Muslim End of Life Care QA

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by Dr. Reshma Khan

 

1) Thinking about care at the end of life, what is important and valued in your community?

End-of-life care is defined as "the active, total care of patients whose disease is not responsive to

Curative treatment. The philosophy of this care is to attain maximal quality of life through control of the myriad physical, psychological, social, and spiritual distress of the patient and the family.

Certainly, a good care for dying patients encompasses attention to spiritual issues at the end of life.

Some quotes from the Quran

Ø The origin of death: change of state when Adam and Eve ate from the forbidden tree, even though they were forgiven: “In the earth you will live, and in it you will die.” Qur’an 7:24

Ø The will of God: “It is not possible for a soul to die except with the permission of God at a term set down on record.” Qur’an 3:139

Ø “When their time comes they cannot delay it for a single hour nor can they bring it forward by a single hour.” Qur'an 16:61

Ø The only guarantee that comes along with birth is death. “To God we belong and to Him is our return” Qur’an 2:156

Spiritual care is an important and integral component of the comprehensive care given. My thoughts are not applicable to each and every patient as each patient is unique.

Indeed, not only do the schools of thought vary, but also the level of observance may vary considerably among patients within the same school of thought.

Muslims believe in divine predestination and attribute the occurrence of pleasure and suffering to the will of Allah.

They generally perceive suf­fering as a way of atonement for one’s sins, as the Prophet (pbuh) said, “No fatigue, no disease, nor sorrow, nor sadness, nor hurt, nor distress befalls a Muslim, even if it were the prick he receives from a thorn, but Allah expiates some of his sins for that.

This interpretation helps patients and families to cope with serious and life-limiting ill­nesses. However, it does not belittle the fact that every effort should be made to relieve suffering. Islamic teachings consider the relief of suffering of man and animal to be highly virtuous

2) Are there rituals or customs that are an important part of end of life care in your community?

In terms of treatment options, Muslim patients re­sort to modern medicine, spiritual healing, and traditional healing practices. The spiritual heal­ing practices include recitation of verses of the Noble Quran, supplications taught by our Prophet (PBUH), drinking of the zamzam water obtained from the well in Makah in Saudi Arabia is also widely practiced. Keeping up with the prayers till the end and facing the Kaba at all times if possible

3) What expectations does your community have of medical caregivers for end of life care?

Let’s start with simple things and then go towards more complex issues

Scripture;

To support psychological and spiritual health and healing, it is widely believed that reading and reciting the Qur'an brings blessings to those who are spiritually and psychologically distressed; therefore, providing a copy of the Qur'an to Muslim patients is helpful

Prayers

The clothes and body of the patient must be free from any amount of urine,

Vomit, stool or pus or any bodily secretions or with any of these substances will render the patient ritually unclean and, therefore, unable to perform prayers.

This is where the nursing staff can be of great help in helping maintain this purity.

The patient is exempted from this requirement only when it becomes very difficult to fulfill. ­­For patients who cannot perform ritual wash­ing before prayers, it is permissible to perform Tayammum, which involves touching clean sand with both palms and gently sweeping them over the face and back of the hands. Prepacked sterilized Tayammum sets are commercially produced but not yet widely available

Every prayer takes about 5–10 minutes and the patients are required to face toward the Ka’abah (the cubical building built by the Prophet Abraham [pbuh] inside the Holy Mosque in Makkah) during the prayers

Prayer at end of life helps Muslims to seek forgiveness, feel closer to God, accept their mortality, and prepare for death or the afterlife.

Prayers, once begun, cannot be interrupted. This can create problems in health care facilities as health care providers may inadvertently enter a patient’s room when they are praying and misinterpret the lack of a response from the patient.

Diet:

Muslims avoid eating pork or drinking alcohol, and are proscribed from taking medicines that contain alcohol or pork byproducts unless they are life-saving drugs and no substitute is available. Usually at a time of necessity Muslims follow the general rule that “necessity dictates exception

Porcine heparin, for example, contains gelatin from pork products, and is the only heparin universally used. That was thought to cause a potential problem for Jewish, Muslim, and Seventh-day Adventist patients

Since January 2006, pork insulin for human use has no longer been manufactured or marketed in the U.S.

( http://www.fda.gov/CDER/drug/beefandporkinsulin/default.htm

In hospices it is helpful to pay attention to pork product usage in the daily food menu for Muslim patients. It is also recommended to inform the patient about medications that contain alcohol.

Today, with the mechanized slaying methods that are disapproved of by Islamic teachings (eg, electric shocking), many observant Muslims will not eat meat that is slaughtered by this method.There are no restrictions on seafood or vegetables. Patients

Special Month of Ramadan.

With advanced and incurable diseases the patient can feed a person for every fast missed but some patients may insist on fasting in the month in these cases, a Muslim chaplain or an Imam may be helpful to encourage and negotiate an alms giving alternative that reduces potential physical weakening



Muslim Women

Whenever a male healthcare provider cares for a female patient, he should always be joined by a female staff member or have the patient attended by one of her adult rela­tives. Exposure of the patient’s body parts should be limited to the minimum necessary, and permission should be asked before gently uncovering any part of the body.

Avoidance of eye contact between a female patient and a male healthcare provider should not be misinterpreted as lack of trust or a sign of rejection but rather as a common sign of modesty in this patient population

Now to the more complex issues

The guiding principle in Islamic medical ethics which is mentioned in Quran and also in the Torah is, "If anyone has saved a life, it would be as if he has saved the life of the whole of mankind."

However, the question that we are faced with, in terms of saving life, is at what cost and what quality. Does the quality of life modify our decision-making process and when resources are scarce, who takes precedence, the individual or the community?

In the question of the right to live or die, the question is should one prolong the life or the misery.

Who determines (the unconscious patient, the family, or the doctor), that the plug should be pulled and the life support system stopped?

What is the definition of death, acceptable to both the medical technology and Islamic jurists?

Is a living will justified?

Is stopping the life support system an act of mercy, a medical decision, a murder, or a financial decision?

What about DNR (Do not resuscitate)?

What about Organ transplants and organ donation?

How to handle after death issues including autopsy and Embalming?

Islamic code of medical ethics

Islam has a parsimonious and rigorously defined ethical theory of Islam based on the 5 purposes of the Law, maqasid al shari’at.

The five purposes are preservation of din, life, progeny, intellect, and wealth. Any medical action must fulfill one of the above purposes if it is to be considered ethical

Some of the rules of Islamic medical ethics are

1) Necessity overrides prohibition that is if there are certain items which are islamically prohibited, under dire necessity they can become permissible.

2) Accept the lesser of the two harms if both cannot be avoided.

3) Public interest overrides the individual interest.

4) Harm has to be removed at every cost if possible.

Islamic Medical Ethics also upholds the four basic principles of biomedical ethics which are 1) Respect for the autonomy, 2) Beneficence, 3) Nonmaleficence, and 4) Distributive Justice

Muslims believe that death does not happen except by God’s permission; “It is not given to any soul to die, save by the leave of God, at an appointed time” (Holy

Quran 3:145).

There is no immunity in Islamic law for the physician who unilaterally and actively decides to assist a patient to die; but delaying the inevitable death of a patient through life-sustaining treatment is neither in the patient’s nor the public’s best interests because of limited financial resources. Withdrawal of life sustaining treatments in such instances is seen as allowing death to take its natural course.

The common belief is that death is the termination of all organ functions. In 1986, at the third International Conference of Islamic Jurists in Amman, Jordan, a fatwa was issued that “equated brain death to cardiac and respiratory death.” This ruling accelerates and facilitates the process for organ transplantation

Since death is viewed as a process that bridges the soul's existence from one life to the next, it is acceptable to discontinue the use of life support equipment that prolongs the life of a patient. In medically-futile situations, in which life support equipment is used to prolong organ functions, the condition needs to be carefully explained to the family so they do not mistake DNR orders with euthanasia.

Reference for aboveThe Islamic Code of Medical Ethics states, "it is futile to diligently keep the patient in a vegetative state by heroic means ... It is the process of life that the doctor aims to maintain, and not the process of dying" (Islamic Organization of Medical Sciences, 1981). Therefore, a clinician may stop interventions that artificially prolong life without hope for a cure, while continuing to treat the patient's pain as long as the patient and/or family desire (UNN Islamic Society, 1999a).

Under such conditions, however, the basic human rights of hydration, nutrition, nursing and pain relief cannot be withheld. These may be carried out at home or in an institution as the case warrants.

Medication realated Sedation

In the Islamic perspective, medication-related sedation could be looked at from two different angles. On the one hand, alleviation of the suffering of a human being is considered very righteous. On the other hand, maintaining a level of conscious­ness as close to normal as possible is of great importance to allow for observance of the worship rites for the longest period pos­sible before death. In terminally ill patients, it may be difficult to maintain a state of equilibrium allowing for optimal symptom control and a normal level of consciousness. In these situations, the pros and cons should be clarified to the patient and family, who may prefer to endure a slightly higher degree of symptoms in order to maintain a better level of consciousness

Transplants

Since there are no specific codes on transplant and organ donation in the Shari'ah, there are different approaches to treatment. Most Muslim jurists and their followers accept organ donations because it is in harmony with the Islamic principle of saving lives

The following requirements should be met before transplantation: (1) a transplant is the only form of treatment available; (2) the likelihood of success is high; (3) the consent of the donor or next of kin is obtained; (4) the death of the donor has been established by a Muslim doctor; (5) there is no imminent danger to the life of a living donor; and (6) the recipient has been informed of the operation and its arrangement for ritual body wash

Quadri, K. H. (2004). Ethics of organ transplantation: An islamic perspective. Saudi Journal of Kidney Diseases and Transplantation : An Official Publication of the Saudi Center for Organ Transplantation, Saudi Arabia, 15 (4), 429-432.

Advanced directive

IMANA ( Islamic Medical Association of North America) recommends all Muslims to have a “living will”, “advance directive” and a case manager for their care, to help physicians to know the wishes of patient, when he or she is unable to give directions (i.e. in a coma). A sample of such proposed living will is provided which can be modified by the patient after consulting with family and attorney. (Ref: JIMA: Vol.29:1997

Autopsy and handling the deceased

The Muslim family expects the body of the deceased to be handled in a dignified manner and as gently as possible, be­cause the sanctity of the dead person is considered the same as the living. Therefore, Islam forbids cremation and, further­more, prohibits walking or sitting on a grave once death is pro­nounced, the rites of washing, shrouding, funeral prayers, and burial should follow as soon as possible. In addition to express­ing empathy, the major role of the healthcare team at this stage is timely documentation to prevent any unnecessary de­lay in proceeding with funeral rites. Condolences to the family

Autopsy is not permissible except when deemed necessary for legal or community health reasons.

What issues does your community have with end of life care as you experience it now in the healthcare system?

Euthanasia is not allowed in Islamic law. Human life is considered a sacred value, given by God, and to be taken only by God (with few exceptions). The Quran states, "If anyone slays a person ... it would be as if he slew the whole people. And if anyone saved a life, it would be as if he saved the life of the whole people" (Quran 5:32). Suicide is forbidden in Islamic law as a crime and a grave sin, met with eternal suffering. Similarly, mercy killing has no place in Islam.

Embalming and cremation are forbidden in Islam; therefore, the families try to bury their loved ones before the body decays

For Muslims, talking to an Islamic spiritual care provider about God, the afterlife and prayers may be helpful at the dying stage. But for hospitalized patients this is not always easy. “Most hospitals have chaplains and they are available around the clock. But, chaplains are predominantly trained in the Christian paradigm,” Very few hospitals have Muslim chaplains

What hopes would you have for end of life care based on your own hopes and your community’s?

For myself I would have the hope of attention to my whole self with respect & compassion, rather than focusing narrowly on bodily functions & lab tests. All interventions used should be to enhance the dignity & autonomy & to increase the amount of enjoyable time that remains, best in familiar surroundings where I may best experience the love of family & friends

To be afforded dignity and privacy and have control over pain relief and other symptom control. To have access to any spiritual need and be able to keep up with my prayers at all time.

To have the time to say good bye and be able to leave when it is time to go and not to have life prolonged pointlessly


Jihad is a Peaceful Struggle

It is true that jihad is one of the most important teachings of Islam. But jihad is not synonymous with war. In Islam another word is used for war and fighting. This word is ‘qital.’ When the Qur’an refers to war or fighting, it uses the word qital and not jihad.

Jihad literally means to strive or to struggle. So jihad actually means peaceful struggle, especially for da‘wah work. The Qur’an says:

Do great jihad with the help of the Qur’an. (25:52)

The Qur’an is simply a book, and not a sword, so “do great jihad with the Qur’an” means do great jihad with the ideological power of the Qur’an. In fact, jihad is only another name for peaceful activism. And peaceful activism is the only weapon by which Islam wants to achieve all its aims and objectives.

The Qur’an has this to say of the mission of the Prophet Muhammad:

We have not sent you forth but as a mercy to mankind. (21:107)

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Main Articles of Islamic Faith

A true, faithful Muslim believes in the following main articles of faith:

1. He believes in One God, Supreme and Eternal, Infinite and Mighty, Merciful and Compassionate, Creator and Provider. This belief, in order to be effective, requires complete trust and hope in God, submission to His Will and reliance on His aid. It secures man's dignity and saves him from fear and despair, from guilt and confusion. The reader is invited to see the meaning of Islam as explained above.

2. He believes in all the messengers of God without any discrimination among them. Every known nation had a warner or messenger from God. These messengers were great teachers of the good and true champions of the right. They were chosen by God to teach mankind and deliver His Divine message. They were sent at different times of history and every known nation had one messenger or more. During certain periods two or more messengers were sent by God at the same time to the same nation. The Holy Qur'an mentions the names of twenty-five of them, and the Muslim believes in them all and accepts them as authorized messengers of God. They were, with the exception of Muhammad, known as "national" or local messengers. But their message, their religion, was basically the same and was called ISLAM, because it came from One and the Same Source, namely, God, to serve one and the same purpose, and that is to guide humanity to the Straight Path of God. All the messengers with no exception whatsoever were mortals, human beings, endowed with Divine revelation, and appointed by God to perform certain tasks. Among them Muhammad stands as the Last Messenger and the crowning glory of the foundation of prophethood. This is not an arbitrary attitude, nor is it just a convenient belief. Like all the other Islamic beliefs, it is an authentic and logical truth. Also, it may be useful to mention here the names of some of the great messengers like Noah and Abraham, Ishmael and Moses, Jesus and Muhammad, may the peace and blessings of God be upon them all. The Qur’an commands the Muslims thus:

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Three Strange Events when Moses Met Khadir

Narrated Ubai bin Ka'b:

The Prophet (s.a.a.w.) said, "Once the Prophet Moses (peace be on him) stood up and addressed Bani Israel. He was asked, "Who is the most learned man amongst the people. He said, "I am the most learned." Allah admonished Moses as he did not attribute absolute knowledge to Him (Allah). So Allah inspired to him "At the junction of the two seas there is a slave amongst my slaves who is more learned than you." Moses said, "O my Lord! How can I meet him?" Allah said: Take a fish in a large basket (and proceed) and you will find him at the place where you will lose the fish. So Moses set out along with his (servant) boy, Yusha' bin Nuin and carried a fish in a large basket till they reached a rock, where they laid their heads (i.e. lay down) and slept. " (based on Sahih Bukhari, Volume 1, Book 3, Number 124)

The story is mentioned in the Holy Quran as follows:

018.060  Behold, Moses said to his attendant, "I will not give up until I reach the
junction of the two seas or (until) I spend years and years in travel."

018.061  But when they reached the Junction, they forgot (about) their Fish, which
took its course through the sea (straight) as in a tunnel.

018.062  When they had passed on (some distance), Moses said to his attendant:
"Bring us our early meal; truly we have suffered much fatigue at this (stage of) our
journey."

018.063  He replied: "Sawest thou (what happened) when we betook ourselves to the rock? I did indeed forget (about) the Fish: none but Satan made me forget to tell (you) about it: it took its course through the sea in a marvellous way!"

018.064  Moses said: "That was what we were seeking after:" So they went back on
their footsteps, following (the path they had come).

018.065  So they found one of Our servants, on whom We had bestowed Mercy from
Ourselves and whom We had taught knowledge from Our own Presence.

018.066  Moses said to him: "May I follow thee, on the footing that thou teach me
something of the (Higher) Truth which thou hast been taught?"

018.067  (The other) said: "Verily thou wilt not be able to have patience with me!"

018.068  "And how canst thou have patience about things about which thy
understanding is not complete?"

018.069  Moses said: "Thou wilt find me, if God so will, (truly) patient: nor shall I
disobey thee in aught."

018.070  The other said: "If then thou wouldst follow me, ask me no questions about
anything until I myself speak to thee concerning it."

018.071  So they both proceeded: until, when they were in the boat, he scuttled it.
Said Moses: "Hast thou scuttled it in order to drown those in it? Truly a strange thing hast thou done!"

018.072  He answered: "Did I not tell thee that thou canst have no patience with me?"

018.073  Moses said: "Rebuke me not for forgetting, nor grieve me by raising
difficulties in my case."

018.074  Then they proceeded: until, when they met a young man, he slew him.
Moses said: "Hast thou slain an innocent person who had slain none? Truly a foul
(unheard of) thing hast thou done!"

018.075  He answered: "Did I not tell thee that thou canst have no patience with me?"

018.076  (Moses) said: "If ever I ask thee about anything after this, keep me not in thy company: then wouldst thou have received (full) excuse from my side."

018.077  Then they proceeded: until, when they came to the inhabitants of a town,
they asked them for food, but they refused them hospitality. They found there a wall
on the point of falling down, but he set it up straight. (Moses) said: "If thou hadst
wished, surely thou couldst have exacted some recompense for it!"

018.078  He answered: "This is the parting between me and thee: now will I tell thee
the interpretation of (those things) over which thou wast unable to hold patience.

018.079  "As for the boat, it belonged to certain men in dire want: they plied on the
water: I but wished to render it unserviceable, for there was after them a certain king who seized on every boat by force.

018.080  "As for the youth, his parents were people of Faith, and we feared that he
would grieve them by obstinate rebellion and ingratitude (to God and man).

018.081  "So we desired that their Lord would give them in exchange (a son) better in purity (of conduct) and closer in affection.

018.082  "As for the wall, it belonged to two youths, orphans, in the Town; there was, beneath it, a buried treasure, to which they were entitled: their father had been a righteous man: So thy Lord desired that they should attain their age of full strength and get out their treasure - a mercy (and favour) from thy Lord. I did it not of my own accord. Such is the interpretation of (those things) over which thou wast unable to hold patience."

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