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


Islamic Concept of God

It is a known fact that every language has one or more terms that are used in reference to God and sometimes to lesser deities. This is not the case with Allah. Allah is the personal name of the One true God. Nothing else can be called Allah. The term has no plural or gender. This shows its uniqueness when compared with the word god which can be made plural, gods, or feminine, goddess. It is interesting to notice that Allah is the personal name of God in Aramaic, the language of Jesus and a sister language of Arabic. The One true God is a reflection of the unique concept that Islam associates with God. To a Muslim, Allah is the Almighty, Creator and Sustainer of the universe, Who is similar to nothing and nothing is comparable to Him. The Prophet Muhammad was asked by his contemporaries about Allah; the answer came directly from God Himself in the form of a short chapter of the Quran, which is considered the essence of the unity or the motto of monotheism. This is chapter 112 which reads:

"In the name of God, the Merciful, the Compassionate. Say (O Muhammad) He is God the One God, the Everlasting Refuge, who has not begotten, nor has been begotten, and equal to Him is not anyone."

Read more...

Allah Creates a Vicegerent

The creation of Adam by Allah T'ala is mentioned several places in the Holy Quran. The first narration appears in Chapter 2 (Surah Al-Baqarah) as follows:
2.029  It is He Who hath created for you all things that are on earth; Moreover His 
design comprehended the heavens, for He gave order and perfection to the seven 
firmaments; and of all things He hath perfect knowledge.
2.030  Behold, thy Lord said to the angels: "I will create a vicegerent on earth." 
They said: "Wilt Thou place therein one who will make mischief therein and shed 
blood?- whilst we do celebrate Thy praises and glorify Thy holy (name)?" He said: "I 
know what ye know not."
2.031  And He taught Adam the nature of all things; then He placed them before 
the angels, and said: "Tell me the nature of these if ye are right."
2.032  They said: "Glory to Thee, of knowledge We have none, save what Thou 
Hast taught us: In truth it is Thou Who art perfect in knowledge and wisdom."
2.033  He said: "O Adam! Tell them their natures." When he had told them, God 
said: "Did I not tell you that I know the secrets of heaven and earth, and I know what 
ye reveal and what ye conceal?"

Read more...

Aishah bint Abi Bakr

Aishah (may Allah be pleased with her)

wife of the Prophet, mother of the believers,
the greatest Muslim woman scholar

The life of Aishah is proof that a woman can be far more learned than men and that she can be the teacher of scholars and experts. Her life is also proof that a woman can exert influence over men and women and provide them with inspiration and leadership. Her life is also proof that the same woman can be totally feminine and be a source of pleasure, joy and comfort to her husband.

She did not graduate from any university there were no universities as such in her day. But still her utterances are studied in faculties of literature, her legal pronouncements are studied in colleges of law and her life and works are studied and researched by students and teachers of Muslim history as they have been for over a thousand years.

The bulk of her vast treasure of knowledge was obtained while she was still quite young. In her early childhood she was brought up by her father who was greatly liked and respected for he was a man of wide knowledge, gentle manners and an agreeable presence. Moreover he was the closest friend of the noble Prophet who was a frequent visitor to their home since the very early days of his mission.

Read more...

Attributes of Allah

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Islamic Caligraphy

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Islamic Architecture

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Natural Beauty

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