An Advance Medical Directive for a Parent in Israel: The American Living Will Stops at the Border, the Israeli Form Speaks Only in the Last Six Months, and the Enduring Power of Attorney Falls Silent Exactly Then

This is orientation, not legal or tax advice. It maps what exists and the questions to take to a licensed professional. It does not tell you what to do about your own estate or taxes.

A son in Baltimore lands at Ben Gurion on a Thursday morning and takes a taxi straight to Rambam. His mother, seventy-nine, had a stroke on Monday. She is in intensive care, sedated, and the senior physician wants to talk about what happens if she needs a ventilator and about whether the family wants a feeding tube placed. The son has come prepared. In his bag is the living will his mother signed in his lawyer's office in Pikesville on a visit in 2017, and the Maryland health care proxy naming him as her agent. He puts both on the desk.

The physician reads them, thanks him, and asks a different question: has his mother deposited hanchayot refuiot mukdamot with the Ministry of Health, or appointed a meyupeh koach under the Dying Patient Law? The son has never heard either phrase. The physician checks the hospital's system, which is linked to the Ministry's registry, and finds nothing. Then she explains, gently, what that means. The American documents will be read as evidence of what his mother wanted. They are not what the Israeli statute requires, and she is not authorized to treat them as if they were.

This page is for that family, in either direction: the Israeli parent whose American children hold American documents, and the American parent who made aliyah with a New York health care proxy in the drawer. It explains what the Dying Patient Law, 5766-2005, does and does not do, which Israeli forms exist, who can sign them and from where, why the enduring power of attorney described on the previous page is silent at exactly this moment, and why the Israeli forms will not help if the parent is ever flown to a hospital in the United States. It then turns to the three American questions that arrive with a serious diagnosis abroad: the records, the money, and the second document.

Two documents, two registries, and a gap of 220,000

Israel has two separate legal instruments for a parent who can no longer decide, and they are kept by two different ministries. The enduring power of attorney, yipui koach mitmashech, lives in the Legal Capacity and Guardianship Law, 5722-1962, is drafted by a certified lawyer, and is deposited with the Administrator General at the Ministry of Justice. It governs money, housing, and ordinary medical matters. More than 260,000 have been deposited since 2017, about 52,000 in 2024 alone.

The end-of-life instruments live in a different statute, the Dying Patient Law, 5766-2005, and are deposited with the Center for Advance Medical Directives at the Ministry of Health in Jerusalem. No lawyer is involved. A doctor or nurse is. The registry that hospital physicians consult has been computerized since 2013. According to preliminary research presented by Dr. Dudi Hausner of Sheba Medical Center at Israel's first national palliative care day in November 2024, only about 40,000 forms had been signed under the law since 2005. The reasons he listed were low public awareness, physician time, and forms that are hard to fill in.

The two numbers describe the situation most Israeli families are in. A large and growing minority of parents have arranged who will manage their affairs if they lose capacity. A much smaller number have said anything, in a form the law recognizes, about how they want to die. Israeli law does not let the first document answer the second question. Section 32(b)(5) of the Legal Capacity and Guardianship Law lists, among the things an enduring attorney may never do, any act or expression of will that a patient, proxy or guardian is authorized to make under the Dying Patient Law, and section 32LG of the same law excludes end-of-life treatment from the advance instructions an appointer can leave for the attorney. The child who was appointed under the enduring power can sign for the rehabilitation placement, pay the caregiver, and consent to a hip operation. When the physician asks about the ventilator, that document has nothing to say.

What the Dying Patient Law starts from

The statute opens from a presumption, and the presumption explains everything that follows. Section 4 provides that a person is presumed to want to go on living unless the contrary is proved, and that where it is not proved beyond reasonable doubt, the physician leans toward life. Section 1 states that the law balances the sanctity of life against the autonomy of the person and the importance of quality of life, and that it rests on the values of the state as Jewish and democratic. A family arriving from a state whose living-will statute starts from the patient's right to refuse treatment should expect the reasoning in an Israeli ICU to run the other way, from life toward the exceptions.

Section 5 sets out how the presumption can be displaced, in a fixed order. A dying patient who still has capacity displaces it by an express wish, and section 15 requires the staff to respect that wish while making a reasonable effort to persuade the patient to accept oxygen, food, fluids and palliative care. For a dying patient without capacity who is at least seventeen, the law looks first for advance directives, then for a decision by a proxy appointed under the law, then for a ruling by an institutional committee. Only if none of those exists does the responsible physician decide alone, and the physician is then required to take into account an express statement by a close person that the patient did not want life prolonged.

That last provision is where the son in Baltimore actually stands. He is a close person. His mother's American documents are evidence of her wishes. Nothing in the law tells the physician to ignore them. But the burden has shifted. Instead of a deposited Israeli form that binds the medical staff, he has a foreign document that a physician weighs, in a system that leans toward treatment when in doubt, and section 36 adds that the mere absence of Israeli directives says nothing about what the patient wanted. A family that agrees, a physician who is comfortable, and a clear American document usually get to the same place. A family that disagrees, or a physician who is not comfortable, ends up before the hospital's ethics committee, which section 5 names as the next stop.

The two words that decide whether the form speaks at all

An American living will typically activates when the patient has a terminal condition or is in a persistent vegetative state or an end-stage condition, and the definitions vary by state. The Israeli forms activate on a narrower and more specific trigger, and the American family needs to understand it before signing anything.

Under section 8(a), a responsible physician may determine that a patient is a dying patient, choleh ha-noteh lamut, if the patient has an incurable medical condition and a life expectancy of six months or less even with treatment. Under section 8(b), a dying patient is an end-stage patient, choleh beshalav sofi, if several vital systems have failed and life expectancy is two weeks or less even with treatment. The Ministry's own service page states the three conditions that must all be met before a deposited form has any effect: a physician has defined the signer as terminally ill with no possibility of recovery, the signer is in significant suffering as the signer defined it in the form, and the signer cannot express their own wishes.

Consider what that leaves out. A parent with advanced dementia who is not within six months of death is not a dying patient under the law. A parent who survives a stroke but does not regain awareness, and whose body is otherwise stable, may not be either. In those situations the Dying Patient Law forms do not speak, because their trigger has not been pulled. Day-to-day medical consent falls back to the medical section of the enduring power of attorney, if one exists, or to an ordinary medical power of attorney under section 16 of the Patient's Rights Law, 5756-1996, or, absent both, to a guardianship application in the Family Court. Families who assume the Israeli directive works like a broad American living will are surprised twice: first that it needs a physician's six-month determination, and second that a long decline with no such determination is governed by an entirely different document.

What can be withheld, and what cannot

The forms let the signer refuse specific treatments, and the law then limits what a refusal can reach. The limits are unfamiliar to Americans and they matter in the room.

For a dying patient without capacity who is in significant suffering and whose wishes have been established under section 5, section 16 says the staff must refrain from treatment connected to the incurable condition. The list is explicit: tests, surgery, resuscitation, connection to a ventilator, chemotherapy, radiation, dialysis. The same section then carves out what it calls accompanying treatment, tipul nilveh: routine care for concurrent or background illnesses, palliative care, and food and fluids, including by artificial means. Accompanying treatment may not be withheld from a dying patient who is not end-stage, even if the patient's directives say otherwise. The feeding tube the physician asked the son about is, for a patient who has six months but not two weeks, something the form cannot refuse.

Section 17 changes the rule for an end-stage patient. Once several vital systems have failed and the physician has determined that two weeks or less remain, all treatment may be withheld, including the accompanying treatment, except fluids, which continue unless the physician determines they cause suffering or harm.

Then there is the distinction the law draws that has no counterpart in a Maryland form. Section 21 provides that nothing in the law permits stopping continuous medical treatment of a dying patient where stopping it may cause death, whether or not the patient has capacity. What the law permits is refraining from renewing cyclical treatment, and refraining from restarting continuous treatment that stopped on its own or lawfully. In practice this is the difference between not connecting a ventilator and disconnecting one. An American family used to the idea that a patient may withdraw any treatment they could have refused will find that the Israeli statute treats withholding and withdrawing as different acts. Sections 19 and 20 close the door on active euthanasia and assisted suicide in the same breath.

Section 18 handles the emergency room. Where a dying patient arrives in a medical emergency, the ordinary rule of section 15(3) of the Patient's Rights Law applies and urgent treatment is given without consent, unless the treating staff know that the patient's wish to refuse treatment in such a situation has been established. For an end-stage patient in an emergency, the staff may refrain from life-saving treatment unless they know the patient wanted it. Either way the word is know. A deposited form in the Ministry's registry, visible in the hospital record, is how the staff come to know. A document in a son's carry-on bag is not.

The Israeli forms, and who signs what

The Ministry of Health publishes five forms under the law, in Hebrew and in English. Two of them do the real work.

The First Schedule form is the advance medical directives themselves, hanchayot refuiot mukdamot. Under section 31 any person with capacity, aged seventeen or over, healthy or already ill, may sign it. Under section 33 it is signed before two witnesses who have no economic or other interest in the signer and who are not the proxy; the Ministry's page adds that the witnesses may not be first-degree relatives. Under section 32 the signer must receive medical information about the treatments the form covers, and the Ministry requires the form to be completed together with a licensed physician or registered nurse, who signs a declaration that the information was given. The form lets the signer define significant suffering in their own words, and then, separately for the dying-patient and end-stage situations, mark which treatments they refuse and which they want even if a physician thinks them pointless. Section 13 of the law protects that second choice: a dying patient who wants life prolonged is entitled to treatment the physician considers unjustified, within the system's ordinary arrangements.

The Second Schedule form appoints a proxy, meyupeh koach, under section 37, with an optional substitute. The proxy decides, in the signer's place, which treatment will and will not be given if the signer becomes a dying patient without capacity. The signer may set conditions and limits, and may define significant suffering here as well. It is signed the same way, before two witnesses and with a physician's or nurse's explanation. Two features matter for a family split between countries. The proxy does not sign the form, so a child in the United States can be appointed without being present. And the law sets no residence or citizenship requirement for the proxy. The Ministry also publishes a short-form proxy that needs no medical explanation and can be signed by a person who has not yet been determined to be a dying patient, which is the version most healthy parents use.

Where both forms exist, the Ministry's guidance is that the signer's own directives are generally preferred over the proxy's decisions. Many practitioners advise signing both anyway, the directives for the treatments the parent has firm views about and the proxy for everything the form did not anticipate.

Depositing, renewing, and the five-year clock

A signed form that stays in a drawer is worth roughly what the Maryland document was worth in Rambam. Sections 33 and 34 contemplate deposit with the Ministry, and the Ministry's page is blunt that correctly completed forms bind the medical staff and should therefore be sent in to be stored in the registry, where they appear in the hospital record when a physician looks.

Since 2025 the forms can be submitted through an authenticated online portal, with the two witnesses signing on screen, the physician's declaration and a copy of the signer's identity card attached, and processing in two to three business days. Registered mail to the Center in Jerusalem still works and takes up to sixty business days. Either way the Center sends a confirmation that the form has been deposited, and that confirmation is the piece of paper the child abroad should keep.

Under section 34, directives are valid for five years from signature, or a shorter period if the form says so, and can be extended for further periods of up to five years each. Section 39 applies the same five-year cap to the proxy. The Ministry sends a reminder before expiry. A form that lapses is not deleted; the Ministry keeps it in the registry, and a physician may take it into consideration, but it no longer binds. For a parent in Israel whose children are in the United States, the renewal is the step most likely to be missed. Someone in the family should own the date.

Two more provisions round out the picture. Section 41 obliges a physician who determines that a patient with capacity is a dying patient to tell the patient that they may give directives or appoint a proxy, or update ones they have. And the signer can revoke or replace the forms at any time while they have capacity, on the Ministry's revocation form or by signing new directives.

Why the American document does not travel, in either direction

Israeli practitioners who work across the two systems say the same thing about living wills and health care proxies from the United States that they say about durable powers of attorney: they are not automatically recognized in Israel, and Israeli institutions cannot be expected to act on them. The reason is the one set out above. The Dying Patient Law channels every binding statement about end-of-life treatment through its own forms, its own witnesses, its own medical explanation, and its own registry. A New York health care proxy satisfies none of those requirements, however carefully it was drafted for New York.

The reverse is also true, and families who plan for a parent to be treated in the United States if a serious illness comes should know it. Recognition of an advance directive made elsewhere is a matter of state law. The Uniform Health-Care Decisions Act, revised in 2023 and enacted in a number of states, provides that a directive is valid if it complies with the receiving state's law or complied, when made, with the law of the state where it was created, and the enacted Delaware text uses exactly that word, state. Some state statutes are broader, some are silent, and a hospital in Baltimore or Boca Raton applies its own state's rules. An Israeli form deposited in Jerusalem, in Hebrew, with a Ministry of Health declaration attached, is at best evidence of the parent's wishes in a US hospital, which is precisely the status the Maryland living will had in Haifa.

The practical conclusion is unglamorous. A parent who might be treated in both countries needs a document in each, signed under each country's law, saying the same thing. A US-citizen parent living in Israel with American children, the most common shape of family reading this site, needs the Israeli forms because that is where the care will almost certainly happen, and a current US health care proxy under the law of the state where the children live, in case it does not.

The three American questions

The Israeli forms settle who decides and within what limits. They do not settle the three things the American child will be asked about within the first week.

The records

The parent's American physicians hold the history the Israeli team wants, and the parent may not be able to authorize its release. The HIPAA Privacy Rule, at 45 CFR 164.510(b), allows a US provider to share with a family member involved in a patient's care the information directly relevant to that involvement, and where the patient is incapacitated, it leaves the decision to the provider's professional judgment about the patient's best interest. That is discretion, not a right, and a cardiology practice in Pikesville has no way to assess a request from a hospital in Haifa. The clean path is a signed HIPAA authorization under 45 CFR 164.508, executed by the parent while competent, naming the child and any Israeli institution, with no expiry date short of the parent's death. It costs nothing and it is the American paper most likely to be missing.

The money

Medicare does not follow the parent. Medicare.gov and the CMS fact sheet on coverage outside the United States are explicit: Original Medicare usually pays nothing for care outside the United States and its territories, with three narrow exceptions involving Canada, Mexico and cruise ships, none of which reaches Israel. Foreign hospitals are not required to file Medicare claims. Part D cannot cover drugs bought abroad. Certain Medigap plans cover 80 percent of emergency care abroad up to a lifetime cap, and a parent who kept one should have the policy number to hand. The Israeli parent's care runs on the kupat cholim and any supplementary insurance, and private additions, a round-the-clock caregiver above all, are paid by the family.

When the American child pays, the way the payment is routed decides whether it is a gift. Under 26 USC 2503(e), an amount paid on behalf of another person directly to the provider of medical care, as defined in section 213(d), is not a gift at all, without dollar limit and without a Form 709. A payment to the parent, or to a sibling in Israel who then pays the hospital or the caregiving agency, is a gift to that person, and above the $19,000 annual exclusion for 2026 it must be reported. The rule is easy to satisfy and easy to trip over, and the child should keep the invoices in the provider's name. Where the child also holds signature authority over the parent's Israeli accounts under the enduring power, the FBAR obligation described on the previous page is already running.

The second document

The third question is whether the parent has a current American directive at all, and whether it says the same thing as the Israeli one. Families who have done the Israeli forms carefully sometimes leave a 2009 Florida living will in place that contradicts them, or a health care proxy naming a sibling who has since died. If there is any realistic chance of treatment in the United States, the American document should be redone in the same season as the Israeli forms, under the law of the state where the child lives or where the parent would be treated, naming the same proxy and stating the same limits. Where there is no such chance, the American document can be left to lapse, but the family should know which case they are in.

When the parent dies

The Dying Patient Law forms expire with the parent. What comes next is the part of the map the rest of this site covers. The Israeli accounts freeze on the death certificate, as the frozen-account page explains; the enduring power gives the appointee ninety days to pay current bills and funeral costs and then expires; and only a succession order or probate order from the Registrar of Inheritance Affairs unlocks the estate, on the process described on getting an Israeli succession order from abroad and probate in Israel for US heirs. If the parent died without a will, the intestacy page sets out how the Succession Law divides the estate among American heirs, and if the parent's US and Israeli wills were meant to work together, the two-wills page explains what has to be true for that to hold.

What to ask, and who to ask it of

Ask the parent's Israeli physician or kupat cholim nurse, while the parent clearly has capacity:

• Whether they, or a nurse in the clinic, can complete the First Schedule directives and the Second Schedule proxy with the parent, and sign the medical-information declaration.
• Whether the parent should also sign the short-form proxy now, before any dying-patient determination, so that a proxy exists even if the full forms take time.
• How the parent wants to define significant suffering, in the parent's own words, and which of the listed treatments the parent refuses, and which the parent wants regardless.

Ask the Israeli lawyer who drafted the enduring power of attorney:

• Whether the enduring power's medical section and the Dying Patient Law forms name the same person, and if not, whether that is deliberate.
• Who will consent to day-to-day medical treatment in a long decline that never reaches a dying-patient determination, and whether an ordinary medical power of attorney under the Patient's Rights Law should also be signed.
• Whether the appointee under the enduring power understands that the ventilator decision is not theirs to make.

Ask the US estate attorney, with the Israeli forms and their translations in hand:

• Whether the parent's existing American living will or health care proxy contradicts the Israeli forms, and whether it should be redone under the law of the state where the child lives.
• Whether a HIPAA authorization naming the child and the Israeli hospitals should be signed now, and what it should say about expiry.

Ask the US accountant:

• How the child should route payments for the parent's care so that they fall under section 2503(e), and what records to keep.
• Whether the child's signature authority over Israeli accounts has already triggered an FBAR, and when.

And ask the family the question that no form can answer for it: does the parent want the child abroad, or the child in Israel, to be the one the physician turns to at three in the morning, and does that child know? The Israeli forms exist to record the answer while it can still be given. The American questions are the price of being the one who answers.