Advance Directives/End-of-Life Issues

Asians were more likely than whites to select less aggressive interventions but were unlikely to use written advanced directives. (Eleazer, GP et.al., 1996). Active end of life care planning is an unfamiliar concept to most Pakistani older adults.

Care providers who have discussions about advance directives and advance care planning should remember that the older adults might be reluctant to participate in these discussions, as they may believe that talking about death may make it a reality. Worse yet, the older adults may believe that the physician is subtly implying that they (the older adults) have a serious illness and that they are dying. Extreme tact and sensitivity are called for when having these discussions. Ensure that you have adequate time and that patient’s family is present and engage a professional interpreter if possible.

Artificial Support

Maintaining a terminal patient on artificial life support for a prolonged period in a vegetative state is not encouraged in Islam. Also, in Islam, withholding food is forbidden. So providers should be very sensitive to issues regarding withdrawal of tube feedings.

Home Care

Pakistani older adults most commonly may wish to die at home, surrounded by their family and community members. Whenever this is requested, the sensitive clinician may wish to facilitate a patient’s return home, to be cared for there until death.

Gender of Nursing Staff

Pakistani older adults often have a strong preference that care be given by same-sex nursing staff. This is especially true when dealing with the dead body.

Gathering Family and Friends

Whether at home or in a hospital, a Pakistani American patient may expect to have family and friends gathered around for a final farewell when death is approaching. This is traditionally an important event in the Pakistani community, allowing a dying person to put right, before death, anything he or she feels is wrong in relationships with family, friends or community. Visiting the sick is a sacred duty according to Islam, as well as a last opportunity to show respect to a fellow Muslim and the family.

Death Rituals

[photo] koran

Moslem elders have extensive death rituals, including ceremonial washing of the body with water, directional positioning of the body towards the Holy Land of Mecca, and recitation of the Holy Koran by the relatives. When a patient is dying, the individual should be made to lie facing the direction of the Qiblah (in the direction of the city of Mecca), lying on his/her right side.

If this is not possible, then it is acceptable to allow the individual to lie on his or her back with the face and soles of the feet facing the direction of the Qiblah. In North America the direction of the Qiblah is the Southeast. Loved ones usually recite verses from the Koran.

Caring for the Deceased

Unrelated people should avoid skin contact with the body of the deceased, because it is believed that the body belongs to Allah. The nurse, therefore, should wear gloves at all times after the patient’s death.

When caring for the deceased, the nurse should close the patient’s eyes; wrap the head with gauze dressing to ensure that the lower jaw is closed; flex the elbows, shoulders, knees and hips before final straightening (this is believed to ensure that the body does not stiffen
and aids in purification).

Eliciting Personal Preferences

Eliciting the family’s personal preferences for care of the remains of their loved one in a sensitive and gentle manner and facilitating and supporting their rites and rituals as much as possible will go a long way toward alleviating the distress of a Moslem family who may be intensely grieving the loss of their loved ones.

Autopsies

Strict Muslims do not want autopsies performed on family members except for medical or legal reasons, and embalming of the deceased is not permitted unless it is mandated by law.