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Care of the Muslim Patient SQNLDR (rtd) Hyder Guam FRCNA

Registered Nurse (UK), Accredited Mediator, Barrister and Solicitor BA, BN, LLB, LLM, MBA, Masters in Islamic Studies, RN (UK)

Principles of Bio-Ethics �  In Islam, life is nothing short of a miracle, from the galactic stars to

the smallest of living organisms. Although Islam treats the life of all creatures as valuable, it gives greater honour to human life. Knowledge of these Maqasid of Shariah, that is the higher objectives, can certainly go a long way to relieving some of the doubt and confusion

�  Scholars generally describe Maqasid as the major objectives of Shariah such as the preservation of religion, human life, progeny, material wealth and human reason. Islamic law aims to preserve essential and other interests by preserving their existence and also protecting them from annihilation.

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Principles of Bio-Ethics - cont �  For every sickness and disease (except aging) God has already

created a cure. This means that scientific investigations and looking for treatment is encouraged.

�  Human life is sacred. The saving of one life is considered to be the same as saving the life of all of humanity. This means that effort ought to be made to save life, however this must not endanger others or be reckless.

�  God does not burden a soul greater than what it can bear. The plain understanding behind this is that we should not be overwhelmed by our illnesses, instead use the experience to strive towards piety and be thankful (shark) for all the gifts from Allah.

�  Necessity can remove a prohibition temporarily for as long as necessity is existing. This means that those things which are clearly prohibited, can be made permissible, such as their use in a medicine (i.e. alcohol) if there is no alternative, and for the period of the necessity.

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Principles of Bio-Ethics - cont �  Islam has made it an onus upon the sick to seek treatment. This

means that searching for a cure is a responsibility for the individual and the community.

�  When confronted with two evils, the lesser evil is preferred. This is not better explained that the utility of organ transplant, especially as a superior religious alternative than choosing to die – see the Fatwa by the Grand Mufti of Australia.

�  Everything in Islam is permissible unless otherwise proved otherwise by clear evidence. This means that Islam approves of most of the biological researches, which aim to benefit human life.

�  Our family and lineage should be protected. This is manifested by the permissibility of IVF within wedlock.

�  Actions will be judged according to intentions. Intention plays a critical role with all bioethical matters. This maxim is the cornerstone for judging actions generally.

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Aspects of General care

� Preservation of life overrides all matters presented in this seminar.

�  In life threatening situations, Islam allows exception to its rules.

�  Islam places the onus of practising religion on the individual.

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Aspects of General care

� Discuss religious observance needs with each patient.

� Cleanliness is part of Islamic faith. �  Strong emphasis is placed on the virtues of

visiting the sick. � Where choice exists, medicines containing

alcohol/pork derivates should NOT be used.

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Aspects of General care �  Same sex health professional as the patient whenever

possible. Unnecessary touching between non-related people of the opposite sex should be avoided.

�  For Muslim patients, there is an overriding objective of modesty and privacy. In some cases, a close family member of the same sex may assist in the washing of the sick person.

�  A beard is considered a very important religious symbol to the Muslim male patient. Like any other patient, permission must be obtained to shave any part of the beard, which should be done by a man.

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Birth �  Reversible contraception (ie pill, IUDs,

condoms) are not forbidden in Islam, but are regarded as undesirable.

�  Termination of pregnancy after 120 days is not permitted, unless there are very strong medical reasons.

�  If pregnancy constitutes a serious threat to the life of the mother, then an termination is permissible irrespective of the period of gestation.

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Birth (cont)

� Muslims consider foetus after the age of 120 days is a viable baby.

� The death of a fetus after 120 days after conception would require a burial - given to the parents for proper burial.

� After delivery, the placenta (which is part of the baby) should be offered to the parents for disposal.

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Birth (cont)

�  It is important for a newborn child to have a prayer call recited in each ear soon after birth. It is possible that the parents may want a learned person (an Imam, Mufti or Sheik) to perform this task.

�  It is a traditional religious observance to shave the head of newborn babies on the seventh day after birth, or thereabouts.

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Birth (cont) �  Circumcision is performed on all male children.

The timing of this varies, but it must be done before puberty.

�  Some cultures place a piece of date/honey in the mouth of the newborn – not recommended.

�  The practice of female genital mutilation not supported by the Islamic faith. It is illegal under Australian law, and has NO basis in religion.

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Administration of Medicines

�  Some medicines not suitable because they contain alcohol, porcine or non-halal ingredients.

� HCP should inform patients about the origins of the proposed medication.

�  See QLD Health Guidelines on Medicines.

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Cleanliness �  Ritual cleanliness before each prayer. �  Washing of hands before meals. �  Washing with water after urination/defecation. �  Removal or armpit and pubic hair. �  Trimmed and clean fingernails and nostrils kept

clean. �  Toilets should be equipped with a small

container for cleaning one’s private parts.

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Ramadan �  Compulsory for all healthy, adult Muslims. �  Pregnant, breastfeeding or menstruating woman,

sick, travellers are exempted. �  Following will not break a fast: �  Injections/blood tests, medications absorbed

thru the skin, and gargling. �  See Diabetes Australia guide for fasting Muslims.

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Mental Health

� A person diagnosed as having a cognitive dysfunction such as ID or a severe mental illness is absolved of all obligatory requirements in Islam.

� Patient’s family is usually responsible.

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Dying and Death �  Death is seen as something predestined by

God. It is not seen as a punishment from God, but rather a return to the Creator.

�  Families may thus appear inappropriately calm and accepting by Western standards.

�  In Islam, grieving is allowed for only three days (except that a widow may grieve for 4 months and 10 days).

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Death and Dying (cont) �  Because death is perceived as predestined by

Allah, Muslims disapprove of any medical care that may hasten the death of a patient, even for humane reasons.

�  If a patient is in a coma, it is preferred that the patient be turned to face Mecca (in Australia, roughly west-north-west), with the right shoulder also being towards Mecca.

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Dying and Death (cont) �  It is important for Muslims to recite the Quran

or prayers in front of the patient or in a room close by.

�  For a patient who has just died, the face and right shoulder of the deceased should be turned in the direction of Mecca.

�  The whole body of the deceased must be covered by a sheet and should be handled as little as possible. The body must be handled with the utmost respect only by a person of the same sex.

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Death and Dying (cont)

� A cross must never be placed on the body. The body should not be washed, as this will be done as part of a special religious ritual before burial.

� Muslim burials are performed as soon as possible after death, sometimes on the same day. Never cremated.

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Care of the Elderly

�  Elderly regarded with deep respect. �  Care of the elderly is regarded as an avenue to Heaven

“heaven found under the feet of one’s mother”. �  Home visits: remove shoes at entrance of house/carpeted

areas – nb OH&S.

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Autopsy

Sanctity Of The Body �  Respect for deceased �  Violation of the body �  Delay in burial

Hospital / Legal Requirements �  Documentation �  Greater good �  Legal obligations

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Autopsy - cont �  Major concerns of relatives: ◦  Respect for the deceased ◦  Delay in burial ◦  Permissibility

�  Permissible when: ◦  deemed necessary to establish cause of death ◦  significant public health interest ◦  required by law (suspicious circumstances, Coroner’s

case)

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Autopsy - cont

� Not accepted for routine documentation/curiosity

�  ICV is working with the Coroner’s Court to produce a fact sheet on autopsies

�  In the UK ‘Virtopsy’ (virtual autopsy) using MRI recently introduced

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End of Life

�  Once treatment has been intensified to save a patient’s life, life-saving equipment cannot be turned off unless the physicians are certain about the inevitability of death ◦  Islamic Juridical Council (meetings of jurists of different schools in

Mecca, Jeddah & Amman) �  Islamic law permits withdrawal of futile and disproportionate

treatment on the basis of consent of immediate family members who act on the professional advice of the physician in charge of the case

�  “It is the process of life that is to be preserved, not the process of death.” - Islamic Organisation for Medical Sciences Symposium

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Definition of Death �  If three attending physicians attest to a totally

damaged brain with: ◦  Unresponsive coma; ◦  Apnoea; and ◦  Absent cephalic reflexes,

the person is biologically dead. Islamic Juridical Council

è Agreed On The Universally Accepted Definition Of Brain Death Islamic Organization for Medical Sciences Symposium 1996

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Withdrawal of Treatment �  Challenge for ALL families: ◦  Confusion : is it euthanasia or withdrawal of futile

treatment? ◦  (Suicide and euthanasia are clearly forbidden in Islam) ◦  Many Muslims may not realise the permissibility of

treatment withdrawal in some cases. ◦  Some may question the inevitability of death (some

scholars have suggested the opinion of two doctors be sought). ◦  The decision to end the life of a loved one is difficult;

regardless of one’s religious or ethnic background.

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Blood and Organ Donation

� Muslims accept blood transfusions and transplants of various human organs.

�  It is acceptable for Muslims to donate blood and organs, as the saving of life is considered an act of great virtue.

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Assisted Reproductive Technologies

� Generally permitted � However, some techniques are not permitted: -  Use of donor sperm; -  Use of sperm that has been cryopreserved if

the father has died; -  Surrogacy is not permitted.

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Tips - Caring for Muslim patients �  Given the centrality of the family, consider

informing family of medical information, and to be involved in the decision-making process.

�  Use your right hand for care - as the left hand is used for washing after elimination.

�  Good communication - develop and maintain trust.

�  Beware the unconscious bias that we all have/ preconceived ideas: where my Mum arrived at a  hospital and an interpreter was organised before she had the chance to open her mouth, despite being fluent in over 6 languages including English J

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Tips (cont) �  Do not point the soles of the feet to the

patient. �  Consider Ramadan when prescribing/

administering medication. �  Consider using elderly members of the

community - as often the controlling force in the family, and with increased age comes increased respect & authority.

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Tips (cont)

�  Time does not dictate need, instead it is need that dictates time - consider when scheduling appointments.

�  Misconception that male is decision maker. �  Nothing to prevent older teens being involved

in decision making. �  Ask family to seek assistance from a Muslim

chaplain or your local Mosque.

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A final point �  Don’t assume every Muslim’s behaviour is due to their

religion, it may be their culture, upbringing, or simply their personality type.

�  Muslims are not a homogenous group; they are extremely diverse.

�  Many Muslim patients may not be proficient in English. �  Beware the ‘nominal’ Muslim.

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Questions?

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REFERENCES

�  Akhatar AG. Nursing with dignity. Nursing Times 16 April 2002: 40. �  Hassan, Sherene (2009), RCH Grand Rounds Presentation. �  ‘Islamic Health and Human Services’, Detroit Riverview Hospital [Muslim

guidelines]. Available at: www.hammoude.com/Rivervew.html �  Kirkwood NA. ‘A hospital handbook on multiculturalism and religion’,

Melbourne: Millennium Books, 1993. �  McKennis AM. ‘Caring for the Islamic patient’, AORN Journal 1999; 69:

1187-1196. �  ‘Muslim patient: a guide to health care workers’, Melbourne: Islamic Council of

Victoria, no date. �  QH and ICQ, ‘Health care providers handbook on Muslim Patients’. �  Sheets DL, El-Azhary RA. ‘The Arab Muslim client: implications for

anaesthesia’, AANA J 1998; 66: 304-312. �  Sutherland D, Morris BJ. ‘Caring for the Islamic patient’, J Emerg Nurs.1995;

21: 508-509.

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Objectives - Consent issues medical procedures/care.

�  What is Assault �  Intentional Touching �  Consent �  Valid Consent �  Informed Consent �  Tips

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What is Assault?

� Assault = unlawful touching of another without their consent/trespass

� Elements - ◦ D must have intended to (as opposed to

accidentally) touch P, ◦ D must have actually touched P, AND ◦  P must NOT have consented!

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Intentional Touching

� = direct physical contact or by means of an instrument of machine (R v Mobile 1991).

� P need not be aware of the touching at the time (egg. asleep or unconscious).

� Damages may be payable.

Consent

� Must obtain valid consent before giving any medical treatment otherwise assault/trespass

� Why? � What about an emergency situation?

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Valid Consent

� Consent may be - ◦ Oral ◦ Written ◦  Implied

� Consent must be - ◦ Voluntary ◦ Cover treatment performed ◦ Given by person with legal capacity

What should you inform a patient to acquire a “valid consent”?

� Must advise and acquire consent in respect of - ◦  nature of the proposed procedure (to avoid

claim of assault), AND ◦  risks and complications involved (to avoid

claim of negligence)

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Case about Consent

� Chatterton v Carson: wrong operation was undertaken – a circumcision instead of a tonsillectomy.

�  Shaw v Wright: operation on the wrong body part – removing a cataract from the wrong eye.

Statute of Limitation ◦ An aggrieved patient may not decide to take

civil action against an individual for a number of years. ◦ An individual may bring a civil action of

negligence to court any time within the 3 year period from the date of the incident was discoverable(Note amendments to LAA – 6 to 3 yrs). ◦  In the case of children/paediatrics the time is

even longer as a child does not have legal rights until they are 18.

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Legal Issues

�  These types of claims demonstrate the importance of good documentation.

�  Try to remember something in detail - a nursing action - that took place three years ago!!

�  Only accurate evidence is good documentation. �  Accurate documentation is part of the duty of care the

nurse owes to the patient. �  Failure to meet the required documentation standard

(that of the reasonable nurse in the same situation) can put the nurses competence and credibility under question.

References �  Edgerton, J. 1995, ‘Law for the Nursing Profession and

Allied Health Care Professionals – 3rd Edition’, CCH Australia, North Ride.

�  Finlayson, B. 1996, ‘The Expert and Lay Witness: Guidelines for Nurses called to give Evidence – 2nd End’, HLE Publications, Toowoomba.

�  McFarlane. P 2000, ‘Health Law in Australia and New Zealand: Commentary and materials (3rd end.), The Federation Press. Sydney.

�  Staunton, P and Why burn, B. 2000, ‘Nursing and the law – 4th Edition’, Harcourt, Sydney.