Introduction
Muslims believe that death as
depicted in Qur'an:
"Every soul shall have a taste of
death". [1]
There is another doctrine every
Muslim submits to: "No soul dies except by Allah permission" [2].
The other doctrine Muslim submits to that only God [Allah] who
determines life and death of a man.
The life of human being in Islam is
sacred and nobody on Earth can end it except in situations of punishing
somebody purposely committing murder or spreading mischief on Earth.
" ... If somebody killed a person,
unless it is for murder or spreading mischief on Earth, it would be as if he
killed all of mankind. And if anyone saved a life it would be as if he saved
the lives of all mankind ..." [3].
So; How Muslim manages the new
development regarding end-of-life issues? He is urged according to his faith to
preserve his life and His doctor is urged to preserve life of mankind.
The decision to withhold life
support from a patient within the intensive care unit (ICU) is modern
medico-legal issue. It goes into many forms:
Organ donation and the issue of
brain death.
Euthanasia and "Mercy Killing"
Do-Not-Resuscitate (DNR) orders
called some time Do-Not-Attempt-Resuscitation (DNAR} or No-Code (NC).
These issues have been encountered
in all modern societies. Many papers in the international literature were
written about its aspects.
They are generally governed by many
crucial factors; ethical, legal, economical and social. These factors can
influence the final decision. The various solutions and final decisions were
reflection of patient views, religious views, legal views and futility views.
Method
Do not resuscitate order Islamic, Google
Scholar and PubMed search
A search of regional and
international literature documents regarding policy and procedures guidelines
was conducted to elicit current practice medical and legal guidelines for DNR
order practices in Arabic and Islamic ICU units in the last months of year
2007.
Results
There were 138 books and articles
dealing with the general key words Do Not Resuscitate order in Google scholar
32 were relevant to guidelines. 12
articles were dealing with research and one leading article death with the
issue of no-code as guidelines incorporated in optimizing the use of ICU in Saudi Arabia.
Other guidelines by medical assembly
of North America Ethical Committee addressed the issue in details and in
suggestion way as such guidelines do not get the same weight of the fatwa or
Verdict of religious scholar.
Discussion
[1]
DNR in Islamic society
Withholding Medical therapy at the
end of life has now been widely accepted in many countries around the world on
medical, legal, ethical, and moral grounds [4].
The Islamic religions concepts
concerning DNR decision have been clarified by the Presidency of the
Administration of Islamic Research and Ifta, Riyadh, KSA, in their Fatwa No.
12086 issued on 30.6.1409(Hijra) [1988 (AD)]. The Fatwa [5] states that: "if three knowledgeable and
trustworthy physicians agreed that the patient condition is hopeless; the
life-supporting machines can be withheld or withdrawn. The family members'
opinion is not included in decision making as they are unqualified to make such
decisions".
Based on the above Fatwa, Many
hospitals in Saudi Arabia
have implemented a "No Code" policy {Appendix-(1)}. The policy states that:
("No Code" status is applied after agreement of three physicians, two of whom
at least are consultants. The family members will be informed about the
decision. In case of conflict with the family, arrangements to transfer care to
another facility may be made. The policy had led to a dramatic reduction in
futile CPR. In fact, DNR orders are written currently for 66% of patients who
die in ICU and 82% of patients who die in the wards [6]. However, there is still a great variability in DNR
practices. For example, DNR orders are more likely to be written on day one of
hospitalization in cancer patients and on the last hospital day in cirrhotic
patients, underscoring the delays in recognizing the futility of the treatment
in some patients [6].
A decision on DNR, particularly
early in the hospital stay, can bring about significant resource use reduction
for an identifiable group of patients [7]. Identifying these patients early and
carefully evaluating them based on objective and well-validated criteria would
allow conducting therapeutic limits reducing unnecessary patient suffering and
medical care costs. CPR should only be performed on patients, who are likely to
benefit from it. Similarly, admission to ICU should be offered only to patients
who are likely to benefit from the admission. [American Thoracic Society. Fair
allocation of intensive care unit resources [8]. Avoidance of unnecessary admissions to ICU can lead
to substantial saving of resources as one day stay on the ward costs only a 6th
of that in the ICU [8,9]. Approaches to address this sensitive matter
may include the following: (i) Raising the awareness among people, particularly
physicians, on the limitations of aggressive life support. As it is important
for the physician to recognize when to provide a therapy, it is of the same
importance to recognize when to withhold therapy. Admission to the ICU and the
provision of aggressive life support, including cardio-pulmonary resuscitation,
should be reviewed as a treatment. Patients may or may not be candidates for
this treatment. While failure to provide a proper therapy is considered
negligence, improper utilization of the ICU should be considered an abuse of
this important resource. Needless to say that not all patients have to be
admitted in the ICU for dying; the ICU is not "dying place" but rather an area
where life supports is provided to patients with reasonable chance of recovery.
Raising the public and physicians awareness can be accomplished by utilizing
the media as well as the medical and health education programs, and organizing
seminars on the end of life issues. More emphasis has to be placed on
end-of-life issues in the curriculum of medical students and the residents. [10] (ii) The practical application of DNR policy
is unlikely to succeed without administrative support and enforcement.
[2]
Islamic medical assembly of North America's
guidelines.
Muslims living in non Muslim
Countries.
Islamic Medical Assembly of North
America (IMANA) made some interesting guidelines for many Ethical many ethical
and medical issues through (ISLAMIC MEDICAL ETHICS) which produce a document
called (The IMANA Perspective) [11]. This document incorporated the status of law
in North America and the right of competent
patient to decide for himself the status of DNR and to write advance directive
for his surrogate to follow his will. Appendix [2].
This is a very serious trial tied to jusfy and help Muslims living in America to
exist in harmony with their new society. It is highlights by this
justifications and raised questions: The DNR issue background stem from the
high expenses of maintaining modern medical care of terminally ill patient. It
is very expensive to keep a patient with terminal cancer or vegetative state
condition in intensive care unit. The question currently asked is Who
determines that the life support should be stopped? Is it the doctor? Is it the
family or the condition of unconscious patient?
What is the definition of death? Is
withholding the support system a crime or act of human nature, or purely
medical issue? Does or should financial factor play a role in the
decision-making?
[3]
The Civil law legal stand on the end of life issue
Arabic
countries laws as in most countries do not support the concept of assisted
suicide or mercy killing or Euthanasia. Any physician who engages in such
process would be subjected to legal proceeding on account of murder. The issue
of DNR is not fully distinct and it was left to physicians' choices and
preferences. The family and society would monitor such divisions and may need
lengthy discussion.
Conclusion
The general consensus was that the issue of end of life in Muslim societies is still evolving. There is great respect to human life and the exciting civil forbids euthanasia or assisted suicide, in regards other issues like brain death and DNR The Islamic Verdicts were facilitating the easy courses of medical futility decided by competent doctors.
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