Dear patient,
The purpose of this guidance is to provide you with vital information for dealing with a colostomy, to maintain your quality of life. In addition to this guidance, you will receive instructions from the stoma care nurse and surgical department nurses who specialize in caring for stoma patients. It is recommended and desirable that a family member or close person to you participate in the guidance so they can assist you at home if needed.
The word "colostomy" consists of two words: "colon" = large intestine, and "stoma" = opening. A colostomy is an opening in the abdominal wall through which feces and gas are excreted. A colostomy is performed as part of a surgical procedure where a part of the large intestine is either removed or bypassed to treat a disease or alleviate symptoms.
The main reasons for the need for a colostomy are:
Cancerous growth along the large intestine.
Diverticulitis.
Bowel obstruction.
Inflammatory bowel diseases.
Trauma.
Congenital malformations.
The large intestine's length is about one and a half meters, and it consists of the colon, the rectum, and the anus.
The role of the large intestine is to absorb fluids and salts back into the body, move waste through peristalsis, and store waste until elimination. The anal sphincter muscles enable control over bowel movements.
A colostomy can be temporary or permanent. Temporary colostomy is performed in situations where the large intestine needs time to heal and rest after surgery or injury. Temporary colostomy is done in cases of infection, bowel perforation, various blockages, etc. The healing time can vary from weeks to months. After colostomy closure, bowel movements will occur naturally through the anus.
A permanent colostomy is performed when there is a disease in the terminal part of the large intestine (the rectum) or irreversible damage to the anal sphincters.
In both cases, the natural elimination process will vary. In a colostomy located higher in the large intestine (far from the anus), there is less time for fluid absorption, resulting in softer bowel movements, and the timing of elimination is unpredictable. Colostomies located lower along the large intestine (closer to the anus) result in firmer bowel movements and predictable elimination times.
With time, for most people, the reflex for bowel movement will return, and the elimination process will be natural and consistent throughout the day. In some cases, bowel movements might be triggered by stimuli such as drinking hot liquids, juice, coffee, or eating.
The major bowel movement will occur after an adequate amount of waste has accumulated above the colostomy opening. Between bowel movements, there may be liquid discharge since there are no anal sphincter muscles to retain the fluid.
After the surgery, the large intestine will be inactive in the initial days, but you will still have the colostomy bag attached. Passing gas will be the first sign of the intestine's return to activity. Afterward, you can gradually start drinking and eating according to your doctor's instructions.
In the first days, the department's nurses will closely monitor the appearance and activity of the stoma. As you feel better, you will learn to take care of the stoma independently with the help of the nursing team.
The recovery period after the surgery usually ranges between 6 to 8 weeks. Physical changes and lifestyle adjustments might cause some anxiety and discomfort. It's normal to find it challenging to look at or touch the colostomy initially, and it's essential to acknowledge and express your feelings. You can also share these emotions with your loved ones.
Initially, the process of learning to care for the stoma might seem complex and time-consuming. However, as you become more experienced, you will gain confidence and adapt to the changes. You will find that stoma care is not as complicated as it may seem and doesn't require an excessive amount of time.
Normal Stoma Appearance:
• The stoma is round or oval.
• Color: red or pink (similar to the color of the mucous membrane inside the mouth).
• The stoma is moist.
• It contains small blood vessels that might bleed slightly during cleaning.
• There is no sensation, and it's not sensitive to pain (avoid applying pressure).
• The stoma discharges mucus (a natural substance from the intestine).
• Bowel movements from the large intestine - soft or formed stools.
Stoma Care Equipment:
Two-piece equipment:
a. Skin barrier adhesive: The adhesive is attached to the skin, surrounding the stoma, and serves as a base for the ostomy bag.
There are two main types of skin barriers:
Pre-cut in a fixed diameter.
An adhesive that can be cut or shaped according to the stoma's size and structure.
The barriers can be convex or flat. The type of barrier depends on the stoma's shape and the abdominal structure.
b. Ostomy bag: The bag is used to collect bowel movements and is securely attached to the skin barrier with a closure system.
There are two types of bags: closed-end bags for single use and open-end bags for multiple uses, depending on the nature of bowel movements. The bags have an inner lining and contain a charcoal filter for gas and odor absorption.
Single-piece equipment:
Equipment that combines the skin barrier adhesive and ostomy bag as a single unit is not suitable for everyone. Its use depends on the frequency and nature of bowel movements, the stoma's structure, and the patient's condition. Here, too, it's possible to use either a closed or open-end bag.
Stoma Bag Change:
Closed-end bag:
Change the bag when it is about one-third full, approximately 1-3 times a day.
It's important to change the bag while sitting or standing. Disconnect the old bag from the skin barrier, clean the inside of the skin barrier and the outer ring, and attach a new bag.
Using deodorant to neutralize odors, add a few drops inside the new bag before connecting it to the skin barrier. Wrap the old bag in a bag and dispose of it in the trash.
Open-end bag (with an opening at the bag's end):
Empty the bag when it is about one-third full, and dispose of the waste in the toilet or a waste bag. Clean the opening's end with dry paper or a towel and close it tightly.
The number of bag changes per day depends on the frequency of bowel movements. You can change the bag once a day or twice a week, depending on the external bag cleaning.
Factors Influencing Skin Barrier Change Frequency:
• Bowel leakage - causing irritation and a burning sensation around the stoma.
• Excessive sweating - during the summer months, physical activity, and strenuous work.
• Oily skin.
• Dry skin.
• Significant weight gain or loss - causing changes in the abdominal structure and stoma's diameter, requiring readjustment of the skin barrier and bag.
Equipment Replacement Procedure:
- Prepare all the necessary equipment for replacement in advance.
Gently remove the skin barrier and bag, supporting the skin during removal (you can use an adhesive remover). Clean any residue on the stoma with a paper towel. - Determine the stoma's diameter using a measuring guide or a suitable pre-cut template.
- Mark the diameter on the backside of the skin barrier and cut the hole according to the stoma's size, or check if the pre-cut hole is suitable for the stoma's diameter (when the stoma's size stabilizes, you can pre-cut the skin barrier). Leave a 1-2 mm space between the stoma and the skin barrier.
- Remove the paper from the skin barrier.
- If needed, use a stoma paste or stoma rings to create a protective layer around the pre-cut hole. Allow the paste to dry before sticking it to the skin (around 5-15 minutes).
- Clean the skin around the stoma with mild soap and water using a soft towel or cloth and dry thoroughly. Do not rub the stoma, as it may bleed.
- If necessary, use a skin barrier powder and/or protective wipe on the skin around the stoma.
- Attach the skin barrier when the stoma is at the center of the inner opening. Ensure that the skin is dry, clean, and taut before attachment.
- Connect the bag's ring to the skin barrier's ring and ensure a tight and sealed connection.
- Attach the belt (if needed).
- After replacing the skin barrier and bag, press gently on the stoma with your hand for 15 to 60 minutes. The warmth of your hand and gentle pressure will help the skin barrier's adhesive adhere better to your body.
- Place the replaced equipment in a plastic bag and dispose of it in the trash. Do not flush any equipment down the toilet.
- Avoid wetting the skin barrier for several hours after replacement.
- Maintaining Healthy Skin around the Stoma:
The skin around the stoma should have a uniform texture, no change in skin color, and be clean, and dry.
- Maintain the cleanliness of the skin around the stoma.
Measure the stoma's structure and the appearance of the skin around it with each replacement. - Attach the skin barrier only to clean and dry skin. Avoid applying oily ointments under the skin barrier.
- Ensure that the skin barrier's diameter is precisely adapted to the stoma's size, and it is attached evenly and completely to the skin.
- If irritation, redness, rashes, skin peeling, or inflammation occurs, contact a stoma care nurse in the community or the hospital for assistance and guidance.
Instructions for Equipment Adjustment:
Equipment adjustment for the stoma will be done with the stoma care nurse or a representative on the ward.
- After the surgery, the stoma shrinks gradually and reaches its stable size after 6-8 weeks. During this period, measure the stoma's diameter once a week.
- Adjust the skin barrier's diameter according to any changes in the stoma's size. Seek assistance from a stoma care nurse in the community if there is a change in the stoma's diameter.
- Store the equipment in a cool and dry place, organized in one location.
- Avoid accumulating excessive equipment (equipment can be damaged).
- The equipment is fully funded by the health fund (in private purchase, the equipment can be very expensive).
- During the hospitalization, you will receive a list of the equipment suitable for you for the initial period after the surgery. With this list, consult your family doctor or the stoma care nurse in your health fund to obtain a prescription. With the prescription, go to the pharmacy to order the equipment. Make sure to order the equipment during your hospitalization so that it will be ready for you at home upon discharge.
- On the day of discharge, you will receive a release kit containing basic equipment, including skin barriers and bags for the initial period after surgery.
There is a wide variety of accessories distributed by different companies and manufacturers. Most of them can be obtained through the health fund. The stoma care nurse in the hospital and the stoma care nurse in the community will assist you in choosing suitable equipment for you.
Important: You must have replacement equipment with you whenever you leave your home.
Diet:
After the surgery, start with a clear fluid diet only, and gradually return to a regular diet as instructed by your doctor.
In the first 3-4 weeks after the surgery, avoid eating foods high in fiber to give the intestine time to rest and allow the remaining intestine to return to normal activity. Avoiding fiber will reduce the feeling of pressure and discomfort caused by gas and bowel movements in the digestive system.
Returning to a regular and balanced menu takes several weeks and varies from person to person, depending on the personal adaptation, the nature of the disease, the size of the surgery, and the drug treatment. Adding new foods may cause temporary changes in the stoma's activity, such as gas and odor or discomfort in the digestive system. These changes are temporary. It is essential to experiment with various types of food and find the ones that suit you.
For colostomy patients, there are no restrictions on the types of food unless there are limitations due to other medical conditions, such as diabetes, heart or kidney diseases. It is essential to have a balanced diet that includes all food groups: proteins, carbohydrates, fats, vegetables, and fruits, and follow correct eating habits, such as regular meals, proper chewing, and increased water intake (approximately 1.5 -2 liters per day).
Important: Do not gain or lose weight drastically as it can cause changes in the abdomen's structure and the stoma's diameter, requiring a new stoma care equipment adjustment.
Important: Consult the hospital's dietitian and the community's stoma care nurse.
How to Deal with:
Constipation:
Constipation is defined as the absence of bowel movement for 2-3 days.
A colostomy does not prevent constipation.
Constipation is more common in colostomy patients located in the lower part of the large intestine.
Causes of constipation:
• Drinking small amounts of fluids
• Unbalanced diet with low dietary fiber
• Eating small amounts of food
• Medications:
Pain-relieving medications (opioids)
Certain chemotherapy treatments
• Lack of physical activity.
Preventive Treatment for Constipation:
• Increase fluid intake – between 1.5-2 liters per day.
• Balanced diet with dietary fiber.
• Drink 2-3 cups of lukewarm water on an empty stomach in the morning, soaked dry figs in water overnight
• Regular physical activity.
If you are taking medications or natural remedies to treat constipation before the surgery, do not continue taking them without consulting with your healthcare provider or stoma care nurse.
Important: Any pain treatment (in any form) requires advice and guidance from a doctor or stoma care nurse regarding treatment to prevent constipation.
Important: In the case of severe constipation accompanied by severe abdominal pain, bloating around the abdomen or stoma, nausea, vomiting, and liquid output through the stoma without a stool, seek medical attention at the hospital.
Diarrhea:
Diarrhea is defined as frequent and watery bowel movements.
Causes of diarrhea:
- Food sensitivity
- Contaminated food
- Inflammatory bowel disease, viral/bacterial infections
- Medication treatments such as antibiotics or chemotherapy
- Radiation therapy
- Stress, tension, or excitement
If you have diarrhea, you should empty the pouch frequently and seek treatment accordingly based on the cause of the diarrhea.
If you experience diarrhea for more than 24 hours, consult a doctor.
If you are undergoing antibiotic or chemotherapy treatment, consult your treating physician. (When taking antibiotics, it is recommended to add probiotic yogurt).
During diarrhea, the body loses fluids and electrolytes (sodium, potassium), and there is a risk of dehydration. Therefore, it is crucial to drink plenty of fluids. Drinking tap water (mineral water sold in bottles is low in sodium) is recommended. You can also use rehydration powders containing salts and minerals. Dissolve these powders in water.
Eat binding foods such as rice, pasta, potatoes, and bananas (see the attached table).
The use of medications for diarrhea treatment should only be done after consulting a doctor.
If the following symptoms occur or some of them indicate dehydration, consult a doctor: dryness in the mouth and tongue, increased thirst, abdominal pain, distortions, concentrated urine, decreased urine, accompanied by weakness, excessive fatigue, and dizziness, especially when standing.
Gas/Odor:
Gas in the intestines is a natural byproduct of the digestive process. During the initial period after the surgery, you may experience increased gas activity, which will reduce as the healing process progresses, and you return to a balanced and regular diet.
To reduce gas:
- Avoid unnecessary air swallowing:
Chew slowly and keep your mouth closed.
Do not drink through a straw.
Reduce chewing gum and smoking.
Avoid carbonated beverages. - Eat meals at regular times and frequently.
An empty bowel produces gas.
Reduce the intake of foods that cause gas (see the table). - To reduce gas sounds, apply gentle pressure on the stoma during air release.
The average time between eating gas-producing foods and the passage of gas through the stoma is about 6 hours.
The best way to prevent odors is to maintain skin hygiene, and clean the skin barrier, and pouch promptly when you notice an odor originating from stool leakage.
The stoma equipment in use is of very high quality. The pouch has an inner lining that repels odors and contains a charcoal filter that absorbs gas and odors. The only times you will be exposed to the odor of stool are during emptying or changing the pouch or the skin barrier. You can also use deodorizing products – consult with the stoma nurse about this.
Colostomy Irrigation:
Colostomy irrigation is not intended to treat constipation. Colostomy irrigation requires medical instruction. Colostomy irrigation has special equipment, and instruction for irrigation is given by a stoma care nurse.
Pancaking - פנקיק'ס:
Pancaking is a condition in which stool remains at the stoma's entrance, not entering the ostomy bag, leading to leakage of stool around the skin barrier. This situation can also irritate the skin surrounding the stoma.
Treatment:
- Objective - Softening the stool by:
Increasing fluid intake (1.5 - 2 liters per day).
Making dietary changes (increase dietary fiber). - Lubricate the stoma and the ostomy bag's opening generously with lubricant fluid (baby oil can also be used). The aim is to allow the stool to come into contact with the lubricant material and slide into the bag.
- Use a stoma belt to hold the skin barrier close to the abdominal wall.
Rectal Discharge:
In surgeries where a stoma is created while the rectum (the last part of the large intestine) remains in place, occasional rectal discharge may occur through the anal ring. This discharge is the natural function of the intestine. If there is a sensation of pressure through the anal ring, it is recommended to use the restroom and try to pass the discharge. Sometimes, the discharge may become difficult to pass on its own. In such cases, a small enema (micro laxative) may be used through the anal ring, or glycerin suppositories may be used to release the obstructed discharge. If the sensation of pressure does not subside, consult a doctor to rule out other causes of the discomfort.
Hernia:
A hernia in the abdominal wall develops due to weakness in the layer that covers the abdominal cavity beneath the muscle envelope. When weakness develops, the abdominal contents (usually the intestine) can protrude through the weak area, creating a bulge under the skin. The bulge is most noticeable when there is pressure on the abdomen, such as during coughing, laughing, or standing. Weakness in the abdominal muscles adjacent to the stoma can lead to a bulge around the stoma and cause a hernia. Hernias can develop over weeks, months, or even years. They are common in older individuals, people who are overweight, smokers, those who previously underwent hernia repair, and individuals with weak abdominal muscles.
During the three months after the surgery, avoid lifting heavy objects, engaging in exercises to strengthen the abdominal muscles, and vigorous physical activities. This allows the surgical wound to heal properly. There are specialized abdominal belts that provide stability and support for the abdomen and the hernia. These belts have a special opening for the stoma. Consult with the surgeon and the stoma nurse for the appropriate use of an abdominal belt. If a hernia develops around the stoma, consult with a stoma nurse for proper stoma care equipment adaptation and correct skin care around the stoma.
Before Discharge:
Before your discharge, a stoma nurse from the hospital will get in touch with the community's healthcare provider associated with your health fund and connect you with the community's stoma nurse. The community's stoma nurse will accompany, guide, and answer your questions.
It is essential to inform your family doctor and the healthcare provider about the surgery you underwent.
When to Contact the Community's Stoma Nurse or Hospital's Stoma Nurse:
• If there is a change in the stoma's diameter and size.
• If there are persistent stool leaks around the skin barrier.
• If there is irritation on the skin surrounding the stoma (burning, rash, redness).
• If there are issues with obtaining stoma care equipment.
• If you want to switch stoma care equipment to another company's products.
• For encouragement and attentive listening.
When to go to the clinic:
• When there is a change in the color of the stoma (e.g., black stoma).
• When there is severe pain around the stoma, accompanied by nausea and vomiting, and no output for several hours.
• When there is excessive and continuous leakage around or from the stoma.
General recommendations:
Clothing:
For colostomy patients, there are no clothing restrictions. You can wear anything comfortable and suitable as long as it doesn't put pressure on the stoma, such as tight belts. You may use special abdominal belts with an opening for the stoma. These belts support the abdominal muscles and protect the skin (consult with a stoma nurse before purchasing).
Bathing:
Showering is possible with a skin barrier and the bag. You can also shower without them when the stoma is exposed and while the bowel is inactive. Make sure that water does not enter the stoma as it can be harmful. Use soap that is non-greasy and non-moisturizing. Avoid using very hot water and direct water flow on the stoma. Swimming in the sea or a pool is allowed after three months following the surgery, and you can use waterproof adhesive tape to reinforce the base of the bag. It's recommended to empty the bag before entering the water. Avoid swimming in the Dead Sea.
Hair Removal:
You can remove hair around the stoma using various methods: sharp scissors, an electric shaver (preferred method), specialized cream, or a shaving knife on dry skin (shave in the direction of hair growth, gently, without harming the stoma or skin).
Physical Activity:
During the first three months after surgery, avoid lifting heavy weights, doing exercises that strain the abdominal muscles, and engaging in vigorous physical activities (light walking is allowed). Gradually return to your previous activities and hobbies according to your ability. It is advisable to use a supportive belt and be cautious with contact sports to avoid injury to the stoma.
Work:
Returning to work will depend on your doctor's instructions. People engaged in physical or strenuous work that requires lifting heavy weights should use a supporting belt for up to a year after surgery.
Driving:
There is no restriction on driving. Remember to wear a seatbelt and make sure it doesn't put pressure on the stoma.
Traveling:
With some planning, you can travel and enjoy any destination:
• Consider the amount of equipment you'll need for the trip, including additional supplies for unexpected leaks.
• If traveling abroad, get a prescription specifying the equipment you use in the local language. Find out where you can get these supplies at the destination.
• Avoid placing stoma equipment in the airplane overhead bin as extreme temperatures may damage it.
• In places where the water is not safe for drinking, avoid washing the stoma with it.
• You can obtain a special border-crossing card for colostomy patients through cancer organizations and stoma equipment companies. For more information on traveling abroad, visit the international organization for colostomy patients' website.
Intimacy:
Returning to sexual activity should be gradual and considerate of your and your partner's feelings and concerns. Negative emotions are normal during the process of accepting the stoma. Intimacy does not harm the surgery or the stoma itself. After creating the stoma, sexual function may temporarily be affected due to emotional or physiological factors. Sensation and sensitivity to touch are not affected. The key to success is support, understanding, and good communication between partners. Support and advice on intimacy and body image are available from the stoma nurse.
Social Support:
Sometimes, after the surgery, patients and their families may face difficulties in self-care and performing basic daily activities. Social workers can help in examining your rights and the services available in your situation. Additional information can be obtained from the National Insurance Institute in your area and the Stoma Association in Israel.
Talking about the Stoma:
Each individual can choose when, to whom, and what to tell about the surgery and their stoma. If you have children, answer them with a simple and honest response. Sometimes, they may want to see the stoma and bag. Discussing the surgery will help alleviate their fear and anxiety. Children will accept the stoma as you do, with your attitude towards it. It is essential to participate in support groups and share common experiences (see websites at the end of the guide). You can also talk or meet with a patient who has a stoma before or after the surgery with the help of the stoma nurse.
Religious Observance and Colostomy - Frequently Asked Questions:
Prayer: There is no prohibition against praying with a stoma. It's recommended to empty the bag before praying and make sure that there are no visible remnants of feces on the equipment.
Asher Yatzar blessing: The blessing should not be recited after defecation. When going to the bathroom for urination, one may intend the blessing also for defecation (response by the Institute for Medicine and Halacha, Rabbi Weiner).
Mikveh (Ritual Immersion): There is no prohibition against immersing in a mikveh (ritual bath) with a stoma.
- Men: Men may immerse in all the equipment, including the skin barrier and bag (there is no concern for squeezing).
- Women: Women may immerse without the skin barrier and bag if the stoma is exposed and agreed upon with the balanit (immersion supervisor). Detailed guidance and directions will be provided by the stoma nurse.
Passover (Pesach): You are allowed to eat matzah during Passover, but be aware that excessive consumption may cause constipation. It is essential to drink plenty of fluids. For further questions, refer to the websites at the end of the guide.
Training Page – Written and Edited by Yochi Kand, RN, MA, Stoma Coordinator, Shaare Zedek Medical Center, Jerusalem. For any inquiries, you can contact me on weekdays from Sunday to Thursday, in the morning hours, at Tel: 050-8685853; Email: yochikand@szmc.org.il. For assistance and advice related to this training, you can reach Deborah Margalit, General Surgery Department, at Tel: 02-6555569, 02-6555769, at any time.
Examples of the Influence of Food Types and Medication on Stoma Output:
Factors that thicken/harden the stool:
Bananas
Rice
Bread
Peanut butter
Applesauce
Yogurt
Pasta
Bagels
Figs
Factors that cause loose stool and increased bowel movements:
Spicy foods
Fried foods or those high in fat
Chocolate
Fresh fruits like apricots, grape juice, and grapes
Dried fruits like prunes, figs, and dates
Legumes
Leafy green vegetables (lettuce, broccoli, Swiss chard, etc.)
Beer, alcohol, caffeinated beverages, tea, cola, coffee
Factors that affect stool odor:
Fish
Eggs
Asparagus
Garlic
Some spices (curry, cumin, caraway)
Beans
Leeks
Cruciferous vegetables (onion, cabbage, cauliflower, broccoli, wheat sprouts)
Hard cheeses
Vitamins, antibiotics
Factors that reduce stool odor:
Yogurt
Parsley
Mint
Orange juice
Ginger
Cinnamon
Cumin
Herbal teas: chamomile, mint
Factors that cause gas:
Beer, carbonated drinks
Milk, dairy products, especially in lactose-intolerant individuals
Soybeans
Cucumbers, squash, zucchini
Radishes, turnips, corn
Nuts
Legumes (peas)
Factors that affect stool color:
Beets
Red jelly
Strawberries
Tomato juice
Food colorings
Iron supplements
High-fiber foods (barley, celery stalks, mushrooms)
Coconut, pineapple
Potatoes with skin, apples, oranges, onions, cabbage, broccoli, wheat sprouts, cooked beets
Examples of foods to avoid eating:
Persimmons (not allowed)
Caffeine (increases bowel movements)
Hot beverages
Hot soup
Cooked vegetables
Fresh fruits
Fruit juice
Drinking 1.5-2 liters of fluids per day
Soaked dried apricots
Useful addresses and websites for additional information:
Israel Ostomy Association
The Cancer Society operates the Israel Ostomy Association, providing guidance, counseling, and support for patients and their families.
Registration is possible to become a member of the Israel Ostomy Association, which includes a subscription to the organization's journal, "Pitchoon Peh."
The Cancer Society:
Information: 1-800-599-995
Silvia: 03-5721618
Address: Beit Mati, 7 Revivim Street, P.O. Box 437, Givatayim 53103
Email: youngostomy@nana.co.il - Young people with stomas.
Stoma Support Forum
Forum administrators: Yael and Hodaya
Service and consultation on sexuality, fertility, and body image
Provided by the Cancer Society's Sexuality Consultation Nurse, free of charge, by prior arrangement, without the need for a medical referral (please leave a voicemail with your details).
Sexuality Consultation Nurse – 03-5721643
Secretary – 03-5721618
International Ostomy Association
The official website of the International Ostomy Association includes information about ostomy organizations worldwide, addresses, and contacts. It is essential to visit this site before traveling abroad.
Stoma equipment companies in Israel:
In Israel, stoma equipment from three leading companies is marketed:
Hollister - 1-800-30-68-68
Coloplast - 1-800-69-69-68
Convatec - 1-800-800-150
Stoma and Halacha (Jewish religious law)
For questions related to stoma and Jewish religious law, you can contact the Schlesinger Institute - Institute for Research in Medicine According to Halacha, next to Shaare Zedek Medical Center, via email: irp@medethics.org.il, or Rabbi Weiner at the Institute for Medicine and Halacha via email: info@j-c-r.org.