INTRODUCTION
Health professionals and organizations are increasingly advocating for an international declaration that palliative care is a basic human right (Radbruch et al., Reference Radbruch, Payne and de Lima2013). This endeavor is supported by an accumulating body of evidence that suggests the benefits of palliative care in relieving suffering, improving quality of life, saving costs, and possibly even offering improved survival (Zhi & Smith, Reference Zhi and Smith2015). Palliative care programs are gaining in terms of global popularity and expanding progressively, serving greater numbers of patients with diverse cultural backgrounds. It cannot be overemphasized that expressing cultural sensitivity and paying due attention to the spiritual aspects of care are integral components of the palliative care approach (Reed, Reference Reed1987; Kaczorowski, Reference Kaczorowski1989).
Muslims are estimated to be the world's fastest-growing religious group, now numbering 1.7 to 2.1 billion (Central Intelligence Agency, 2015; Muslim Population Worldwide, 2015). They constitute a majority in 50 countries and exist as minorities of various size in almost all non-Muslim countries, where they are often cared for by non-Muslim health professionals. They generally regard their religion as a belief system as well as a way of life. Hence, the practice of Islam has a major impact on Muslims' perception of, and interaction with, all aspects of their lives, including health-related issues, the experience of suffering, and death. This emphasizes the need for improving awareness among non-Muslim palliative care professionals about those aspects of Islamic teachings pertinent to the principles and practice of palliative care.
THE RELIGION OF ISLAM
Islam simply means obedience to the teachings of God (the creator of the universe), which He revealed to His last messenger, Muhammad (peace be upon him [pbuh]). Out of the dozens of names of God in Arabic (the language of Islam's sacred scriptures), Allah is the one most commonly employed. The fundamentals of Islam include (1) the “testimony” (shahadah) that the creator of the universe is the one and only true God and that Muhammad [pbuh] is his final messenger to all mankind; (2) performing prayers; (3) almsgiving; (4) fasting during the daytime throughout Ramadan (the ninth lunar month); (5) undertaking the Hajj (pilgrimage to Makkah) once in a lifetime for those who are physically and financially able; and (6) believing in the angels, prophets, holy books, the Day of Judgment, and Divine Predestination.
Islam is meant to encompass all aspects of a Muslim's life, as stated in the Qur'an (the word of Allah revealed to the Prophet Muhammad [pbuh]): “Say (O Muhammad): verily my prayer, my sacrifice, my living and my dying are for Allah alone, the Lord of the whole universe” (Qur'an, 6:162). In essence, the wholeness of Islam means that all Muslims' beliefs and behaviors are to be guided by Islamic rules and teachings. Obviously, the degree to which Muslims observe those teachings may vary substantially among individuals depending on the level of their religious stringency. Another reason for such variation may be attributable to variation between schools of thought in interpretation of the Islamic scriptures, though the relevance of that debate to the theme of this paper is minimal, if any. Of note, an increased interest in spirituality and religion among terminally ill patients has been observed in many cultures. This suggests that it is important for palliative care professionals to pay considerable attention to the spiritual component of their total-care approach when treating dying patients (Puchalski, Reference Puchalski2002).
EXISTENTIAL MEANING
Islam declares that nothing comes into existence by chance—that everything in the universe is created for a purpose. As stated in the Qur'an, “and We did not create the heavens and the earth, and all that is between them, for play” (Qur'an, 44:38). The purpose of existence, however, may or may not be revealed to human beings. For instance, the existence of food, water, and oxygen on earth is obviously necessary for human life, whereas the purpose of creating such harmful things as poisonous animals, malignancy, and congenital disease may not be easily comprehended.
Islamic teachings have addressed such existential queries. The Qur'an states that when Allah told the angels that He would place mankind on earth, the angels asked, “Will You place therein those who will make mischief therein and shed blood, while we glorify You with praises and thanks and sanctify You? He said, I know that which you do not know” (Qur'an, 2:30). The angels then said, “Glory be to You. We have no knowledge except what You have taught us. Verily, it is You, the All-Knower, the All-Wise” (Qur'an, 2:32). Therefore, the Islamic approach to the unrevealed existential meaning is simply to refer it to the ultimate wisdom of Allah. This approach possibly plays a pivotal role in preventing existential distress in Muslim patients suffering from a terminal illness.
HUMAN LIFE
Purpose
Islam teaches that human beings were created to worship Allah, who said, “and I created not the jinn and mankind except that they should worship Me (Alone)” (Qur'an, 51:56). However, the notion of worship is not limited to ritual aspects (e.g., prayers, Hajj) but rather involves viceroyalty on earth, which entails establishing and continuously maintaining an atmosphere conducive to righteousness in every aspect of life. In other words, throughout a lifetime, Muslims are expected to strive to do what is good for the planet and its inhabitants as best as they can and to avoid doing bad, guided always by the teachings of Islam. The Prophet Muhammad (pbuh) said, “If the last hour comes and someone has a shoot of a palm tree in his hand, that person should still plant the tree” (Hrynkow, Reference Hrynkow, Fitzpatrick and Walker2014). One of the Prophet's close companions (Abdullah Ibn Amr Ibn Al-Aas) elegantly explained how to be a balanced worshipper of Allah: “Work for your worldly life as if you are living forever, and work for your Hereafter as if you are dying tomorrow” (Islamweb, 2006). This belief is in harmony with the palliative care principle of living life to the fullest while being ready for its end in the near future. Evoking such tenets that are deeply rooted in the Muslim patient's belief system may help to boost their coping skills.
Sanctity
Islam views human life as a trust that Allah has given to man, who is considered a trustee (not an owner), and who is fully responsible for preserving that life and living it according to Islamic teachings. Human life is given a very special honor, as the Qur'an states, “And, indeed, We have honored the Children of Adam, and We have carried them on land and sea, and have provided them with At-Taiyibat [lawful good things], and have preferred them above many of those whom We have created with a marked preference” (Qur'an, 17:70). Saving life is considered a very righteous deed, and deliberately ending it is one of the greatest sins, as plainly stated in the Qur'an: “If anyone killed a person not in retaliation of murder, or (and) to spread mischief in the land—it would be as if he killed all mankind, and if anyone saved a life, it would be as if he saved the life of all mankind” (Qur'an, 5:32).
In view of this affirmation of human life, Islam encourages Muslims to seek treatment when they fall ill. The Prophet [pbuh] said, “Seek treatment, because Allah did not send down a sickness but has sent down a medication for it—known to those who know it and not known to others—except for death” (Al-Jibaly, Reference Al-Jibaly1998, p. 71). Also, Islam absolutely rejects the concept of hastening the death of others or oneself, even if the intentions are claimed to be for relief of suffering, because, as the Prophet Muhammad [pbuh] said, “A man was inflicted with wounds and he committed suicide, and so Allah said: ‘My slave has caused death on himself hurriedly, so I forbid Paradise for him'” (Khan, Reference Khan1994, p. 340). This is further emphasized by the fact that a Muslim is prohibited from wishing for death as a result of a difficult experience such as suffering associated with severe illness. According to the Prophet [pbuh], “None of you should wish for death, for if he is a good-doer, he may increase his good deeds, and if he is an evil-doer, he may stop the evil deeds and repent” (Khan, Reference Khan1994, p. 1027).
In the literature originating from non-Muslim countries, euthanasia and physician-assisted suicide, on one hand, and palliative care, on the other, have been presented as two competitive alternatives, with proponents and opponents of each approach (Caplan, Reference Caplan1997; Erdek, Reference Erdek2015). In Muslim communities, however, the absolute unacceptability of euthanasia or physician-assisted suicide precludes such a debate. This, together with the religiously motivated family and community support given to patients as well as the great emphasis Islam places on caring for the elderly, may signal a bright future for palliative care in Muslim countries despite the currently observed slow progress (Al-Shahri, Reference Al-Shahri2002). Nonetheless, the Islamic belief in the sanctity of human life and the need to exhaust every possibility of saving it may cause some Muslim patients and families to express hesitation in accepting the concepts of palliative care when first introduced to them. Such patients and families may be mistakenly equating palliative care with despair, which suggests complete loss of hope, which is prohibited in Islam as it conflicts with the tenet of reliance (tawakkul) on Allah, Who is able to do anything He wants, including curing the apparently incurable. To emphasize how deep this doctrine is in a Muslim's faith, it is worth mentioning that the Qur'an states in 33 verses distributed in various chapters that “Allah is able to do all things.” Further, the sacred Islamic scriptures are full of stories about miracles performed by Allah for His messengers in order to help them convince their people to believe in God. In such situations, organizing family meetings to clarify palliative care goals and principles is usually sufficient to overcome any misconceptions, especially when patients and families are reassured that palliative care does not interfere with medical or spiritual modalities of healing. Health professionals could also gently and sensitively help patients and families to achieve a state of balance between believing in Allah's ability to perform miracles and the fact that there are universal laws (also created by Allah) that govern the way the universe operates, and such laws will normally function in a sustainable manner.
The concept of “do not attempt resuscitation” (DNAR) for terminally ill patients, when cardiopulmonary resuscitative measures are deemed futile by medical specialists, is widely accepted by Muslim scholars based on the fact that the anticipated benefits of resuscitation in such cases are negligible while the expected harm is considerable (Al-Shahri et al., Reference Al-Shahri, Fadul and Elsayem2007; Albar, Reference Albar2007; Saiyad, Reference Saiyad2009). Although the concepts of living wills, advance directives, and power of attorney are now supported by the Islamic Medical Association of North America and several other reports written by Muslim physicians and ethicists (Khan, Reference Khan2002; Athar, Reference Athar2011; Al-Jahdali et al., Reference Al-Jahdali, Baharoon and Al Sayyari2013), the support given to such concepts by Islamic jurisprudential bodies or prominent Muslim scholars is apparently still lacking. This may reflect the low interest of Muslim communities in such concepts, so that prominent Muslim scholars and Islamic jurisprudential bodies may not see these as priority subjects for discussion. Probably based on the doctrine of tawakkul, the usual attitude of mentally competent Muslim patients is to make their own decisions regarding their current problems, and leaving decisions about future problems to the family should their decision-making ability be impaired.
SUFFERING
Based on the belief in Divine Predestination, Muslims attribute the occurrence of suffering (resulting from disease or some other source) to the will of Allah. They generally perceive suffering as a way of expiation of 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” (Khan, Reference Khan1994, p. 934). Suffering may also be perceived as a sign of love for the sufferers, as Allah rewards them for their patience by further elevating their rank in the Hereafter. The Prophet [pbuh] said, “How wonderful is the believer's affair. All of his affairs are good, unlike anybody else. When he experiences joyful occasion, he is grateful; and it will be good for him. And if he suffers misfortune and endures it patiently, then it will be also good for him; he bears it with patience, and that is good for him” (Al-Mundhiri, Reference Al-Mundhiri2000, p. 1117). He also said, “Those most afflicted among the people are the prophets, then the most righteous, then the next most righteous” (Al-Jibaly, Reference Al-Jibaly1998, p. 14). Finding meaning in suffering is believed to improve the sufferer's ability to cope (Puchalski, Reference Puchalski2002). This has been elegantly articulated by Victor Frankl (Reference Frankl1984), who wrote, “Man is not destroyed by suffering; he is destroyed by suffering without meaning.” Nonetheless, some Muslim patients may perceive suffering as a mode of worldly punishment inflicted on them by Allah as a result of their sins, and that the punishment waiting for them in the hereafter is even more severe. This may augment the suffering that the patients are already enduring. A spiritual care provider may be able to markedly contribute to the spiritual well-being of a patient by reinforcing a positive way of perceiving calamities according to Islamic teachings.
While Islam urges Muslims to experience and express patience in difficult times, it does not prevent them from seeking relief. Indeed, Islamic teachings promote prevention and treatment of suffering and consider the relief of suffering of man and animal to be highly virtuous. Imam Ibn Qayyim Al-Jauziyah (1292–1350 ce) recommended palliation of disease whenever treatment with curative intent is not possible or is likely to cause more harm (Al-Jauziyah, Reference Al-Jauziyah and Abdul Rab1999, p. 127). Islam also allows for modest expression of suffering in a way that does not reflect any degree of rejection of the concept of Divine Predestination. This may lead some Muslim patients to report somatic symptoms more readily than spiritual or psychological suffering. Expressions that represent existential suffering such as “Why me?” are not commonly observed in Muslim patients. Stoicism, though uncommon, may lead to underreporting of severe symptoms by a patient who assumes that reporting such symptoms may be a sign of impatience.
Muslim patients usually consider various options when seeking cure (or palliation) of their illnesses. These options include modern medical interventions, spiritual healing, and traditional remedies. The spiritual healing modalities may involve repeatedly reciting verses of the Qur'an and certain prophetic supplications. Black cumin (Nigella seeds) and honey are also believed to possess healing properties, as per sacred Islamic scriptures (Al-Mundhiri, Reference Al-Mundhiri2000, pp. 776–777). Drinking the water obtained from Zamzam (the well in the Holy Mosque of Makkah) is very commonly used for spiritual healing as a result of prophetic recommendations (Al-Jauziyah, Reference Al-Jauziyah and Abdul Rab1999, pp. 340–341). Cauterization is a traditional healing method that is still occasionally used, though it was discouraged by the Prophet [pbuh] (Al-Jibaly, Reference Al-Jibaly1998, p. 79).
The use of substances with properties that affect mentation (e.g., opioids, cannabinoids, and brain stimulants) is normally prohibited, except when deemed medically necessary and where no alternatives are available (Islam Question and Answer, 2015, fatwa no. 192321; Islam Question and Answer, 2015, fatwa no. 176623). Patients and families usually accept treatment with opioids for symptom control if the rationale is clearly explained to them. It is important to educate patients and their families about potential side effects, as they may show significant concerns regarding things like drowsiness. From the Islamic perspective, medication-related sedation can be looked at from two different angles. First, the alleviation of suffering is a righteous deed, even if it cannot be achieved except through accepting some degree of sedation. Second, preserving consciousness is of great importance to allow for performance of worship rites for the longest period possible before death. However, in terminally ill patients, it may become difficult to maintain a state of balance allowing for optimal symptom control and a normal level of consciousness at the same time. In these circumstances, the benefits and burdens should be made clear to patient and family. A tradeoff is practiced by some patients, who may, for instance, elect to endure slightly more severe pain in order to maintain a higher level of alertness.
DEATH AND DYING
Muslims believe that all mankind are mortal and that the longevity of every person is only known to Allah, and is determined by Him. As the Qur'an states, “Everyone shall taste death. And only on the Day of Resurrection shall you be paid your wages in full. And whoever is removed away from the Fire and admitted to Paradise, he indeed is successful. The life of this world is only the enjoyment of deception (a deceiving thing)” (Qur'an, 3:185). Allah also said, “And no person can ever die except by Allah's Leave and at an appointed term. And whoever desires a reward in (this) world, We shall give him of it; and whoever desires a reward in the Hereafter, We shall give him thereof. And We shall reward the grateful” (Qur'an, 3:145). In Islam, life is viewed as a stage of preparation for the hereafter. Muslims believe that death is the beginning of a different form of life called Al-Barzakh (literally, the barrier), which refers to the interval between death and resurrection. If well prepared by the healthcare team, the family who might have expressed some skepticism about palliative care in the beginning will mostly show acceptance once the dying phase ensues. This is probably due to the deeply rooted balance in a Muslim's faith between two concepts: the sanctity of life and the inevitability of a predestined and precisely timed death.
A person of wisdom, usually a family member or a friend, often sits at the bedside of the dying and speaks of the great generosity of Allah and gently helps the dying to say the shahadah. The Prophet [pbuh] said, “Let none of you die, except when he is thinking well of Allah” (Al-Mundhiri, Reference Al-Mundhiri2000, p. 260). He also visited a young man who was dying and asked him, “How do you feel?” The man replied, “By Allah, O Messenger of Allah, I have hope in Allah and I fear my sins.” The Prophet [pbuh] also said, “These two qualities do not dwell together in a person's heart in this situation [of dying], but Allah will grant him what he hopes, and save him from what he fears” (Al-Jibaly, Reference Al-Jibaly1998, pp. 15–16). Conscious patients should face the Holy Mosque in Makkah during their prayers if at all possible. However, despite the lack of clear religious evidence, some Muslim families highly appreciate it if the bed of an unconscious dying patient is moved (or the room changed) so as to be facing the Holy Mosque. The availability of a Muslim spiritual care provider at this difficult time will usually be of invaluable assistance to patients, families, and healthcare professionals alike. Patients and families routinely welcome the involvement of a spiritual care provider, whose suggestions and spiritual healing interventions are often highly valued.
AFTER DEATH
According to the teachings of Islam, the dead body should be handled with dignity and gentleness. The recommended actions immediately following death include closure of the eyes of the dead, removal of tubes and catheters, and coverage of the entire body with a cloth sheet. Other signs of respect of the dead body include the forbiddance of cremation, autopsy, and walking or sitting directly on a grave (Al-Jibaly, Reference Al-Jibaly1998, pp. 23–24, 221, 258). Islamic funeral rites are simple and carry no financial burden if practiced according to the recommendations of the Prophet [pbuh]. These include washing, shrouding, funeral prayers, and burial. The process should be completed as soon as possible (it takes no more than a few hours in normal situations to complete all funeral rites). Healthcare providers are expected to avoid any preventable delays in proceeding with funeral rites. Condolences may begin to be offered to the family of the deceased immediately after death, and there is no time limit on this. However, some Muslim communities follow the tradition of limiting the period of condolences to three days from the time of burial. The funeral prayer is the last funeral rite performed by the Muslim community before taking the dead body to a Muslim graveyard for burial. Islamic teachings guide the neighbors or other community members to serve food to the family of the deceased to express support and solidarity.
The simplicity of funeral rites and the intense community participation are possibly contributory to normal family grieving. Indeed, Islam allows for grieving by expression of compassion and weeping, whereas wailing and lamenting are not permitted (Al-Jibaly, Reference Al-Jibaly1998, p. 48). In normal situations, where family and community support is optimal, bereavement follow-up may not be necessary. However, the healthcare team needs to early on identify families or individuals who might be at risk for abnormal grieving and tailor their bereavement plan of care accordingly, preferably in collaboration with the local Muslim community.
CONCLUSION
Islamic theology fits the principles of palliative care perfectly. Affirming life, relieving suffering, normalizing natural death, and treating the dying with compassion and dignity are among the principles shared by Islam and palliative care. The wholeness of Islam cares about the details of a Muslim's life. Similarly, the holism of palliative care calls for sensitively and genuinely considering the cultural and spiritual aspects of care for Muslim patients. This suggests that it is very important for non-Muslim palliative care professionals caring for Muslim patients to raise their awareness of the Islamic principles pertinent to palliative care.
