Addressing Spiritual Issues of Muslim Patients in Palliative Care
Spirituality is the inherent nature of all human beings. It's the means through which individuals experience transcendence; to live beyond self and establish connections with other human beings and their environment (Hatamipour et al., 2015). This may sometimes be done in association with a superior divine power. Religion, as a means through which people express spirituality, helps provide answers to complex life mysteries and thus gives purpose and meaning to life.
Islam, for example, teaches that human existence on earth is only a transient stop on the way to a better eternal life (Aisha, 2009). This teaching shapes a believer’s approach to life. Understanding this view is crucial for proper assessment and management of a patient’s spiritual issues that may arise due to a serious illness like cancer. It provides an insight into how the patient and the family are likely to cope with the disease.
Assessing a patient for spiritual needs is an important component of the holistic approach to effective management of pain in totality because spiritual issues affect overall well-being (HAU-BPC1211, 2012). Spiritual needs become more pronounced in times of crisis such, as when faced with a life-limiting disease. They also keep evolving as the disease progresses (Hatamipour et al., 2015). Identifying spiritual needs requires skills like effective communication, empathy, and compassion. It involves the use of broad, open-ended questions designed to suit the individual patient.
Questions to Ask in Spiritual Assessment for a Muslim Patient
- How important is it to you, to worship God?
This question aims at exploring the magnitude of value a patient attaches to worshiping God, and the extent to which the illness may be affecting their ability to worship. A devout Muslim with a prayerful life may explain that the illness has greatly hindered ability to worship according to Islamic tradition.
This inability to perform prayer may make the patient feel disconnected from God which may cause a lot of spiritual suffering. Islam requires a believer to perform five prayers a day because prayer is a direct link between the worshiper and God; as there are no intermediaries between God and the worshiper (guide to understanding Islam, 2002). The prayer is performed in a particular way that may require getting out of bed and also to bend, all of which may not be possible in advanced disease. Other acceptable means of worship can be explored with the help of religious leaders. The palliative care team can work with family members to consider possibilities like directing the bed in the direction of Mecca. It may also be helpful to assist with the mandatory ritual of washing up (wuzu) before daily prayer (Taheri, 2008).
On the other hand, if daily prayer hasn’t been part of one’s daily life, the inability to perform five prayers a day may not be too distressing. Addressing the issue of worship will depend on how much value a patient attaches to daily prayer and how much distress it’s causing to patient and family.
2. What or who do you think is responsible for the illness?
It is important to remember that in many societies, incurable illnesses are often associated with witchcraft, sorcery and dark magic. Family members or friends may be tempted to seek the intervention of traditional spiritual healers. But sorcery is deemed evil and forbidden by Islam (Aisha, 2013).
“And from the evil of those who practice witchcraft when they blow on knots” (Holy Quran 113:5)
A patient in such circumstances may feel confused and could request for spiritual cleansing with the help of a Muslim cleric in order to receive forgiveness from God. The palliative care team needs to be prepared for this.
This question is also important in assessing spiritual aspects because it attempts to obtain a patient’s understanding of the diagnosis. It seeks to explore their view of the disease in relation to religious teachings and can shade light on whether the illness is viewed as a punishment from God for previous deeds. This may elicit anger towards God.
However, it can also bring about remorse and the need for forgiveness. Some religions depict suffering as punishment for willful separation from God’s commands (HAU-BPC1211, 2012). Some people adopt this mindset when faced with difficult illnesses, and may desire re-connection with God in order to obtain spiritual healing.
3. Do you congregate at any specific place of worship?
This seeks to examine whether the patient is part of a particular spiritual community. It aims at determining connectedness with other believers. For believers, gathering together to worship is important. It provides a feeling of belonging to a community of people with shared values and ways of life. This community is central to the spiritual and social experience. Yet, sometimes, as illness progresses, the individual gets cut off from the community (HAU-BPC1211, 2012). This can result in a feeling of abandonment and cause anger. It is thus important to carefully assess this by listening to the patient’s response to the question about their place of worship. This question could be followed up by; “how do you feel about your fellow believer’s availability during this time of illness?” The patient can then express feelings about how available and supportive the religious community has been and how they have affected spiritual well-being. Religious communities are a source of support for their members in difficult times.
4. Does Islam forbid any specific parts of medical care? If any, what is your view of them?
The aim here is to explore any actual or perceived restrictions to medical care that may be based on one’s religious beliefs. According to Rabin (2010), Muslims generally differ in their adherence to Islamic tradition and rituals. It’s for this reason that careful assessment of the patient’s religious devoutness is necessary.
Islam, for example, emphasizes modesty pertaining to interaction between people of opposite sex who are not related by blood or marriage. A prophetic tradition states that when a non-mahram woman and man (not related by blood or marriage) are alone together, Satan is the third among them. Therefore, devout Muslim men may refuse to be cared for by female practitioners, and vice versa (Rabin, 2010). This can be important, and if not observed or addressed may cause discomfort.
The palliative care team needs to understand such restrictions based on religion, and put them into consideration when designing a management plan.
5. How would you like to be assisted in your spiritual care?
Asking a patient to express their desires in relation to their spiritual care can be perceived as a sign of respect for the patient and his family. It helps them feel like they are at the center of the care plan. This results in compliance with medical interventions and, hence, improved quality of life (HAU-BPC1211, 2012). Allowing the patient to express their concerns and desires regarding their management enables the palliative care provider to avoid making assumptions which may not directly or fully address the patient’s real needs. It also conforms to the concept of patient-centered care which is one of the key principles of palliative care.
As any other form of care, spiritual assessment and management should be focused on the patient’s wishes. The patient should thus be treated with respect and involved in discussions about care and treatment (HAU-BPC1112, 2012).
However, unrealistic desires should be identified. If the patient wants to get out of bed to perform prayer but his physical condition does not permit it, there is need to explain and explore other acceptable alternatives.
Islamic Teachings That Can Help Support Palliative Care Patients
Islamic teachings are important in counseling and providing hope for patients and their families. They help provide answers to some of the complex concerns and fears surrounding life limiting illness as well as death. Some of the teachings are explained below;
- Islamic teachings reflect that life is a gift from Allah given to mankind. Life limiting illnesses come from him since he decides how to live.
“How can you disbelieve Allah when you were lifeless and he brought you to life, then he will cause you to die…” (Islam Stack Exchange, 2017).
This shows that life should not be taken for granted as it is a precious gift from Allah himself.
It shows that Allah has control over the life of a believer in both good and trying times like in the presence of illness. Illness comes from Allah as a test of one’s faith.
“And certainly we shall test you with something of fear hunger, loss of wealth, lives, fruits, but give glad tidings to the patient ones (Holy Quran 2:155).
Islam teaches that God tests believers with trials and tribulations. If they endure patiently, they attain greater good; either here on earth or in the life hereafter. God has power over all things and his infinite mercy and wisdom want only what is best for humankind even in the face of trial (Aisha, 2009).
This teaching can be used to guide the discussion about who or what the patient and his family believe is the cause of the disease. Exploring this can help bring hope and peace of mind to the patient and cause resolution of any conflict brought about by blaming one another for the situation.
- Allah is also the overall healer of all life-limiting illnesses since he is the most merciful and the most gracious. However, spiritual treatment and healing, in place of physical healing, is also considered as peace of mind to a patient because it gives food for thought and soul.
Prophet Mohamed (PBH) said there is no disease which Allah has created, without also creating its remedy (Taheri, 2008). However spiritual healing is equally important in times of serious illness because it treats the soul which is the immortal part of the human being that will live with God for eternity. This teaching shows that even when physical cure is elusive, Allah can still provide healing for the soul and thus give peace of mind. The patient and family need to be reminded of this teaching especially when they are in desperate search for a physical cure.
- “But to no soul will Allah grant respite when the appointed time for it has come” (Quran 63:11). Death occurs in different situations and at different times depending on Allah’s wish (Innah-Lilah-Wa- Innalilah-Rajuunah); He gives and takes away.
This teaching means that death will occur to every human being and the place, time and date are pre-programmed by Allah and that he will not grant any delay to a single soul when that time comes.
Only Allah grants life, and, in his hand, it returns at the appointed time. The human being is helpless in this regard and can only submit to Allah (Mission Islam, 2017).
This teaching is useful as a reminder that death is an inevitable reality in the face of a life-limiting illness like cancer and that human beings have no power over it.
- There is also a belief that life continues after death and human life is immortal; the soul does not die until the final Day of Judgment (Kiyaa-mah). Purification of the dead body portrays the eternity of life hereafter.
According to Islam, human life on earth is only a transient stop on the way to eternal life (Aisha, 2009). This teaching means that death is not the end of life. Rather it is simply a bridge to the afterlife where the soul will live for eternity in 'Janah', depending on God’s judgment of one’s life on earth. It is a great source of hope to devout Muslims and would be important in bringing peace of mind to a patient and his family.
- Punishing the soul starts with death until the Day of Judgment (Kiyaa mah) when Allah decides where life should be lived after death, (Janah or Jahanama) depending on one’s good or bad deeds on earth.
This teaching depicts punishment in the grave. The torment in the grave varies according to the sins a person commits while still living. It is believed that when a disobedient Muslim dies and is placed into the grave, and after all his companions have left, two angels come and torment his soul as punishment for his sins. This happens as one awaits the final day of Judgment (Idealmuslimah, 2016). This teaching can be significant in bringing a patient to seek forgiveness and peace from God before the inevitable time of death comes. The possibility of involving a religious leader to help explain this teaching should be considered by the palliative care team.
Proper spiritual assessment is important in exploring and managing a patient’s pain in totality. It requires the palliative care practitioner to have qualities like effective communication, compassion among others. Early recognition of spiritual symptoms is crucial for proper management. Unidentified issues will lead to inadequate pain control because spirituality contributes to a person’s emotional, physical and intellectual well-being (HAU-BPC1211, 2012). The assessment should be done with open-ended questions that are designed to suit individual patients to facilitate elaborate discussion. The health worker should avoid bias that could lead to imposing own spiritual belief onto the patient. Spiritual assessment should be ongoing since new symptoms may arise as the disease progresses.
Aisha, S. (2009) How to behave when struck by illness. Available at: www.islamreligion.com/articles/2231/how-to-behave-when-struck-by-illness-part-1 (Accessed 8 March 2017).
Aisha, S. (2013) What does islam say about sorcery. Available at: www.islamreligion.com/articles/5246/socery-in-islam-part-1 (Accessed 9 March 2017)
A Brief illustrated guide to understanding Islam (2002). What are the five pillars of Islam? Available at: https://www.islam-guide.com/frm-ch3-16-2.htm (Accessed 10 March 2017).
Hatamipour, K., Rassouli, M., Yaghmaie, F., Zendedel, K., and Alavi, H. (2015) ‘Spiritual needs of cancer patients: A qualitative study’, Indian journal of palliative care. 21(1). Available at: http://www.jpalliativecare.com/article.asp?issn=0973-1075;year=2015;volume=21;issue=1;spage=61;epage=67;aulast=Hatamipour [Accessed 9th march 2017].
Hospice Africa Uganda: Institute of hospice and palliative care in Africa (BPC 1112 (2012) Patient centered care, p.68); HAU publications.
Hospice Africa Uganda: Institute of hospice and palliative care in Africa (BPC 1211 (2012) Religions define suffering in different ways, p.28); HAU publications.
Hospice Africa Uganda: Institute of hospice and palliative care in Africa (BPC 1211(2012) Spiritual assessment tools - community p.37); HAU publications.
Hospice Africa Uganda: Institute of hospice and palliative care in Africa (BPC 1211 (2012) Spirituality definition, p. 24); HAU publications.
Idealmuslimah (2016) Specific Punishment in the grave (23). Available at: idealmuslimah.com/the-hereafter/death-and-the-grave/2519-specific-punishments-in-thegrave-23.html (Accessed 14 March 2017).
Islam stack exchange (2017) Are incurable diseases a curse from the almighty Allah? Available at: Islam.stackexchange.com/questions/8421/are-incurable-diseases-curses-from-the-slmighty-allah (Accessed 13 March 2017).
Maulawi, A. (2004) The holy Quran- Arabic text and English translation. Islamabad: Islam international publications limited.
Mission islam (2017) Death. Available at: www.missionislam.com/knowledge/Death.htm (Accessed 7 March 2017).
Rabin, R. (2010) Respecting Muslim patient needs. Available at: https://mobile.nytimes.com/2010/11/01/health/01patients.html (Accessed 12 March 2017).
Taheri, N. (2008) Health care in islamic history and experience. Available at: ethnomed.org/cross-cultural-health/religion/health-care-in-islamic-history-and-experience (Accessed 9 March 2017).
© 2017 Ian Batanda