Η < — <
The Dying Patient Law, 2005[1]
Translated by Vardit Ravitsky, Ph.D. and Adv. Michael Prawer
Chapter 1: Goal and Fundamental Principle
Goal 1. (a) This Law regulates the medical treatment of the terminally ill patient based on an
appropriate balance between the value of the sanctity of life, the value of the individual's autonomous will, and the importance of quality of life.
(b) This Law is based upon the values of the State of Israel as a Jewish and democratic state and on fundamental principles in the realm of morality, ethics and religion.
Fundamental 2. In prescribing the medical treatment of the terminally ill patient, his medical condition, his will and Principle the degree of his suffering are the exclusive considerations.
Definitions 3. In this Law:
“A close person” - A person who, in the view of a responsible physician, pursuant to the directives of the Minister under section 60(a)(1), satisfies these two conditions:
(1) Has a familial or emotional connection to the terminally ill patient and is devoted to him;
(2) He is well acquainted with the terminally ill patient, based on a continuous and long-lasting relationship during the period preceding his medical treatment or in the course thereof.
“Guardian” - guardian of the person;
“Competent” - a person to whom all of the following apply:
(3) He is seventeen years old;
(4) He is able to express his will;
(5) He has not been declared legally incompetent
(6) He has not been excluded from the presumption of competency as stated in section 6;
“Director General” - the Director General of the Ministry of Health;
“Prior medical directives ” - medical directives given by a person in accordance with the provisions of Chapter 5;
“Informed consent” - within the meaning of Chapter 4 of the Patient’s Rights Law;
“National Committee” - The committee appointed pursuant to the provisions of section 50;
“Institutional Committee” - A committee appointed pursuant to the provisions of section 45;
“Terminally ill patient” - A patient regarding whom it was determined pursuant to the provisions of section 8(a) that he is a terminally ill patient;
“An end-stage patient” - A patient regarding whom it was determined pursuant to the provisions 8(b) that he is an end-stage patient;
“Patient’s Rights Law” - Patient’s Rights Law, 5756-1996.1
“Palliative care” - Palliative care as stated in Article 5 of Chapter 4;
“Medical treatment”, “patient”, “medical information”, “medical emergency” and “medical record” - as defined in the Patient’s Rights Law;
“Cyclical medical treatment” - any of the following:
(7) Medical treatment administered cyclically and with interruptions, regarding which it is possible to clearly and practically distinguish between the end of one cycle of treatment and the beginning of the next cycle;
(8) Treatment that was planned in advance, using appropriate technological means, for being administered cyclically, even though in its essence it was administered in a continuous and non-interrupted manner;
“Continuous medical treatment” - medical treatment which by its essence is administered continuously and without interruptions, excluding periodic medical treatment as defined in section 2 of the definition of cyclical medical treatment;
“Power of attorney" "Representative" - as defined in section 37, with respect to the representative, including a substitute;
“Database” - The database established in accordance with Article 5 of Chapter 5;
“Medical institution” - a hospital within the meaning of section 24 of the Health Ordinance of 1940,[2] a clinic within the meaning of section 34 of the aforementioned Ordinance, as well as a sick fund, within the meaning of the National Health Insurance Law, 5754-1994[3]
"caregiver" - Physician, nurse, social worker and psychologist;
“Significant suffering” -
(1) As defined by a person who has given advance medical directives, in those directives, or by a person who has granted power of attorney, in that power of attorney;
In the absence of a definition as stated in paragraph (1), pain or suffering that a reasonable (2) person would be prepared to make a substantial effort in order to avoid or discontinue, even if it involved significantly impairing his quality of life or of his life expectancy.
“Social worker” - As defined in the Social Workers Law, 5756-1996;[4]
“Psychologist” - a person registered in the Register of Psychologists pursuant to the Psychologists Law, 5737-1977[5]
“Physicians Ordinance” - Physicians’ Ordinance [New Version] 5737-1976;[6]
“Minor” - A person not yet 17 years old;
“Physician” - A licensed physician within the meaning of the Physicians Ordinance;
“Specialist” - A physician accredited as specialist according to the Physicians Ordinance;
“Responsible physician” - One of the following:
(1) Director of a department or a unit, in a medical institution, who is responsible for the medical treatment of the terminally ill patient, or a specialist who has been appointed by the director of the medical institution, the director of the department or the director of the unit - with regard to patients being treated in a medical institution;
(2)
A district physician of a sick
fund, or a physician appointed by him - with regard to patients cared for in
the community;
(3) A physician as stipulated in sections (1) or (2) - also in respect of patients not being treated in a medical institution or by a sick fund.
“Personal physician" - A physician, who is closely acquainted with the patient, and his wishes and positions regarding his medical treatment, whether a family physician of the patient or a physician who coordinates the treatment of the patient in the community or in a medical institution;
“The Minister” - The Minister of Health.
Chapter 3: The Will to Live and Competence - Presumptions
A
person shall be presumed to wish to continue living, unless proven otherwise;
if not proven otherwise beyond any reasonable doubt - the tendency should be to
decide in favor of the wish to continue living.
5.
A
terminally ill patient shall not be excluded from the presumption that he
wishes to continue living, and medical treatment shall not be withheld from him
under the provisions of this Law, except in accordance with the conditions
enumerated in this section, as the case may be,
(a) Where the terminally ill patient is competent - based on his explicitly expressed wish ;
(b) Where the terminally ill patient is incompetent and is seventeen years old, based on one of the following:
(1) Advance medical directives that he gave and which that satisfy the provisions of sections 33 and 34(a);
(2) A decision of a representative in accordance with a power of attorney that satisfies the provisions of sections 38 and 39(a);
(3) A decision of an institutional committee or the National Committee rendered in accordance with the provisions of Chapter F.
(c) In the absence of directives or decisions as specified in subsection (b) - based on the decision of a responsible physician, provided that such decision is adopted having consideration for -
(1) An explicit declaration of a close person to the effect that the terminally ill patient does not wish to continue living;
(2) In the absence of such a declaration - having consideration for the position of the terminally ill patient’s guardian, who is a close person, to the extent that such exists, to the effect that the terminally ill patient's wish is that his life not be prolonged.
6. A person who is 17 years or older and has not been declared legally incompetent is presumed to be cognitively, mentally, and emotionally competent to make decisions concerning his medical treatment based on understanding and discretion, and free will.
7. A terminally ill patient may not be excluded from the presumption of competence as defined in section 6 for purposes of this Law, other than by a thorough, reasoned, and documented medical decision rendered by the responsible physician after consulting with the caregivers of the terminally ill patient and with relevant physicians or experts, as the case may be, and if possible with his personal physician.
Chapter 4: The Treatment of the Terminally Ill Patient
Article A: General
Determining a 8. (a) A responsible physician is authorized to determine that a patient is a terminally ill
patient’s medical patient, if satisfied that the patient is suffering from an incurable medical problem and
condition that
his life expectancy, even if receiving medical treatment, does not exceed six
months.
(b)
A
responsible physician is authorized to determine that a terminally ill patient
is an end-stage patient, if satisfied that he is in a medical condition in
which a number of vital systems in his body have failed and his life
expectancy, even if receiving medical treatment, does not exceed two weeks.
(c) A determination of a responsible physician in accordance with this section will be made following a consultation with the experts treating the patient and if possible also with his personal physician.
9. Where a responsible physician has determined that a patient is a terminally ill patient
10. (1) The responsible physician or a person authorized by him for this purpose, will make a
reasonable effort to obtain all the pertinent data and the documentation for the determination of the patient's wish, pursuant to section 5(b) and (c) and all in accordance with the rules established for that purpose in the regulations;
(2) The responsible physician or a person authorized by him for this purpose, will check in the database whether according to the records therein, the patient has given advance medical directives, or appointed a representative; where a responsible physician, or a person authorized by him for this matter, has determined, based on the clarification by way of the database or in any other manner, that the patient has given advance medical directives, or appointed a representative, the responsible physician, or a person authorized by him for this matter, will add that information to the medical record conducted in respect of that patient.
(a) Where a responsible physician has determined that a patient is a terminally ill patient, and is incompetent, the responsible physician or a person authorized by him for that purpose, will notify the patient’s representative, close person, and his guardian, if such exist and if they can be located with reasonable effort, that he intends to act in accordance with the patient’s advance medical directives or in accordance with the representative’s directives, as the case may be.
(b) A responsible physician will disclose medical information regarding an incompetent terminally ill patient and will enable examination of his medical record by a person whose opinion is required in order to adopt a decision on the treatment to be given to him in accordance with this Law.
(c) The provisions of any law prohibiting the disclosure of medical information will not pertain to the disclosure of information according to this section
11. (a) Where a responsible physician has determined that a patient is a terminally ill patient, he will, as soon as possible, conduct a detailed consultation with the other caregivers who are caring for the patient, regarding the patient's medical condition and the medical treatment that should be given to him, and will decide on the matter, all in accordance with the provisions of this Law.
(b) Where a responsible physician has determined the type of medical treatment to be provided to the terminally ill patient, he will record the consultation process, the decision adopted and its reasons in the medical record; the provisions of this section are in addition to the documentation provisions of section 17 of the Patient’s Rights Law.
12.
The responsible physician must
periodically evaluate the competence, the medical condition, and the wish of
the terminally ill patient; where a change has occurred in any of the above, he
must adopt a new decision regarding the type of his medical treatment.
Article B: A Terminally Ill Patient Requesting Extraordinary Life-Prolonging Treatment
|
The terminally ill |
13. |
Where a terminally ill patient who wishes to prolong his life and requests medical treatment |
|
patient’s right to |
|
that the responsible physician considers to be unjustified under the circumstances, his wish |
|
receive |
|
should be respected and the requested treatment should be provided in accordance with any |
|
extraordinary life- |
|
other law and in accordance with the conditions and the arrangements prevailing from time to |
|
prolonging |
|
time in the Israeli medical system; the provisions of this section will not apply to medical |
|
medical treatment |
|
treatment that in the opinion of the responsible physician is not expected to prolong the life of |
|
|
|
the patient, or liable to significantly harm the patient or someone else. |
|
Determining the |
14. |
The terminally ill patient's wish regarding the receiving of medical treatment as stated in |
|
wish to receive |
|
section 13, will be determined according to the following specifications, as the case may be: |
|
extraordinary life- |
|
(a) When a terminally ill patient is competent - according to his expressed explicit wish; |
|
prolonging |
|
When a terminally ill patient is incompetent and is 17 years old, according to one of the |
|
treatment |
|
(b) following: |
|
|
|
(1) According to advance medical directives given by him, that satisfy the provisions |
|
|
|
of sections 33 and 34(a); |
|
|
|
(2) According to a decision of his representative based on a power of attorney that |
|
|
|
satisfies the provisions of sections 38 and 39(a); |
|
|
|
(3) According to a decision rendered by an institutional committee or the National |
|
|
|
Committee that satisfies the provisions of Chapter F. |
|
|
|
(c) In the absence of directives or decisions as specified in subsection (b), according to - |
|
|
|
(1) An explicit statement of a close person regarding the wish of the terminally ill |
|
|
|
patient; |
|
|
|
(2) And in the absence of such a statement, the wish of the terminally ill patient will |
|
|
|
be ascertained in accordance with the position of his guardian who is a close |
|
|
|
person, if such exists. |
|
|
|
(d) The provisions of section 9(1) will also pertain with regard to this section mutatis |
|
|
|
mutandis. |
|
Article C: A Terminally Ill
Patient Who Does Not Wish To Have His Life Prolonged |
||
|
Withholding |
15. |
(a) When a competent terminally ill patient does not want his life prolonged his wish |
|
Medical |
|
should be respected and his medical treatment withheld |
|
Treatment from a |
|
(b) The caregivers of the terminally ill patient as stated in sub-section (a) will make a |
|
competent |
|
reasonable effort to persuade him to receive oxygen, nutrition and hydration, even by |
|
terminally ill |
|
artificial means, and to receive routine treatments required for the treatment of |
|
patient |
|
simultaneous or background illnesses as well as palliative care. |
|
Withholding |
16. |
(a) Where an incompetent terminally ill patient is suffering significantly, and in respect of |
|
medical treatment |
|
whom it has been determined pursuant to the provisions of section 5(b) that he does |
|
from an |
|
not want his life prolonged, medical treatment relating to his incurable conditions |
|
incompetent |
|
should be withheld from him, including tests, operations, resuscitation, ventilation, |
|
terminally ill |
|
chemotherapy, radiation or dialysis, all in accordance with his wish as ascertained |
|
patient |
|
pursuant to section 5(b). |
|
|
|
(b) (1) In this subsection, ancillary treatment” - medical treatment of the terminally ill |
|
|
|
patient, that is totally unrelated to his incurable condition, including routine |
|
|
|
treatments necessary for the treatment of simultaneous or background illnesses |
|
|
|
and palliative care, as well as nutrition and hydration even by artificial means. |
(2) Ancillary treatment should not be withheld as stated in subsection (a), even if the terminally ill patient's wish as ascertained pursuant to section 5(b) is not to receive medical treatment.
|
An incompetent |
17. Notwithstanding the provisions of section 16(b), where an incompetent end-stage patient is |
|
end-stage patient |
suffering significantly, and in respect of whom it was determined pursuant to section 5 (b) that he does not want his life prolonged, all medical treatment should be withheld from him, including ancillary treatment as stated in section 16(b)(1), all in accordance with his wish as ascertained pursuant to section 5(b); Notwithstanding the abovementioned in this section, hydration should not be withheld, even by artificial means, unless the responsible physician has determined that provision of fluids causes suffering or harm to the patient. |
|
A medical |
18. (a) If the terminally ill patient is in a state of medical emergency, the provisions of section |
|
emergency |
15(3) of the Patient’s Rights Law will apply, the caregiver becomes aware that it was determined pursuant to section 5, that the terminally ill patient wishes to have medical treatment withheld in such a case |
(b) Notwithstanding that which is stated in sub-section (a), with respect to an end-stage patient in a state of medical emergency, it is permitted to withhold life saving medical treatment, unless the caregiver becomes aware that it was determined pursuant to section 14 that the end stage patient wishes to receive medical treatment in such a situation.
Article D: Prohibited Acts
Nothing in these provisions shall permit an
act, even if constituting medical treatment, is intended to cause death, or
which will almost certainly result in death, irrespective of whether or not it
was motivated by kindness and compassion, and irrespective of whether or not it
was at the request of the terminally ill patient or any other person.
Nothing in the provisions of this Law shall permit any act, even if constituting medical treatment, that contributes to assisted suicide, irrespective of whether or not it was motivated by kindness and compassion, and irrespective of whether or not it was at the request of the terminally ill patient or any other person.
Nothing in the provisions of this Law shall permit the withdrawal of the continuous treatment of a terminally ill patient that is liable to cause his death, irrespective of whether or not he is competent; however it is permitted to refrain from the renewal of continuous treatment that was withdrawn unintentionally or not in contravention of the law, and it is also permitted to avoid the renewal of cyclic medical treatment, all subject to the provisions of Article C.
Should it become known to a responsible physician that there is a dispute regarding a decision or a determination concerning a terminally ill patient, and that a person has applied to an institutional committee or intends to apply to an institutional committee in order to resolve the dispute, the responsible physician will act in a way that enables the continued life of the terminally ill patient, provided that if possible, this should be done by non-continuous medical treatment.
Article E: Palliative care
23.
(a) The responsible physician will make sure that everything possible is done
in order to alleviate the pain and suffering of a terminally ill patient, even
if this involves a reasonable risk of the patient's death, including by means
of medication, pain killers, or psychological methods, nursing, and
environmental measures, and all in accordance with the appropriate principles
of palliative care and in accordance with the conditions and arrangements
prevailing from time to time in the Israeli health care system, and in accordance
with the wish of the terminally ill patient, pursuant to the provisions of this
Law and pursuant to the provisions of the Patient’s Rights Law.
(b) The responsible physician will make sure that everything possible is done in order to alleviate the burden on the family members of a terminally ill patient and to ensure their well being during the patient's stay in the medical institution, all in accordance with the appropriate principles of social work and palliative care and in accordance with the conditions and arrangements prevailing from time to time in the Israeli health care system.
Article F: Treatment of the Terminally Ill Minor
|
Authority of |
24. A minor’s parent is authorized to represent him regarding his medical treatment, whether in |
|
parents of a minor |
the matter of prolonging his life or in the matter of refraining from prolonging his life; a guardian of a minor, who is a close person, is permitted to voice his position in this matter and the responsible physician is permitted to act in accordance therewith; if he has no parents, or the parents’ guardianship has been revoked and no other guardian has been assigned for the minor, or if his guardian is not a close person, the institutional committee will make a decision in respect of him. |
|
Hearing the |
25. A minor who is a terminally ill patient is entitled to participate in the adoption of a decision |
|
position
of a minor |
regarding his medical treatment, if these two conditions are satisfied: |
|
|
(1) |
The minor is aware of his condition and requests to participate in the adoption of the |
|
|
|
decision regarding him; |
|
|
(2) |
The responsible physician determines that the minor's cognitive and mental capacity |
|
|
|
and maturity enable his participation in adopting the decision regarding him. |
|
Giving medical |
26. A responsible physician will give the minor information that pertains directly to his health or |
|
|
information to a |
his medical treatment, if these two conditions are satisfied: |
|
|
minor |
(1) |
The responsible physician is convinced that giving the information, or a part of it, will |
|
|
|
not cause physical or mental harm to the minor, or endanger his life; |
|
|
(2) |
The responsible physician has determined that the minor’s cognitive and mental capacity and maturity enable him to appropriately understand the information and its |
|
|
|
meaning. |
|
Duty of |
27. Decisions as stated in sections 25(2) and 26 will be adopted after consultation with the minor’s |
|
|
consultation |
parents, his guardian if appointed, the minor's caregivers, and the relevant physicians or |
|
|
|
experts, as appropriate, and if possible with his personal physician. |
|
Resolving dispute 28. (a) In the event of a dispute between the parents of a minor who is a terminally ill patient, in the matter of a or between them and the responsible physician, with regards to his medical treatment,
minor an institutional committee will resolve the matter
(c) Where there is a dispute between a minor who is a terminally ill patient and his parents, or between them and the responsible physician, with regards to his medical treatment, the following provisions shall reply:
(1) Where the minor expressed his wish for his life to be prolonged the responsible physician will act in accordance with that wish, subject to the provisions of this Law;
(2) If a minor less than 15 years of age has expressed his wish that his life not be prolonged, an institutional committee will decide on the matter.
(d) When an institutional committee discusses the matter of a minor who is a terminally ill patient, it should hear the minor’s position as well, if expressed, and the committee should also receive the particulars of the information that was given to the minor.
(e) The institutional committee will take the best interests of the minor into account among its other considerations, and will be entitled to determine that his life should not be prolonged, if convinced that prolonging his life would not be in his best interests, subject to the provisions of subsection (b)(1).
Article G: Treatment of the Terminally Ill Protected Person
29. (a) In this Law, “protected person“ - a person regarding whom all of the following apply -
(1) He cannot, routinely, take care of his own matters because of a cognitive or a mental handicap;
(2) The condition as stated in section (1) existed before it was determined that he is a terminally ill patient;
(3) There are no valid advance directives or valid power of attorney relating to him.
(b) If a protected person expressed his wish for his life to be prolonged the responsible physician will act in accordance with his wish, subject to the provisions of this Law; if the protected person expressed his wish for his life not be prolonged, an institutional committee will decide upon the matter; the provisions of sections 25, 26 and 27 will apply mutatis mutandis, as the case may be.
(c) If the protected person's wish is unknown, and the responsible physician and the guardian have agreed to prolong his life - the responsible physician will act accordingly, subject to the provisions of this Law; in any other case - the institutional committee will decide in the matter of the protected person.
(d) The institutional committee will consider the best interests of the protected person amongst its other considerations and will be entitled to determine that his life should not be prolonged, if convinced that prolonging his life would not be in his best interests, subject to the provisions of subsection (b).
Chapter 5: Advance Expression of a Wish
Article A: Methods of Expressing Advance Directives
Advanced 30. A person is entitled to express his wish in advance, regarding his medical treatment in the
Expression of Wish case of his becoming an incompetent terminally ill patient by providing advance directives, appointing a representative, or a combination of both, based on the provisions of this chapter and provided that he does so of his own free and independent will and not under family, social, or any other type of pressure.
Article B: Advance Medical Directives
Advance medical 31. A competent person is entitled to give advance medical directives in which he explains his directives wish in detail with respect to his future medical treatment if it is determined that he is an
incompetent terminally ill patient, all in accordance with the provisions of this Law.
Medical information 32. (a) Advance medical directives will be given after the person giving the directives has for giving advance received from a physician or a certified nurse such medical information as is
medical directives reasonably required for the sake of providing advance medical directives (in this Law
- the information giver).
(b) Notwithstanding the provisions of subsection (a), where a determination has been made pursuant to the provisions of this Law that a person is a terminally ill patient, he will give advance medical directives after receiving information regarding his medical condition from an expert physician, including medical information regarding his condition that is relevant for giving the directives as well as the medical information reasonably required for giving advance medical directives.
|
Methods of
providing directives and their documentation |
33. |
(a) |
Advance medical directives will be given in writing, on an advance medical directives form, the wording of which appears in the First Supplement, signed by the directives giver in the presence of two witnesses who have no financial or other interest in respect of the directives giver, and who are not a representative, although one of the witnesses can be the information giver; the witnesses will confirm that the directives giver signed as stated by signing the form on the same occasion. |
|
|
|
(b) |
Advance medical directives may include the definition of significant suffering as provided by the directives giver and will also include - |
|
|
|
|
(1) A declaration that the directives are given of his own free will, based on his own understanding and discretion; |
|
|
|
|
(2) A summary of the medical information that was provided to the directives giver, as stated in section 32; the summary will be registered by the information giver, who will confirm by his signature that he gave the information to the directives giver and that he explained all the medical terms to the directives giver pursuant to the provisions of section 13(b) of the Patient's Rights Law. |
|
|
|
(c) |
Advance medical directives may be given in other ways, as determined by the Minister, with the approval of the Labor, Welfare and Health Parliamentary Committee, and they may be determined as stated in general or for specific types of cases that he determines. |
|
Validity
of advance medical directives |
34. |
(a) |
Advance medical directives shall remain valid for five years after the signing date of the advance medical directives form unless a shorter period was stipulated, and their validity may be extended for additional periods, each one of which shall not exceed five years; the extension will be effected by means of the extension form in the Third Supplement. |
|
|
|
(b) |
Advance medical directives that do not comply with all the provisions of this section or advance medical directives that have expired according to subsection (a) are not valid, but the responsible physician should examine them and may take them into consideration with regards to sections 5(c) and 14(c). |
|
Unclear or
inappropriate directives |
35. |
Where it is impossible to clearly ascertain the wish of a terminally ill patient based on the advance medical directives that he gave, or where the advance medical directives are inappropriate under the circumstances of the case, or in the absence of a representative or clear testimony of a close person -the institutional committee will resolve the matter. |
|
|
Absence of
advance medical directives |
36. |
The absence of advance medical directives does not, in and of itself attest to the wish of the terminally ill patient regarding his medical treatment or the withholding of treatment from him. |
|
Article C: Power of Attorney
37.
(a)
A competent person is entitled to appoint a representative using the form the
wording of which appears in Supplement Two and in that power of attorney he is
entitled to appoint a substitute for the representative.
(b)
The representative will be authorized to
decide in his stead regarding the medical treatment that he will or will not be
provided with if the terminally ill patient becomes incompetent; should the
representative be unable or unwilling to fulfill his role at the designated
time, the substitute representative will become the representative.
(c) The power of attorney will specify the circumstances and the conditions under which the representative is authorized to make the above decisions.
(d) Should the representative be appointed with regards to specific medical conditions or specific medical treatments - the person giving the power of attorney will receive medical information in accordance with the provisions of section 32, mutatis mutandis.
38. (a) A power of attorney will be given in writing, of free and independent will, based on understanding and discretion, and will be signed by the person granting the power of attorney and by two witnesses who have no financial or other interest in respect of the person granting the power of attorney, and who are not representatives, but one of them can be the information giver as stated in section 37(d); the power of attorney may include the definition of significant suffering as provided by the person granting the power of attorney and should also include -
(l) A statement that the power of attorney is given out of free will, based on understanding and discretion
(m) Where the power of attorney granted as stated in section 37(d), the provisions of section 33(b)(2) will apply mutatis mutandis.
(n) In the power of attorney the person granting the power of attorney will indicate that the representative will be authorized to adopt decisions in his place regarding his medical treatment in the event that he becomes an incompetent terminally ill patient, and he can specify the circumstances and the conditions under which the representative will be authorized to make decisions in his stead regarding all or some of his medical treatments
(o) Appointment of a representative may be effected in other ways, to be determined by the Minister, with the approval of the Labor, Welfare and Health Parliamentary Committee, and they may be determined as stated in general or for specific types of cases that he determines.
39. (a) A power of attorney will be valid for five years, and its validity may be extended for additional periods none of which shall exceed five years; the extension will become effective by using the extension form, the wording of which appears in Supplement Three.
(b) Where the power of attorney does not specify the period of its validity, it will be valid for five years from the date on which it was given; where a person has not renewed a power of attorney that he gave, or the period of its validity is not determined, the power of attorney will not be considered valid, but the responsible physician should examine it and he may take it into consideration with regards to sections 5(c) and 14(c).
40. Where a person has a reasonable suspicion that a representative is not acting according to the wish of the terminally ill patient or out of a conflict of interests, he may apply to the institutional committee; where the institutional committee is satisfied that the representative's acts are based on motivations that do not reflect the wish of the terminally ill patient or out of a conflict of interest, it is entitled to determine the appropriate medical treatment for the terminally ill patient or to cancel the power of attorney.
Article D: General Provisions
Duty to inform 41. Where a responsible physician determines that a patient is a terminally ill patient, and that he is competent, the responsible physician will inform him regarding the possibility of giving advance medical directives or appointing a representative, or inform him regarding the possibility of updating advance medical directives or the power of attorney that he gave; for this purpose, an expert physician will provide him with the necessary medical information, subject to the provisions of section 13(d) of the Patient’s Rights Law.
|
Possibility
of Combination |
42. |
(a) |
A person is entitled to combine giving advance medical directives pursuant to the provisions of Article B with the appointment of a representative according to the provisions of Article C. |
|
|
|
(b) |
In the advance medical directives and in the power of attorney a person is entitled to include directives for a case in which there is a contradiction between an advance medical instruction and a provision in the power of attorney. |
|
|
|
(c) |
In the absence of a directive as stated in subsection (b) the advance directive will prevail; however, if the power of attorney was given at a significantly later period than the giving of the directive, the matter will be submitted for the resolution of an institutional committee that will determine whether the power of attorney prevails over the advance medical directive. |
|
Modification
and cancellation |
43. |
(a) |
(1) If advance medical directives were given and then given again, the advance medical directives most recently given will prevail; the same will apply to the appointment of a representative pursuant to this Law. |
(2) Advance medical directives or a power of attorney may be cancelled by way of a form in the wording appearing in Supplement Four, in writing, in the presence of two witnesses or in another way as determined by the Minister pursuant to sections 33(c) or 38(c).
(b) Modification or cancellation in favor of the wish to continue to live in a medical emergency can be unwritten and one witness will suffice; provided that the directive regarding the medical treatment in said medical emergency and the testimony be documented in writing as soon as possible thereafter; when the medical emergency has passed, the valid advance medical directives or the power of attorney retain their validity, unless one of the following is the case:
(1) The directives or the power of attorney were cancelled pursuant to the provisions of subsection (a).
(2) The patient was unable, reasonably, to modify or cancel the directives or the power of attorney.
(c) Notwithstanding the provisions of subsection (a), where a person is unable to modify or cancel advance medical directives or power of attorney that he gave in the manner prescribed in that subsection, whether in favor of the wish to live or not in favor of the wish to live, by reason of an illness or defect that renders him incapable of performing the required practical actions, he may give his directives by way of another person, under the conditions and in the manner determined by the Minister.
Article E: Database
44. (a)
The Minister will establish a database in which advance medical directives and
powers of attorney will be registered and will appoint a person to be
responsible for the database.
(b) Any person is entitled to request the registration in the database of advance medical directives or powers of attorney that he gave, as well as any cancellation or modification thereof as stated in section 43, by notifying the person responsible for the database.
(c) Once every five years at least the person responsible for the database will send reminders to the person registered in the database, to his address as appearing in the population register, or to any other address specified in the registration request, to renew the advance medical directives or powers of attorney.
Chapter 6: The National Committee
and Institutional Committees Article A: Institutional
committee
45.
(a)
The Director General is entitled to instruct the director of a medical
institution to appoint an institutional committee; where the Director General
has given directives as stated, the director of the medical institution, in consultation
with the chairman of the national committee and having received the approval of
the Director General, will appoint an institutional committee.; And these are
its members: -
(1) Three physicians, who are not treating the patient directly, who are experts in one
of these disciplines: internal medicine, geriatrics, cardiology, neurology, oncology, intensive care, anesthesia, family medicine; if the patient is a newborn, one of the above will be an expert in neonatology; if the patient is a minor, one of the above will be an expert in pediatrics and replacing one of the above will be a clinical or medical psychologist who specializes in children and youth;
(2) A physician who does not treat the patient directly, who is an expert in psychiatry;
(3) A registered nurse;
(4) A social worker or clinical psychologist;
(5) An academic who is an expert in the discipline of philosophy or ethics;
(6) A jurist who is qualified to be appointed as a district court judge, chosen from a list prepared by the Minister of Justice;
(7) A religious authority representing the religion of the patient, to the extent possible.
(b) A substitute person who has the qualifications required under this section shall be appointed for each committee member.
(c) An institutional committee will elect its chairman from among its members.
(d) An institutional committee will convene as close as possible to the time of its receiving the application, and at a time ensuring the relevance of its decision.
(e) An institutional committee is entitled to authorize a sub-group of its members to discuss urgent cases; the sub-group must include at least the following members:
(1) A physician with the qualifications specified in subsection (a)(1) or (2);
(2) One of the following committee members: a registered nurse, a social worker or a clinical psychologist;
(3)
One of the following committee
members: an academic as specified in subsection (a) (5); a jurist as specified
in subsection (a) (6); or a religious authority as described in subsection
(a)(7).
|
Application to |
46. (a) |
An application to an institutional committee may be made by one of the following |
|
|
the Committee |
|
persons: |
|
|
|
|
(1) |
A patient who has not been determined as being a terminally ill patient pursuant to section 8 or a patient determined as being a terminally ill patient pursuant to the provisions of the aforementioned section (in this chapter - the patient), or a |
|
|
|
|
person on behalf of such a patient; |
|
|
|
(2) |
The patient's representative; |
|
|
|
(3) |
A close person or a guardian of an incompetent patient; |
|
|
|
(4) |
A caregiver who is a member of the medical staff in the medical institution in |
|
|
|
|
which the patient is being treated; |
|
|
|
(5) |
The patient's personal physician; |
|
|
|
(6) |
A social worker. |
|
|
(b) |
Where an application has been made to the institutional committee by a person who is not the patient or on his behalf behalf, regarding the matters enumerated in section 47, the committee will give notice thereof to the patient or person on his behalf; if the patient is incompetent, the committee will also notify his representative and his guardian |
|
|
|
|
should there be such, as well notifying a close person, as the case may be. |
|
|
The authorities |
47. (a) |
An institutional committee is authorized to decide in cases in which there is dispute |
|
|
and decisions of |
|
between the relevant persons or where a doubt arises regarding the nature of the |
|
|
institutional |
|
treatment to be administered to the patient, and inter alia in the following cases: |
|
|
committee |
|
|
|
|
|
|
(1) |
An objection to the decision of a responsible physician regarding the presumption of the wish to continue living pursuant to section 4 or the presumption of |
|
|
|
|
competence pursuant to section 6; |
|
|
|
(2) |
A dispute between the parents of a minor, between themselves, or between themselves and the responsible physician, as well as a dispute between a minor who is a terminally ill patient and his parents or between himself and his caregivers, as |
|
|
|
|
stated in section 28; |
|
|
|
(3) |
A dispute between a guardian and a minor patient, his parents, or the responsible |
|
|
|
|
physician, regarding section 24; |
|
|
|
(4) |
Ascertaining the wish of a terminally ill patient based on advance medical |
|
|
|
|
directives that he gave as stated in section 35; |
|
|
|
(5) |
An objection to the decision of a representative as stated in section 40; |
|
|
|
(6) |
Establishing priorities between advance medical directives and a power of attorney |
|
|
|
|
as described in section 42(c). |
|
|
|
(7) |
Determination of a responsible physician in the matter of whether a patient is a |
|
|
|
|
terminally ill patient or an end-stage patient as stated in section 8; |
|
|
|
(8) |
Determination of a responsible physician to the effect that a person is a close |
|
|
|
|
person to the terminally ill patient; |
|
|
(b) |
When deciding in a dispute as stated in section (a) an institutional committee shall ascertain the wish of a patient regarding his medical treatment and give directives regarding the fulfillment of his wish based on the facts presented to it and subject to the provisions of this Law; in the absence of facts regarding the wish of the patient, in a discussion based on section (a)(1)-(6), the committee shall decide in accordance with the |
|
presumed wish of the patient, based on his world view and his way of life, and when necessary based on a consultation with a close person to the terminally ill patient and with people who represent a world view similar to that of the patient; in the matter of a minor or a protected person, the committee shall also decide based on section 28(d) or 29(d), as the case may be.
(c) The persons mentioned in section 46(a), as well as any person with an interest in the patient, are entitled to present their claims before the institutional committee.
(d) The decision of an institutional committee, other than in the framework of a discussion held by a sub-group as stated in section 45(e), will only be valid if at least five members participated in the discussion and in the adoption of the decision, among them the jurist, one physician and two additional members who are not physicians; the decisions of the committee will be based on majority opinion; if the opinions are balanced, the chairman's opinion will be the deciding opinion.
(e) An institutional committee is entitled to decide a case, to submit a case for the decision of the National Committee or to bring the parties involved to an agreement; if the parties agree - the committee will not decide in the matter.
(f) An institutional committee in a medical institution will discuss the matter of a patient being treated in the medical institution to which it is assigned, and the matter of a patient who is not treated in that medical institution if the responsible physician for that patient is employed by the medical institution; an institutional committee of a sick fund will discuss the matter of a patient who is treated by a responsible physician who is not a physician as specified in paragraph (1) of the definition of a responsible physician, who is a district physician or was appointed by him, and the committee will be the institutional committee of the sick fund in which the patient is registered; an institutional committee will also discuss the case of a patient regarding whom the Director General instructed it to discuss and decide concerning him.
Renewed 48. Where an application pursuant to section 46 was forwarded to the committee for a second discussion by the time regarding a matter pertaining to a terminally ill patient, such matter already having been
committee discussed and decided by the committee, and where there has been no change in the
circumstances of the case, the chairman is entitled to determine that the application will not be forwarded to the committee for renewed discussion.
Exception to 49. The committee will not discuss an application in respect of which an appeal has been filed renewed pursuant to section 51(a) (4), or a petition filed to the High Court of Justice.
discussion
Article B: The National Committee
Appointment
of 50. (a) The Director General will
appoint the National Committee and these will be its
|
a national |
members: |
|
|
committee and |
(1) |
Four medical experts, at the level of unit director, department director or hospital |
|
its panels |
|
director; |
|
|
(2) |
Four senior level registered nurses, at a senior level; |
|
|
(3) |
Four members who are social workers in a medical institution, at a senior |
|
|
|
management level, or clinical psychologists in a medical institution, at a senior |
|
|
|
management level; |
|
|
(4) |
Four academics who are experts in the discipline of philosophy or ethics, at a |
senior
academic level;
(5)
Four jurists who are qualified to be appointed as district court judges or that
are at a senior academic level;
(6) Four religious authorities.
(b) The appointed members should be experienced in the areas discussed by this Law; a Jewish religious authority will be appointed after consultation with Israel’s Chief Rabbis and the non-Jewish religious authority will be appointed after consultation with the president of the appeal court of that religious community in Israel; the jurist will be appointed after consultation with the Attorney General.
(c) The Director General will appoint the chairman of the committee and his substitute from amongst its members.
(d) The chairman of the committee will appoint the panels of the committee from amongst its members; six members will be appointed to each panel, each from a different discipline as specified in paragraphs (1) to (6) of subsection (a), and he will also appoint a substitute for each one of them; the committee’s chairman will appoint a chairman and his substitute for each panel.
(e) A member of the national committee will be appointed for a period of five years, and his appointment may be renewed for additional periods.
51. (a) The national committee is authorized to discuss and decide the following:
(1) Disputes between the members of the institutional committee, based on a request of at least one of them;
(2) Exceptional cases which are of fundamental importance, submitted by an institutional committee for its resolution;
(3) Cases that an institutional committee submitted to the national committee without deciding upon;
(4) An appeal regarding the decision of an institutional committee, submitted by a person entitled to apply to an institutional committee.
(b) When deciding on a dispute as stated in subsection (a) the National Committee will ascertain the patient's wish regarding his medical treatment and give directives regarding the fulfillment of his wish based on the facts presented to it and subject to the provisions of this Law; in the absence of factual data regarding the patient's wish, the Committee shall decide in accordance with the presumed wish of the patient, based on his world view and his way of life, and when necessary based on a consultation with a close person to the terminally ill patient and with people who represent a world view similar to that of the patient; in the matter of a minor or a protected person, the Committee shall also decide based on section 28(d) or 29(d), as the case may be.
52. (a) The persons enumerated in section 46(a) as well as any person who has an interest in the patient are entitled to present their claims before the National Committee.
(b) The decisions of the National Committee will be based on majority opinion; if the opinions are balanced, the chairman's opinion will be the deciding opinion.
(c) The decision of an institutional committee will only be valid if at least one representative from each discipline specified in sub-sections (1) to (6) of section 50(a) participated in the discussion.
(d) The National Committee will decide an appeal or an application that has been brought before it.
The Minister is charged with implementing
the provisions of this Law and is entitled to establish regulations for its
implementation.