Do-Not-Resuscitate Orders : Islamic viewpoint

It is imperative to seek remedy in life-threatening situations. When treatment benefit is doubted, seeking remedy becomes facultative. If the treatment is futile, there is no need to continue. Resuscitation has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort, and consume resources. The do-not-resuscitate (DNR) order and advance directives are still a debated issue in critical care patients.The DNR order in the case of terminal illness is encouraged in Islam. International Journal of Human and Health Sciences Vol. 02 No. 01 Jan’18. Page : 8-12


Introduction
In the 40 years since its introduction, the do-notresuscitate order has become part of our society's ritual for dying. 1 A well informed competent patient has decision-making capacity and has the right to refuse medical therapy, including treatment that will sustain life artificially.During critical illnesses and in case of sustained coma such decision would be taken on his behalf by physicians and or next of kin.In Islamic societies, euthanasia and assisted suicides are forbidden.But the wishes of patient not to have his dying prolonged artificially with the presence of hopeless prognosis are well preserved.Such wishes may be declared in advance directive or accepted standing Do Not Resuscitate (DNR) order in certain hopeless medical conditions. 2 Case history Mrs. M. was a 56-year-old woman who was looked after by a physician in the hospital for 145 consecutive days.Her physician stated that he had some disagreements with her family and, therefore, would like to pass on the case to someone else.In addition, this patient was Muslim, and he thought a Muslim physician would be in a better position to understand and manage the social issues that had become challenging in the care of this patient.She was in hospital for so long because of multiple complications after being admitted initially for abdominal pain and anemia.She had gastrointestinal bleed secondary to erosive gastritis, respiratory failure, and then nosocomial pneumonia.She subsequently had multiple other infections with full blown sepsis that led to acute renal failure requiring dialysis.She finally ended up having a tracheotomy, peg tube feeding, and continued hemodialysis.She continued to have multiple organisms and recurrent pneumonias and, therefore, no nursing home would admit her.The family refused a DNR for the patient.She continued to survive for few more months in the hospital on dialysis and continued tracheotomy care.She ultimately died from worsening sepsis.She was made DNR when the doctors had a consensus that she was terminally ill.The family agreed for the DNR order at that time. 3

Cardiopulmonary Resuscitation
Cardiopulmonary resuscitation (CPR) is now routinely performed on any hospitalized patient suffering cardiac or respiratory arrest.The frequent performance of CPR on patients who are terminally ill or who have remote chance of surviving has raised concern that resuscitation efforts may be utilized too broadly.The health care providers soon realized that CPR was not appropriate for every patient, and this lead to the emergence of Do Not Resuscitate (DNR) policy to identify patients who would not benefit from CPR. Concerns were raised that many patients were kept alive through futile medical therapy.This contributed to further worries about the emotional and financial burdens imposed on the patients and their families.Advanced invasive procedures and treatments that may sustain life may not confer any foreseeable benefit, and in fact may invoke further suffering to the patient and the family.4Therefore,CPR may be withheld if, in the judgment of the treating team, an attempt to resuscitate the patient would be futile.Do Not Resuscitate "Do Not Resuscitate" (DNR) is a medical order to provide no resuscitation to individuals for whom resuscitation is not warranted.The American Heart Association in 2005 moved from the traditional do not resuscitate (DNR) terminology to (do not attempt resuscitation) (DNAR).DNAR reduces the implication that resuscitation is likely and creates a better emotional environment to explain what the order means.Allow natural death (AND) is the name recommended in some settings to make the meaning even clearer.Most hospitals still use the obsolete DNR term.Medical staffs should consider moving to DNAR and in some settings to AND as Language here is extremely important. 5A Do Not Treat (DNT) order relates to treatment of the primary disease condition, such as cancer, when that treatment is considered futile.A DNT order is sometimes misunderstood to mean that resuscitation is not carried out for cases of reversible cardiorespiratory arrest. 6o not resuscitate (DNR) is an important entity of medical practice.However, only a few studies from Arab Muslim countries address this issue. 7A cohort study of data prospectively collected from 15/10/2008 through 15/01/2009 for patients where DNR was initiated in a tertiary care center in Saudi Arabia ,DNR was initiated in 65 patients referred to the intensive care unit (ICU).DNR was initiated by ICU physician in 80% of cases and by most responsible physician (MRP) in 20% of cases.Documentation of discussion with the family was absent in 53.8% of cases.The authors concluded that ICU physicians have a role in initiating DNR. 7he need for education of the public is an essential part of DNR practice.The global medical community must educate patients and families to realize that there often comes a point when best medical care will not result in survival and will only prolong the suffering of patients and their loved ones.

Islamic view
The Islamic perspective regarding DNR decisions is a moving target.In Hadith, Prophet Muhammad (peace be upon him)said that 'None of you should wish for death because of a calamity be falling him but if he has to wish for death, he should say''O Allah!Keep me alive as long as life is better for me, and letme die if death is better for me" 8 There is no relevant distinction between withholding and withdrawing life-sustaining treatment.The Islamic religion's concept concerning DNR decision has been clarified by the Presidency of the Administration of Islamic Research and Ifta, Riyadh, KSA, in their Fatwa No. 12086 issued on 28/3/1409 (1989).The Fatwa 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".The fatwa was based on questions raised on using resuscitative measure on the following conditions: 1.If the medical file of the patient is already stamped: "Do not resuscitate", according to the patient's or his proxy's will and the patient is unsuitable for resuscitation, as agreed by three competent specialized physicians, then there is no need to do any resuscitative measures.2. If three physicians have decided that it is inappropriate to resuscitate a patient who is suffering from a serious irremediable disease and that his death is almost certain, there is no need to use resuscitative measures.

If the patient is mentally or physically
incapacitated and is also suffering from stroke or late stage cancer or having severe cardiopulmonary disease and already had several cardiac arrests, and the decision not to resuscitate has been reached by three competent specialist physicians, then it is permissible not to resuscitate.4. If the patient had irremediable brain damage after a cardiac arrest and the condition is authenticated by three competent specialist physicians, then there is no need for the resuscitative measures as they will be useless.
5. If resuscitative measures are deemed useless and inappropriate for a certain patient in the opinion of three competent specialist physicians, then there is no need for resuscitative measures to be carried out.The opinion of the patient or his relatives should not be considered, both in withholding or withdrawing resuscitative measures and machines, as it is a medical decision and it is not in their capacity to reach such a decision" 9 In summary, the fatwa delineates six situations where a DNR is granted: if the patient arrives dead at the hospital, if the panel of physicians determines that the condition is untreatable and death is imminent, if the patient's condition does not make him or her fit for resuscitation, if the patient is suffering from advanced heart or lung disease or repeated cardiac arrest, if the patient is in a vegetative state, and if resuscitation is considered futile. 9lthough, according to the fatwa, families and guardians cannot decide on the application or removal of resuscitation measures or procedures, as they are not considered qualified, the medical practice in Saudi-Arabia involves the guardians and families in the discussion of DNR.The DNR Form is valid only under when it is signed by three qualified physicians (mainly 2 consultants, and 1 staff physician), and only acceptable within the hospital during the patient's admission.When signed, the form is kept in the patient's record, and it has to be reviewed by the physicians according to the institution's policies.The Fatwa of this Permanent Committee in Saudi Arabica should be explained to the family.If the family still insists on doing everything possible then they should be offered the possibility of transferring their patient to whichever hospital agrees to accept the patient. 10,11ased on the Fatwa, some hospitals in Kingdom ofSaudi Arabia have implemented a ''No Code'' policy.The policy had led to a dramatic reduction in futile CPR.In fact, DNR orders was shown in one study to be written for 66% of patients who die in ICU and 82% of patients who die in the wards in a tertiary care hospital in Saudi Arabia.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 with widespread metastasis, and on the last hospital day in cirrhotic patients, underscoring the delays in recognizing the futility of the treatment in some patients. 12decision on DNR, particularly early in the hospital stay, can bring about significant resource use reduction for an identifiable group of patients. 13Identifying 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. 1Not all patients have to be admitted in the ICU for dying; the ICU is not a "dying place" but rather an area where life supports is provided to patients with reasonable chance of recovery.The implementation of this Fatwa may vary among different Muslim countries.This Fatwa is contrary to the practices in the United States where patient wishes and family involvement are considered a top priority. 14According to this Fatwa, a DNR order or withdrawal of care is a physicianbased decision that does not need involvement of families.However, in a survey among 461 Muslim physicians in the US and other countries, more thanhalf of the respondents did not agree with this and nearlyone-third felt that families could over rule the patient'sdecisions despite his wishes. 15e believe that it would be impractical not to discuss the issue of DNR with the family, since it is not uncommon for a member of the family to be around when the patient sustain a cardiac arrest and it would be very difficult for the doctor not to react to the patient's cardiac arrest as he is bound by the DNR policy.Poor explanation to the family resulted in family dissatisfaction in most of the cases, as reported in Western studies. 16n a cross-sectional study conducted between May and December 2013 in Jeddah, Saudi-Arabia, a total of 140 questionnaires were sent to interns and residents to find out whether they are familiar these policies and their attitudes toward DNR.While more than half of both interns and residents were familiar with the term DNR, the greatest proportion of both were not sure whether a clear DNR policy exists in their hospitals and whether a DNR policy exists at a national level.The authors concluded that there was a lack of familiarity with DNR's policies and the fatwa and also a lack of understanding when it comes to treating DNRlabeled patients.The majority opinion was to include the patient in the decision-making process who is excluded according to the fatwa. 17he Islamic Medical Association of North America (IMANA) believes that when death becomes inevitable, as determined by physicians taking care of terminally ill patients, the patient should be allowed to die without unnecessary procedures.While the patient is still alive, all other ongoing medical treatments can be continued.IMANA does not believe in prolonging misery on mechanical life support in a patient in a vegetative state, when a team of physicians, including critical care specialists, have determined that no further attempt should be made to sustain artificial support.Even in this state, the patient should be treated with full respect, comfort measures and pain control.The patient should be allowed to die peacefully and comfortably.No attempt should be made to enhance the dying process in patients on life support. 18MANA also recommends that the patient 'be permitted to die naturally with only the provision of appropriate nutrition and hydration' and any medications and procedures that are necessary to provide comfort and alleviate pain.The patient should not be neglected or left to die in agony. 7urthermore, the Islamic Organization for Medical Sciences (IOMS) has recommended the following: In his defense of Life, however, the Doctor is well advised to realize his limit and not transgress it.If it is scientifically certain that life cannot be restored, then it is futile to diligently keep on the vegetative state of the patient by heroic means of animation or preserve him by deep-freezing or other artificial methods.It is the process of life that the Doctor aims to maintain and not the process of dying.In any case, the Doctor shall not take a positive measure to terminate the patient's life. 19f the patient is competent enough (which is rare in such cases), it should be discussed with him.He should be ensured of giving him all necessary care and medication to alleviate pain and distressing symptoms.If the patient is not competent enough, DNR should be discussed with the family members especially the most appreciative and comprehending person. 11Physicians' beliefs Physicians' religiosity affects their approach to end-of-life care (EOLC) beliefs.Studies exist about end-of-life care beliefs among physicians of various religions.However, data on Muslim physicians are lacking.Saeed et al 15 studied the beliefs centering on aspects of end-of-life care among 461 Muslim physicians in the US and other countries.The survey was targeted toward Muslim physicians practicing in the United States, Pakistan, India, Bangladesh, United Kingdom, and Kingdom of Saudi Arabia.Nearly 66.8 % of the respondents believed that DNR is allowed in Islam, compared to 7.38 % of the respondents who did not believe that it is allowed.Muslim physicians' beliefs on EOLC issues are affected more by the area of practice, country of origin and previous experience in talking about comfort care than the religious beliefs. 15There is a gap of knowledge on EOLCbeliefs with respect to do not resuscitate (DNR) orders andadvance directives in this group of physicians.Ur Rahman et al 20 designed a questionnaire which was sent to members of the Pan Arab Society of Critical Care.The majority of responders were trained in western countries.Admission of DNR patients to the ICU was acceptable for 47.7% of respondents.DNR was considered equivalent to comfort care by 39.5%.They concluded that the training background and level of seniority in critical care provider does not impact opinion on most of end of life issues related to care of terminally-ill patients. 20

DNR in Practice
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. 21There is evidence of the lack of DNR order policy worldwide.Therefore, it appears clear that there is a need for standardization.To improve the attitude about the DNR order, it is necessary to achieve several goals such as: increased communication, consensus on law, increased trust among patients and health care systems, and improved standards and quality of care to respect the patient's will and the family's role. 21ospitals are required to have a do-not-resuscitate (DNR) policy in place.Practitioners are advised to first consider what is best for the patient and, when in doubt, to communicate with patients or surrogates and with colleagues to arrive at the most appropriate care plan.If irreconcilable conflicts arise, consultation with the institution's bioethics committee, if available, is beneficial to help reach a resolution. 22nfortunately, the advance directive is not a usual practice in Middle Eastern countries.DNR is never discussed with patients but rather with the family, and only when the situation is critical.Cultural, educational, and religious issues were found to be the main reasons for poor communication between staff and family members emphasizing the need to continuously evaluate DNR practice in Arab and Muslim countries. 7Conclusion DNR order means that a DNR patient receives all treatments except for cardiopulmonary resuscitation.All interventions that ensure patient's comfort and dignity will be taken.The Do Not Resuscitate order is a physician decision, but the family must be informed and the medical and religious Fatwa explained fully to them (without seeking their involvement in the decision).A clear policy from the ministry of health regarding DNR and end of life issues is urgently needed for all hospitals and health care providers in most, if not all, Arab and Muslim countries.