 1960 supports this 

attitude: “The physician must openly tell the patient the 

measures that should be taken in his/her situation, if it is 

not likely to make his/her illness worse by disturbing his/

her mood, unless it seems appropriate to hide a serious 

prognosis.” (Information supplied by Prof Yasemin Oguz, 18 

September 2005.)

24. Buken NO. Truth-telling information and communication 

with cancer patients in Turkey, JISHIM, 2003;3:31-36 www.

ishim.net/ishimj/4/05.pdf

25. Aydin E. Rights of patients in developing countries: the case 

of Turkey, Journal of Medical Ethics, 2004;30:555-557

26. Arda, BB. Bioethics in Turkey, Eubios Journal of Asian and 

International Bioethics, 1995;5:64-65.

27. Oguz NY. Euthanasia in Turkey: cultural and religious perspectives, Eubios Journal of Asian and International Bioethics, 1996;6:170-171.

28. Aksoy S. Ethical considerations on end of life issues in Turkey, In Song KY, Koo YM, and Macer DDRJ, eds., Bioethics 

in Asia in the 21st century Eubios Ethics Institute, 2003. 

www.biol.tsukuba.ac.jp/~macer/ABC4/abc4079.htm

29. Bozcuk H, Kolagasi O, Samur M, Yıldız M, Ozdogan M, 

Artac M, Savas B. A brief information sheet on opioid effects 

improves quality of life in cancer patients on opioids, The Internet Journal of Pain, Symptom Control and Palliative Care, 

2003;2:2 www.ispub.com/ostia/index.php?xmlPrinter=true&x

mlFilePath=journals/ijpsp/vol2n2/opioids.xml 

30. Aksoy S. Ethical considerations on end of life issues in 

Turkey, In Song KY, Koo YM, and Macer DRJ eds. Bioethics 

in Asia in the 21st century (Eubios Ethics Institute), 2003, 

www.biol.tsukuba.ac.jp/~macer/ABC4/abc4079.htm (see also 

Arda B, Evaluation of research ethics committees in Turkey, 

Journal of Medical Ethics 2000;26,459-461.)

31. Ozyalcin NS, Talu GK, Camlica H, Erdine S. Efficacy of 

celiac plexus and splanchnic nerve blockades in body and 

tail located pancreatic cancer pain, European Journal of Pain, 

2004;8,539-545.

32. Email communication: Professor Yasemin Oguz--4 August 

2005

33. IOELC questionnaire: Professor Yasemin Oguz--31 December 2003

34. Email communication: Dr. Eoin Tiernan--10 March 2005

35. Kav S. Cancer Nursing Education in Turkey, Report for 

ISNCC--International Society of Nurses in Cancer Care, 

2005. www.isncc.org/about/ (Sultan Kav is an oncology 

nursing educator at Hacettepe University Hospital and a 

member of the Turkish Oncology Nurses Association)

36. National Cancer Bulletin: Eliminating the suffering and 

death due to cancer. Special Issue National Cancer Institute 

2004;1:43, November 9 www.cancer.gov

National Cancer Institute 115 MECC Palliative Care Monograph 

 International Observatory on End of Life Care

PALLIATIVE CARE IN (Name of country)

1 Name of your organization ________________________________________________

2 Address________________________________________________________________

3 Telephone______________________ 4 Email ________________________________

6 What date was your organization established?________________________________

7 Why did it begin? ________________________________________________________

_________________________________________________________________________

What types of service are provided?

Please tick as appropriate

8 ADULT 9 PEDIATRIC

Home care______________ Home care_____________

Inpatient care___________ Inpatient care__________

Day care________________ Day care_______________

Clinic/ Drop-in Center____ Clinic/ Drop-in Center___

Hospital support team____ Hospital support team___

Other__________________ Other_________________

If other, please state: _____ If other, please state: ____

_______________________ ______________________

Appendix 1

Example of the IOELC questionnaire

sent to participants for MECC

country report project 2005 
Appendix 1 Questionnaire

National Cancer Institute 116 MECC Palliative Care Monograph 

10 How many staff work for the organization i) full-time_______ii) part-time_______

11 Number of staff by role i) doctor________ii) nurse_______ iii) chaplain_________ 

iv) counsellor______ v) social worker______ vi) educator______ vi) pharmacist_____ 

viii) administrator______ ix) fundraiser_______x) volunteer____ 

12 How are your staff trained?_______________________________________________

_________________________________________________________________________

13 How many patients did your service care for during 2003? ____________________

14 What drugs are used for pain relief? _______________________________________

_________________________________________________________________________

15 How are these drugs prescribed and administered? __________________________

_________________________________________________________________________

_________________________________________________________________________

16 What are the three major challenges facing palliative care development at present?

i)

ii)

iii)

17 What are the three major opportunities for palliative care development?

i)

ii)

iii)

18 What are the ethical issues facing palliative care in South Africa?

19 What are the key successes of your service? 

20 Any other information you would like to add?

Your name_________________________________ Your role______________________

Thank you for your help; it is very much appreciated.

Amanda Bingley: International Observatory on End of Life Care, IHR Lancaster 

University, UK. March 2005
National Cancer Institute 117 MECC Palliative Care Monograph 

Interviews: general guidelines

Generic questions

This is a broad list of generic questions. It’s sometimes not possible to include all of these, especially if 

supplementary questions are asked, but these are the main areas.

1 How did you come to be involved in palliative care?

2 When did your service begin and why? Who were the main activists? What area does the service 

cover?

3 In what sense is your service a hospice/palliative care organization? 

4 How many nurses/doctors/administrators/volunteers other staff are associated with your service? 

How many work full-time/part-time for the organization? 

5 What training programs are associated with your service? 

6 How are patients referred to you?

7. What drugs do you use for pain relief? Who prescribes them? 

8 How accessible is morphine? How are prescriptions written and supplied? What regulations 

govern the use/supply of morphine? 

9 What provision is made for the spiritual dimension of palliative care? Who gives spiritual care? 

What does spirituality mean to the patients?

10 How many patients does your service care for each year? What are the most common diseases? 

11 What are the major ethical issues facing the service at present?

12 What successes have been achieved so far?

13 What does the service need now?

14 What are your priorities for the future?

Appendix 2

IOELC interview template as used

for MECC country report project 2005

National Cancer Institute 119 MECC Palliative Care Monograph 

The MECC region members have widely differing 

economies (Table A). These range from the high per 

capita Gross Domestic Product (GDP) of Israel (Intl 

$22,731) and Cyprus (Intl $15,602) to the poorer 

economies of Turkey (Intl $7,688), Jordan (Intl $4,947), 

Egypt (Intl $4,274) and resource-poor Palestinian 

Authority (West Bank Intl $1,100, Gaza Strip Intl $600). 

Table A: GDP per capita (Intl $): MECC members 2006 *

Country/Area GDP per capita (Intl $)

Israel 22,731

Cyprus 15,602

Turkey 7,688

Jordan 4,947

Egypt 4,274

Palestinian Authority West Bank 1,100

Palestinian Authority Gaza Strip 600

Source: WHO report (2006) * Figures refer to 2004 data 

with the exception of Jordan which refers to 2003

The disparity between the economies of MECC members 

is reflected in their different capacities to support adequate 

resources for health care services, which, as discussed 

in Chapter 2, tends to impact on the resources available 

to fund hospice and palliative care services. Two longrunning political and military conflicts also beset the 

region. The internationally recognized Greek Cypriot 

south and the unrecognized Turkish north of the island of 

Cyprus have been in conflict for over 40 years. Israel and 

the Palestinian Authority (occupied Palestinian Territories) 

have been embroiled in conflict over the last six decades 

which seriously disrupts political life and the economies of 

both communities. The intensification of events since 2000 

has severely interfered with the capacity of the Palestinian 

Authority to provide social and health care in the occupied 

Palestinian Territories. The Israeli/Palestinian conflict also 

has led at different times to conflict with Jordan and Egypt. 

Appendix 3

Comparison of the political economies

of Cyprus, Egypt, Israel, Jordan,

Palestinian Authority, and Turkey

Increasing tourism tends to boost the economy in Cyprus, 

Turkey and Egypt, despite political instability continuing to 

put a strain on the socioeconomic resources of the region. 

The political economy of Jordan is reasonably stable, and the 

ruling Hashemite Kingdom of Jordan under King Abdullah 

is committed to maintaining and developing adequate social 

and health care programs. Although Egypt is a relatively 

stable regime, various complex socio-economic and 

population pressures result in significant levels of poverty and 

inequalities in health care provision across the country. The 

political background to individual MECC member countries 

and the Palestinian Authority are briefly summarized below:

Cyprus

A former British colony, Cyprus gained independence in 

1960 as the United Nations (UN)-recognized Republic 

of Cyprus. The island has been divided since 1974 when 

continuing conflicts between the Greek Cypriot majority 

and the Turkish Cypriot minority culminated in a Turkish military invasion. The United Nations was asked to 

intervene and subsequently UN peacekeeping forces established a buffer zone known as the “Green Line,” which 

still separates the two ethnic communities inhabiting the 

island (Greek Cypriots in the south and Turkish Cypriots 

in the north). This separation dominates Cypriot life and 

has a significant impact on provision of health services in 

the two communities. In 1983 Turkish Cypriots in the north 

declared independence and formed a “Turkish Republic 

of Northern Cyprus” (TRNC), recognized only by Turkey. 

Since 2003 greater access has been agreed between the 

two areas. The internationally-recognized Greek Cypriot 

Republic of Cyprus in the south is now a member of the 

European Union having joined in May 2004. Now every 

Cypriot carrying a Cyprus passport has the status of a 

European citizen. There are no direct trade and economic 

links between the Greek Cypriot south and the Turkish 

Cypriot north. The south, however, is considerably more 

prosperous, supported in part by relatively high revenues 

from a successful and growing tourist industry, agricultural exports, and the development of positive trade and 
Appendix 3 Economies

National Cancer Institute 120 MECC Palliative Care Monograph 

economic links in Europe. At the time of writing, talks 

between two communities, brokered by the UN, have 

failed to agree on a unity plan.1

Egypt

The Arab Republic of Egypt is a largely desert country, 

bisected by the highly fertile Nile valley, home to 99% 

of the population and the site of most economic activity. 

The Egyptian government inherited a highly centralized 

economy from President Nasser 30 years ago. Since 1981, 

led by President Mubarak, the government has worked 

towards economic reform to create a decentralized, mainly 

privatized system. The process has been slow, given growing population pressure on extremely limited agricultural 

and land resources combined with very little foreign direct 

investment. Egypt is no longer self-sufficient in food, 

and imports nearly half its foodstuffs. Low annual GDP 

growth has resulted in considerable economic problems 

that deepened from the mid-1990s. In 2003, Egyptian officials increased subsidies on basic foodstuffs to placate 

public unrest but this worsened existing budget deficits, 

despite good revenues from tourism and the Suez Canal. 

In 2005, Prime Minister Ahmed Nazif reduced tax rates 

and energy subsidies, and privatized some government 

enterprises, which increased the GDP. These policies, 

though, have not made any substantial improvement in 

living standards for the average Egyptian. The government has to provide subsidies for basic necessities and 

also runs a “Social Fund for Development” to support the 

poorest sector by subsidizing community infrastructure 

and services, and supporting small businesses.2

Israel

The political economy of Israel is heavily affected by 

historical events and conflicts, which have continued since 

the end of WW2, when the British withdrew from their 

mandate of Palestine, and the UN partitioned the area 

into Arab and Jewish states. The Israelis defeated the 

Palestinian Arabs in a series of wars without ending the 

deep tensions between the two sides. In 1993, Israeli and 

Palestinian officials signed a Declaration of Principles (the 

“Oslo accords”) guiding an interim period of Palestinian 

self-rule. Outstanding territorial and other disputes with 

Jordan were resolved in the 1994 Israel-Jordan Treaty of 

Peace. In May 2000, Israel withdrew unilaterally from 

southern Lebanon, which it had occupied since 1982, 

but hostilities recurred in July 2006 leading to a second 

Israeli invasion of southern Lebanon. In September 2006 

a ceasefire agreement was reached with the intervention 

of international peacekeeping forces. Since September 

2000, international efforts to encourage a permanent status 

agreement with the Palestinian Authority have failed in the 

face of ongoing violent conflicts. Following the death of 

Yassir Arafat, a new Palestinian leader, Mahmoud Abbas 

was elected in January 2005. This coincided with the formation of a Likud-Labor-United Torah Judaism coalition 

government in January 2005, and the successful Israeli 

disengagement from the Gaza Strip (August-September 

2005), which presented an opportunity for a renewed peace 

effort.3 In 2006, internal Israeli and Palestinian political 

events further destabilized the political situation into another bitter phase of conflict. 

Despite limited natural resources, Israel has intensively 

developed agricultural and industrial sectors. Importing 

substantial quantities of grain, the country is largely selfsufficient. Despite using advanced irrigation and agricultural 

methods, Israel has limits on water supplies and few energy 

resources, and is completely dependent on foreign supplies 

of oil, coal and gas. The US is Israel’s major source of 

economic and military aid. In the 2000s, adverse effects of 

the Israeli-Palestinian conflict together with difficulties in 

the high-technology, construction, and tourist sectors have 

resulted in relatively wide fluctuations in GDP, around 

a third of which funds defense. The Israeli government 

maintains a strong commitment to supporting basic social, 

health care and educational needs in the population.4

Jordan

Jordan gained independence from British administration 

in 1946, since when the country has been ruled by the 

Hashemite Kingdom. King Hussein ruled from 1953 until 

his death in 1999, when he was succeeded by his eldest 

son King Abdullah II. A pragmatic ruler, King Hussein 

successfully navigated competing pressures from the major 

powers of the day (US, USSR, and UK), various Arab states, 

Israel, and a large internal Palestinian population despite 

several wars and coup attempts. In 1989 he re-instituted 

parliamentary elections and gradual political liberalization; in 1994 he signed a formal peace treaty with Israel. 

King Abdullah has continued with political reforms and has 

instigated progressive reforms in the economy and health 

care system. Parliamentary and municipal elections took 

place in the summer of 2003. In December 2005 the newly 

elected government declared its commitment to accelerated 

economic and political reforms and the new cabinet includes 

an unprecedented four women as ministers.3 Jordan has 

limited supplies of water and other natural resources such 

as oil. Debt, poverty, and unemployment are significant 

problems. Since 1999, King Abdullah has undertaken some 

broad economic reforms in a long-term effort to improve 

living standards, by improving productivity and foreign 

investment. Jordan imported most of its oil from Iraq, 
Appendix 3 Economies

National Cancer Institute 121 MECC Palliative Care Monograph 

but the US-led war in Iraq in 2003 made Jordan more 

dependent on oil from other Gulf nations, forcing the 

Jordanian Government to raise retail petroleum product 

prices and the sales tax base. Jordan’s export market, 

which is heavily dependent on exports to Iraq, was also 

affected by the war.3

Palestinian Authority 

The occupied Palestinian Territory has a long history of 

conflict dating back to the end of the Ottoman Empire 

during WW1, after which Palestine was under British 

mandate until 1947. At the end of WW2 the UN negotiated 

partition of Palestine to create the independent State of 

Israel in 1948; this resulted in the 1948 war when Israel 

expanded into 77% of existing Palestinian territory, including a large part of Jerusalem, causing over half the 

indigenous population to flee or be expelled. In the 1967 

war Israel secured the remaining territories (Gaza Strip, 

the West Bank and East Jerusalem) from Jordanian and 

Egyptian control and a further estimated half a million 

Palestinians fled to neighboring countries.5 In 1987, following 20 years of failed attempts by the UN and the 

international community to resolve the conflict, a mass 

uprising of Palestinians marked the first “intifada,” but 

led to heavy Israeli reprisals. From 1991, proposals to 

bring about a peaceful resolution to the conflict were 

made by the UN and supporting countries, culminating 

in 1993 with the signing of the Israel-PLO Declaration 

of Principles on Interim Self-Government Arrangements 

(the DOP). This agreement allowed an elected Palestinian Authority to self-govern the Gaza Strip and the West 

Bank. In successive years until 1999 negotiations between 

the Palestinian Authority and Israel Gaza Strip aimed to 

secure permanent agreements about transferring powers 

and responsibilities to the PA for additional areas in Gaza 

and the West Bank. This process was disrupted by new 

waves of conflict arising from the second “intifada” in 

September 2000. In April 2003 the US, EU, UN, and Russia 

presented a “roadmap” to a final settlement of the conflict by 2005 based on reciprocal steps by the two parties 

leading to two states, Israel and a democratic Palestine. 

The proposed date for a permanent status agreement has 

been postponed indefinitely due to violence and accusations that both sides have not followed through on their 

commitments.3 Mahmoud Abbas was elected Palestinian 

president in January 2005, bringing hope of a turning 

point in the conflict. During August and September 2005, 

Israel withdrew all its settlers and soldiers and dismantled 

its military facilities in the Gaza Strip and four northern 

West Bank settlements, retaining controls over maritime, 

airspace, and most access to the Gaza Strip. Another bitter round of hostilities erupted in 2006 following the 

Palestinian election of the Hamas government, leading 

to fierce fighting and Israeli reprisals in the Gaza Strip. 

At the time of writing there are renewed attempts to 

maintain a ceasefire and start new negotiations towards 

a peaceful resolution.3

The beginning of the second “intifada” in September 

2000 sparked an economic downturn, largely the result of 

Israeli closure policies which were imposed in response 

to security interests, but disrupted labor and commodity 

relationships with the Gaza Strip. In 2001, and even more 

severely in 2003, Israeli military action in Palestinian 

areas resulted in the destruction of much capital plant, 

the disruption of administrative structure, and widespread 

business closures. The UN estimates that over 100,000 

Palestinians out of the 125,000 in Gaza and the West Bank, 

who used to work in Israel or in joint industrial zones, 

have lost their jobs. Half the labor force is unemployed. 

In the West Bank, high unemployment and limited trade 

opportunities, due to continued closures both within the 

West Bank and externally, continues to stem economic 

growth.3 The Israeli withdrawal from the Gaza Strip in 

September 2005 initially offered some medium-term opportunities for economic growth, especially given the 

removal of restrictions on internal movement. Agreements and continuing negotiations on the administration 

of Gaza’s border crossings increased the prospects for 

trade. In 2006, renewed conflict with Israel and internal 

political instability has led to the reinstatement of tough 

border restrictions and an escalating humanitarian crisis 

in Gaza.6

Turkey 

The modern state of Turkey was founded in 1923 by 

national hero Mustafa Kemal (known as Ataturk, or “Father of the Turks”), following the defeat of the Ottoman 

Empire. After a period of one-party rule, an experiment 

with multi-party politics led to the 1950 election victory 

of the opposition Democratic Party and the peaceful transfer of power. Since then, Turkish political parties have 

multiplied, but democracy has been fractured by periods 

of instability and intermittent military coups (1960, 1971, 

1980), which in each case eventually resulted in a return 

of political power to civilians. In 1997, the military again 

helped engineer the ouster--popularly dubbed a “postmodern coup”--of the then Islamic-oriented government. 

Turkey has been in conflict with Cyprus since 1974 when 

it intervened militarily to prevent a Greek takeover of 

the island and now acts as patron state to the “Turkish 

Republic of Northern Cyprus,” (TRNC) which only Turkey recognizes. Since 1984 an ongoing military conflict 

between the Turkish government and Kurdish separat-
Appendix 3 Economies

National Cancer Institute 122 MECC Palliative Care Monograph 

ist insurgency--now known as the People’s Congress of 

Kurdistan or Kongra-Gel (KGK)--has claimed more than 

30,000 lives. After the capture of the group’s leader in 

1999, the insurgents largely withdrew from Turkey, mainly 

to northern Iraq. In 2004, KGK announced an end to its 

ceasefire and attacks attributed to the KGK increased. 

Turkey joined the UN in 1945 and in 1952 it became a 

member of NATO. In 1964, Turkey became an associate member of the European Community; over the past 

decade, it has undertaken many reforms to strengthen its 

democracy and economy, enabling it to begin accession 

membership talks with the European Union.3

Turkey has a strong traditional agriculture sector that 

accounts for more than 35% of employment, along with 

a very active industrial base. The economy is turning 

around with the implementation of economic reforms, 

and 2004 GDP growth reached 9%. Inflation fell to 7.7% 

in 2005--a 30-year low. Further economic and judicial 

reforms and prospective EU membership may encourage 

foreign investment. The state still plays a major role in 

basic industry, banking, transport, and communication, 

although the private sector is strong and growing. The 

government is committed to supporting basic social care, 

health care and education. 

ENDNOTES

1. This is a précised account of the history of conflict and the 

ongoing negotiations towards a peaceful resolution between 

the Greek Cypriots in the south of the island and Turkish Cypriots in the north. See United Nations Peacekeeping Mission 

in Cyprus UNFICYP website. More details can be found on 

the UN website:

http://www.un.org/Depts/dpko/missions/unficyp/index.html. 

Also see World Factbook:

http://www.cia.gov/cia/publications/factbook/geos/cy.html

2. See the United Nations http://www.uneca.org/aisi/nici/country_profiles/Egypt/egyptab.htm and the World Factbook 

https://www.cia.gov/cia/publications/factbook/geos/eg.html

for sources of this summary and more details of the political 

economy of Egypt.

3. Parts of this citation are précised from the World Factbook 

entry accessed 10 October 2006 

https://www.cia.gov/cia/publications/factbook/geos/is.html

4. See the United Nations 

http://www.unodc.org/egypt/en/country_profile_israel.html

and the World Factbook 

https://www.cia.gov/cia/publications/factbook/geos/eg.html

for sources of this summary and more details of the political 

economy of Israel.

5. For an overview of Palestinian history see the UN website 

http://www.un.org/Depts/dpa/qpalnew/overview.htm

6. WHO Health Crisis in Action Report, July 2006 access on 

weblink http://millenniumindicators.un.org/unsd/mi/mi_results.

asp?crID=275&fID=r15

NIH Publication No. 07-6230

Printed March 2008