[End-of-life decision-making process]

Since time immemorial the attitude toward the dying patient has been one of the most difficult issues in medical ethics. The diversity of philosophical, religious, social and legal approaches does not enable one to reach a universal consensus to solve the many problems involved in end-of-life decisions. Within the health care system in Israel there is currently no consensual practice concerning the dying patient. Moreover, there is no published information on the actual decision-making processes within hospitals, hospices and geriatric facilities in Israel concerning the dying patient. A group of investigators in Shaare Zedek Medical Center in Jerusalem recently performed a prospective study to explore the decision-making process concerning DNR orders within this hospital. The results of this study demonstrated that the terminally-ill patients never take part in the decision-making process, they are never consulted about their wishes, and there is no effort to discover their previous wishes concerning their treatment at the terminal stages. Moreover, in many instances even the family was not consulted and did not take part in the decision-making process. In a significant minority, the final decision of a DNR order was undertaken by a single physician. This approach represents an extreme form of unethical paternalism, and it requires an urgent societal intervention to establish an ethically sound decision-making process. Recently, a national committee ("Steinberg Committee") formulated a widely agreed upon legislative proposal organizing all the fundamental and practical issues related to the dying patient. This proposal is based upon a balance between opposing values such as autonomy, life, quality-of-life, beneficence, non-maleficence and "slippery-slope" concerns. It relates to various treatment modalities, such as resuscitation, ventilation, dialysis, medication and sustenance. It establishes a clear position on euthanasia, physician-assisted suicide, withdrawing treatment and withholding treatment. It establishes a hierarchy of decision-making agents, and it validates advanced medical directives. It also promotes a legally-binding requirement of modern palliative care.