Background: There are approximately 1.8 billion followers of Islam (Muslims) in the world, making it the second largest religion (1). In the US, there are more than 3 million Muslims, a number that is expected to double by 2030 (1). This Fast Fact summarizes the published medical literature relating to the need for sensitive and inclusive aspects of end of life (EOL) care for Muslim patients (2). 

Importance of Cultural Humility and Responsiveness: Muslims come from various sects, sub-sects, and cultural and geographic backgrounds. As with all religions and cultures, there are significant differences in social, religious, and personal practices such that nothing in this Fast Fact will be true for every Muslim patient and believing so risks harm from generalizations. See Fast Fact #216 for further information about the importance of culturally humble, individualized inquiry, assessment, and care (3).

Aspects of EOL care for Muslim patients:

1) Suffering and palliative medications: Though acceptance of curative and palliative treatments for illness is common, many Muslims attribute the occurrence of suffering to the will of Allah (God) (4,5). Suffering may be perceived as a way of atonement of sins and this concept of ‘redemptive suffering’ can be a spiritual source of comfort for many (4). Spiritual leaders may encourage faithfulness and patience to cope with suffering (6). Medications which palliate symptoms (e.g., opioids) are acceptable if they do not cause unnecessary sedation and thereby interfere with saying regular prayers or ‘Shahadah’ (a prayer known as the Testimony of Faith which may be recited daily and/or at the time of death) (2,4). Since there is considerable individual variation, clinicians should carefully discuss the balance of alertness with the degree of relief of physical suffering with the patient and/or family (7).

2) Family and caregiver involvement: Muslim families often are closely involved in clinical decision making, and if a patient is incapacitated, often an older male helps their family with necessary decisions (8). At certain times, family may request the clinician not to share certain diagnoses with a decisional patient. In such cases, openly exploring the patient’s input in how they would like their healthcare information shared can preserve the patient’s autonomy and cultural preferences (8).

3) Common Arabic words/phrases: Becoming familiar with common Arabic words/phrases and their rough translations may help clinicians understand their patient’s illness perspectives better. 

1. Insha’Allah: “If Allah wills it”; often said when hoping or planning for something in the future. 
2. Alhamdulillah: “Praise be to Allah”; usually said in gratitude when something good is noticed.
3. Masha‘Allah :“What Allah willed, has happened”; applied when appreciating or protecting something. 
4. Haram: Strictly forbidden. 
5.  Imam: A Muslim religious scholar or leader.

4) Life sustaining treatment (LST) preferences: Teachings from the Quran (holy book of Muslims) and Sunnah (actions and sayings of the Prophet Muhammad) do not specifically address LST preferences. Also, there is significant individual variability regarding LST preferences and desire for prognostic information among Muslim patients. Therefore, clinicians must openly explore care preferences and values and never assume them based on any religion alone. Chaplains, including non-Muslim chaplains, can help connect patients to faith leaders which can be critical when navigating EOL care dilemmas and LST preferences (6). Additional pearls from the published medical literature include: 

• Most surveyed Muslim physicians (67%) feel their faith allows for do not resuscitate orders (9). 
• The Islamic Medical Association of North America states that when death becomes inevitable, patients should be allowed to die without unnecessary procedures. If a patient is on mechanical support or other forms of LST, this can be withdrawn (6).
• Most Muslims consider withdrawal of LST to be acceptable in “futile” circumstances (8). 
• Many Muslims believe that medically administered nutrition and hydration should be provided if indicated unless it shortens life or causes more harm than benefit (10). 
• Islam clearly prohibits suicide and euthanasia (6). 

5) Care at the time of death: Islam recognizes death as cessation of breathing. However, there is minimal spiritual guidance on death using neurologic criteria (11). Collaborate with an Imam or chaplain to provide guidance and support in the case of death using neurologic criteria (8). When patients are imminently dying or have died, many Muslims prefer that the face of the deceased be repositioned towards Kaaba (Holy Mosque in Makkah, Saudi Arabia) (2). Loved ones may recite Shahadah or other prayers (2,4).

6) Care of the body: Many Muslims prefer prompt burials (2). Postmortems are usually not acceptable unless required by law (12). After release, the body may be given a “Ghusul” which means a final bath usually by same gender family members. The body is then wrapped in “Keffin” or white cloth for burial (2).

7) Other considerations:

• Modesty: Modesty and respect for personhood is important for many Muslim patients. Knocking on the door and waiting for permission to enter is recommended since many Muslim women cover their head. Clinicians should also seek permission prior to applying physical touch for the physical exam (2). Although not always possible, having same gender clinicians is often preferred (2).
• Needs during hospitalization: Dietary restrictions are common as many Muslim patients prefer Halal (animals sacrificed in the name of Allah) food and avoid pork products. Many patients may appreciate the provision of a Quran, prayer beads, and prayer mats. If possible, clinicians should try to avoid rounds and procedures during the daily five times of prayers (12,13).
• Muslim spiritual and traditional treatments: Muslim families may read prayers around the patient and gently blow on them or around their bed after prayers. This is considered part of spiritual healing. Certain nutritional items like black cumin, honey, and water that comes from a holy mosque in Makkah, Saudi Arabia (Zam Zam Water) are valued for their spiritual and health properties (14).
• Muslim chaplains/ Muslim clinicians: Although not always possible, pairing a Muslim patient with a Muslim chaplain or clinician may improve patient care satisfaction (2).

References:

1. Lipka M. Pew Research Center.  Muslims and Islam: Key findings in the U.S. and around the world. August 9, 2017. Accessed September 19, 2017. https://www.pewresearch.org/fact-tank/2017/08/09/muslims-and-islam-key-findings-in-the-u-s-and-around-the-world/
2. Harford JB, Aljawi DM. The need for more and better palliative care for Muslim patients. Palliat Support Care. 2013 Feb;11(1):1-4. 
3. Lahaj M. End of Life Care and the Chaplain’s Role on the Medical Team. J IMA. 2011;43(3):173-178. 
4. Al-Shahri MZ. Islamic theology and the principles of palliative care. Palliat Support Care. 2016 Dec;14(6):635-640. 
5. Sachedina A. End-of-life: the Islamic view. Lancet. 2005 Aug 27-Sep 2;366(9487):774-9. 
6. Leong M, Olnick S, Akmal T, Copenhaver A, Razzak R. How Islam Influences End-of-Life Care: Education for Palliative Care Clinicians. J Pain Symptom Manage. 2016 Dec;52(6):771-774.e3.
7. Al-Shahri MZ, al-Khenaizan A. Palliative care for Muslim patients. J Support Oncol. 2005 Nov-Dec;3(6):432-6.
8. Gustafson C, Lazenby M. Assessing the Unique Experiences and Needs of Muslim Oncology Patients Receiving Palliative and End-of-Life Care: An Integrative Review. J Palliat Care. 2019 Jan;34(1):52-61. 
9. Saeed F, Kousar N, Aleem S, et al. End-of-life care beliefs among Muslim physicians. Am J Hosp Palliat Care. 2015 Jun;32(4):388-92.
10. Alsolamy S. Islamic views on artificial nutrition and hydration in terminally ill patients. Bioethics. 2014 Feb;28(2):96-9. 
11. Al-Mujannid SM. Cases in which it is permissible not to resuscitate. Islamic Questions and Answers. October 4, 2008. Accessed November 13, 2021. https://islamqa.info/en/answers/115104/cases-in-which-it-is-permissible-not-to-use-resuscitation-equipment
12. Gatrad R, Sheikh A. Palliative care for Muslims and issues after death. Int J Palliat Nurs. 2002 Dec;8(12):594-7. 
13. Boucher NA, Siddiqui EA, Koenig HG. Supporting Muslim Patients During Advanced Illness. Perm J. 2017;21:16-190.
14. Adu-Gyamfi S, Teikillah A, Nyaaba AY, Kuusaana MM, et al. Muslim Healers and Healing: An Ethnographic study of Aboabo community of Ghana. Int. J. Mod. Anthrop. 2020. 2:14:291-316.

Conflicts of Interest:  none reported

Version History:  first electronically published in December 2021; originally edited by Sean Marks MD

Authors Affiliations: ¹Rutgers Cancer Institute of New Jersey/Robert Wood Johnson University Hospital, New Brunswick, NJ; ²Northwell Health System, Staten Island NY; ³University of Missouri, Kansas City, MO