Emergency Measures

We are told hospital overcrowding is only getting worse; but on June 2, Ichilov Hospital's internal medicine ward was calm and orderly, without a soul housed in the hallway.

Last month's state comptroller's report contains a harsh picture of the hospitalization crisis.

The findings, based on statistics collected from January to August 2010, are so dire that they were presented in preliminary form in July of that year to Prime Minister Benjamin Netanyahu, who also holds the Health Ministry portfolio, Deputy Health Minister Yaakov Litzman, and Finance Minister Yuval Steinitz.

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On June 2, I visited Ichilov Hospital after reading relevant sections of the report, including "The hospitalization crisis in internal medicine units in general service government hospitals," "Aspects of the treatment needs of the elderly" and "The granting of community-based nursing care to the elderly."

The facts are plain to see: following increased life expectancy and a growth in the number of elderly citizens in Israel, a severe hospitalization crisis has arisen in recent years in internal medicine wards, which are utilized mainly by older citizens suffering from complex medical problems.

According to the comptroller's report, in 2010, people older than 65 constituted 10 percent of Israel's 7.6 million citizens.

My anxiety level rose as I approached the hospital. The comptroller's shocking descriptions would soon turn into shameful sights and smells: "In the internal medicine units of many general hospitals, patients are kept in difficult and substandard conditions ... in 2010, rooms meant for two patients contained three and even four, while three-patient rooms held five; patients were hospitalized in corridors and dining rooms, which lacked vital equipment and oxygen; men and women were hospitalized in the same rooms and hallways, so close to one another that privacy could not be maintained. It is estimated that every day 300 patients are hospitalized in substandard conditions."

But at around 10:00 in the morning of June 2, there was no sign of a crisis at the entrance to Ichilov's emergency room. Two obliging clerks politely helped two Filipino aides, their elderly charges in wheelchairs at their sides. The spring sun peeked through the glass walls, lines did not snake down the hall, people moved toward where they needed, some on their own and some supported by others, no ambulance arrived to create a commotion, there was no tension in the air, and the people I saw in the ER did not appear to be in a fatalistic mood.

The chief nurse in the emergency room pointed out, of course, the need for an increase in the number of beds and staff positions. A pleasant and intelligent woman, she spoke about their awareness, as service providers, of the patient as a client, of friendly design that attempts to keep the hospital experience out of mind.

The ER had a colorful atmosphere, more like that of a travel agent's office, with pleasant lighting instead of cold neon, computer stations scattered about, and a coffee stand at the entrance. Nonetheless, hospitals send out a penetrating and personal message: personal, because we all expect to arrive there at some point, and penetrating because it shows where each of us really stands.

The hackneyed image of an elderly woman lying on a bed in a hallway, a picture which filled television screens this winter, represents more than overcrowding; it also marks the abandonment of respect.

Every now and then the woman in the hallway is asked to cast aside her pride when the sheet slips from her body as someone passes by in the hall and accidentally bumps into her bed, and to give up on values such as privacy in the most basic sense; this complete exposure leaves her with no choice but to petrify and shrink into an ill and unconscious body.

But on the Thursday I visited, no one was hospitalized in the hallway of Ward A in the internal medicine department. The rooms contained a reasonable amount of patients; the doctors and nurses were not overly busy, behavior was tolerant, the nursing staff carried out its work, no one cried out "Nurse, nurse!" and those who approached the nursing station to clarify matters were answered immediately.

Even the 88-year-old man who agreed to be photographed with me seemed optimistic and energetic, filled with cheer ahead of his discharge.

On Thursday, June 2, there was no hospitalization crisis at Ichilov Hospital.

I am not making this claim out of spite. I am pointing out the facts. June is not winter, there is no flu epidemic, and the department is not running at 150 percent of capacity. The question is: are there many days like Thursday, June 2, and, to be precise, what is the proportion between days of sanity and days when the system collapses under the load?

Capital and cures

What is confusing about the difference between the comptroller's report and the appearance of tranquility at Ichilov is the difficulty of speaking about human life in economic terms. Human life is something which cannot be priced; we say that it has no price. But in our capitalistic world, everything does, and so, in the absence of an alternative, a price is calculated. Each society has its own charges.

It is possible to disagree, for example, with the rates imposed by the health maintenance organizations which decide to send patients to overcrowded hospitals. After the units have reached their limits, the HMOs pay a reduced price for each additional hospitalization. We must not ignore the fact that hospital overcrowding stems, according to the report, also from the 15 percent of patients who have finished their treatment, but have nowhere to go.

The question of what to do with the increasingly large population of the elderly who need constant care is a big one. Isn't it time to do as the comptroller suggests, and open community-based nursing services, including house calls by doctors and nurses?

The state has budgeted NIS 20 million for such services, which is, of course, too little, and in practice it grants even less. For their part, the HMOs are in no rush to act. On June 2, there was no pressure on the ward, and no flurry to release patients.

On average, some 20 percent of those released from this ward are re-hospitalized within 30 days of discharge. The length of a hospital stay in Israeli internal medicine units is short (4.1 days ) compared to those in more developed countries, where the average is 6.7.

Hospital readmission is often the result of a problem that was not solved during the first hospitalization. A study conducted at the Assaf Harofeh Hospital found that 48 percent of readmittances could have been prevented, and at Kaplan Hospital - 33 percent.

Dr. Moshe Mittelman, head of Ward A, was walking down the hall, and in the way of doctors, deep in conversation with a social worker - Elinor Bar Menashe.

The two were coming to meet me, at the directive of the hospital spokesman. There was something genuinely embarrassing about the gap between what I saw on that day and the inferno depicted in the comptroller's report. In order to confirm that the comptroller, Mittelman and I were on the same page, I repeated to him the main elements of the report.

Mittelman agreed: internal medicine was facing extinction; the wards desperately needed more beds and additional staff.

I asked him his opinion about whether the medical profession was ready to deal with the rise in life expectancy. Mittelman admitted that Israel society's approach to the elderly, in particular to Holocaust survivors, was shameful.

Afterwards he drew my attention to a social worker quietly exiting a room where invalids were hospitalized. Out of the corner of my eye, I caught a glimpse of a very elderly man, pale and lying peacefully, attached to a breathing machine. His face was expressionless, but also free of suffering. A nursing aide passed by with a smile; she understood that we were talking.

Appearances are misleading. It is unpleasant to ask direct questions about doctors honoring a patient's will. Nonetheless, cancer strikes one in three people in their lifetimes. Some 50 percent of all people over 85 are affected by Alzheimer's; many patients are hospitalized in the last months of their lives against their will, and are not interested in life-prolonging treatments.

Mittelman is not embarrassed by the question. The law is perfectly clear: "As much as the matter is in the hands of doctors, they try to respect the patients' desires. Those they believe are lucid. They include them in each procedure, including difficult conversations, considering with them the possibilities for treatment and the option to refrain from treatment as well. This is an important part of a doctor's schedule," he said.

On June 2, his words sounded completely logical. On a ward that worked like a well-oiled machine, even death seemed like a matter for personal consideration and decision-making. "Doctors are not allowed to take active steps," Mittelman explained. A person who sees himself as a healer does not assist people in dying. In his eyes, such an active role is a betrayal of the profession.

In the absence of clear guidelines, the accepted practice today in Israel is to treat patients even in terminal stages and to make every effort to prolong life. Terminally ill patients are defined as those with less than six months to live.

Bar Menashe, the social worker, said that it was much easier for the staff if a patient had made a "living will" or signed over medical power of attorney according to clause 16 of the patients' rights law, a form that defines exactly which actions a patient allows and which may not be taken when illness reaches its final stages.

It is interesting to note that the law came into force on December 15, 2006, but as of February of this year, only 3,900 people have signed such declarations at the Health Ministry.

Literary people are not medical journalists. Perhaps for this reason I secretly hoped to discover an existential truth in internal medicine Ward A at Ichilov Hospital, something beyond technical terminology and the worrisome numbers in the comptroller's report.

In literature, a person about to die is granted moments of grace, an epiphany and deep understanding. On June 2, there was no room for these. The large questions about the future, about a changing society having difficulty facing the economic cost of aging - these questions arise in winter, during flu epidemics, when the hospital stands at 150 percent capacity and the hallways spill over with patients, violence bursts out, the staff runs about helplessly, and the elderly woman in the corridor is again filmed for the nightly news.

And so it is year after year, and then again, and meanwhile budget increases are insufficient, flu strains develop new resistance to drugs and human society grows older and older.