Ethical Dilemmas at the End of Life: Islamic Perspective

End of life care preferences in the Arab population in Israel- bridging the gap between unfounded assumptions and autonomous wishes

INTRODUCTION

End-of-life (EOL) decision-making involves complex ethical, cultural, and religious considerations, particularly within minority communities. In Israel, the Arab population, comprising approximately 21% of the country's population, remains underrepresented in EOL research. This study explores the EOL care preferences of elderly Arab individuals and their families, focusing on the interplay between cultural values, religious beliefs, and personal autonomy.

METHODS

A qualitative study was conducted using semi-structured interviews with 24 participants, including elderly individuals (aged 60+) and their family members. Participants were recruited through purposive and snowball sampling in community settings across northern Israel. Data were transcribed, translated, and thematically analyzed to identify key patterns in attitudes toward EOL care.

RESULTS

Findings reveal a strong preference among elderly Arab participants for a peaceful and dignified death at home rather than in a medicalized setting. Quality of life was prioritized over life-prolonging treatments, with religious beliefs playing a significant role in shaping perspectives. However, cultural taboos and generational differences hindered open communication within families. Many younger family members assumed their elders preferred life extension, while elderly participants often desired comfort-focused care. Additionally, a lack of awareness of advance care planning tools limited the ability of patients to formally express their preferences.

DISCUSSION

A major challenge identified in this study is the absence of open discussions about EOL preferences, driven by cultural taboos, emotional discomfort, and fear. Many participants avoided such conversations due to beliefs that discussing death invites misfortune or imposes an emotional burden on loved ones. Younger family members, in particular, hesitated to engage in these discussions, leading to decisions based on assumptions rather than explicit patient wishes. Encouraging structured, culturally sensitive conversations and increasing awareness of advance care planning could help ensure that patients' preferences are recognized and respected.

CONCLUSIONS

Bridging the gap between assumptions and actual preferences requires culturally sensitive communication, increased awareness of advance care planning, and structured family discussions. These measures will ensure that EOL care respects both individual autonomy and cultural values, fostering a more inclusive and patient-centered healthcare approach.

The use of palliative care by people of Islamic faith and their preferences and decisions at the end of life: A scoping review

OBJECTIVES

The use of palliative care (PC) services from people of Islamic faith is seen limited. There are a fundamental lack of PC services appropriate to the target group and a lack of knowledge and acceptance. The transition from curative to PC is often perceived as problematic. Factors influencing PC use and end-of-life (EOL) decisions and preferences among people of Islamic faith are largely unclear.

METHODS

A scoping review was carried out using the methodology of the Joanna Briggs Institute. Studies of any design, published in English, German, or Arabic, and published by the end of August 2022, were eligible for inclusion. The systematic literature search was conducted in MEDLINE via PubMed, CINAHL, Cochrane Library, and Web of Science. Study statements were analyzed with a clear distinction between PC as EOL care and other EOL decisions, such as euthanasia, withdrawal, or withholding of one or more life-sustaining treatments or medications.

RESULTS

Sixty studies published between 1998 and 2022 were included. Only a few studies made statements about EOL care. The majority of studies focused on forms of euthanasia and indicated negative attitudes toward euthanasia, assisted suicide, and some other EOL decisions. Reasons for rejection include theological arguments, ethical and moral considerations, and others. Reasons for acceptance were principles of good death and dying, medical justifications, and others. The following barriers to the use of PC were identified laws and policies, lack of necessary resources, cultural norms and values, structure of the health-care system, communication and interaction between patients, relatives, and health-care staff, and others.

SIGNIFICANCE OF RESULTS

This review identifies the preferences for and difficulties in making EOL decisions and identifies barriers to specific PC for the Muslim population. Findings suggest how these barriers might be overcome.

Disclosure of true medical information: the case of Bangladesh

BACKGROUND

Truth-telling in health care is about providing patients with accurate information about their diagnoses and prognoses to enable them to make decisions that can benefit their overall health. Physicians worldwide, especially in the United Kingdom (U.K.) and the United States (U.S.), openly share such medical information. Bangladesh, however, is a Muslim-majority society with different social norms than Western societies. Therefore, we examined whether Muslim culture supports truth disclosure for patients, particularly how and to what extent medical information about life-threatening diseases is provided to patients in Bangladesh.

METHODS

This was a phenomenological qualitative study. We conducted thirty in-depth interviews with clinicians, nurses, patients and their relatives at Shaheed Suhrawardy Medical College Hospital in Dhaka, Bangladesh. We also used observations to explore interactions between patients, families and healthcare professionals regarding their involvement in medical decisions and truth disclosure issues. NVivo software was used to identify common themes, and a thematic analysis method was utilised to analyse the datasets.

RESULTS

This study identified three recurring themes relevant to the ethics and practice of truth disclosure: best interest rather than autonomy, the ambivalent value of deception and who understands what. The participants revealed that physicians often withhold fatal medical prognoses from terminally ill patients to ensure the best healthcare outcomes. The results indicate that deception towards patients is commonly accepted as a means of reducing burden and providing comfort. The participants opined that true medical information should be withheld from some patients, assuming that such disclosures may create a severe burden on them. Whether or to what extent medical information is disclosed primarily depends on a family's wishes and preferences.

CONCLUSIONS

While truth disclosure to patients is considered an ethical norm in many cultures, such as in the U.K. and the U.S., the practice of concealing or partially revealing severe medical prognoses to patients is an actual medical practice in Bangladeshi society. This study emphasises the importance of recognising a patient's active involvement and respecting the cultural values that shape family involvement in medical decision-making. These findings may have significant policy and practical implications for promoting patient autonomy within Bangladeshi family dynamics and religious-based cultural values.

Intersectional employee voice inequalities and culture care theory: the case of migrant palliative care nurses in Saudi Arabia

PURPOSE

This narrative literature review examines intersectional employee voice inequalities in a non-Western, high power distance context to develop a multilevel conceptual framework.

DESIGN/METHODOLOGY/APPROACH

The authors use Leininger's (1997, 2002) culture care model to explore multilevel influences on intersectional voice inequalities. The article applies insights from a review of 31 studies to the specific challenges of migrant palliative care (PC) nurses in Saudi Arabia.

FINDINGS

The themes identified in the review indicate how better transcultural communications might mitigate voice inequalities that influence migrant employee wellbeing and intentions to quit which result from cultural incongruities.

ORIGINALITY/VALUE

The impact of national culture differences and intersectional inequalities on employee voice has largely been ignored in academic research. This paper offers unique insights drawing on culture care theory into intersectional voice challenges from a non-Western perspective in the underresearched setting of Saudi Arabia which is mid-way through a national transformation program. It starkly contrasts policy ambitions for advancing healthcare with discriminatory practices based on conservative attitudes which stifle migrant worker voices.

Psychometric properties of Persian version of advance care planning questionnaire among older adults in Iran

INTRODUCTION

Advanced age is associated with life-threatening conditions at the end of life. Many of these persons at the end of their lives cannot make decisions because of the variable consciousness. They are able to make decisions and identify their care priorities, in a process called advanced care planning. So, an instrument is required for investigating ACP of the elderly population. This study was performed to determine the psychometric properties of the Persian version of the advanced care planning questionnaire(ACPQ) in elderly population referring to Tehran.

METHOD

This methodological study was performed in five hospitals in 2021-2022. A total of 390 eligible elderlies were included. The psychometric assessment including translation, face validity, content validity were performed Alsothe exploratory factor analysis and confirmatory factor analysis were assessed. Reliability were done by internal consistency by assessing Cronbach alpha and stability was performed using test-retest.

RESULTS

The face validity of the instrument was performed with minor changes. The content validity index for all of the items was above 0.79. In EFA four factors was extracted also CFA showed that the four-factor model has a good fit of the data (RMSEA: 0.04; NFI: 0.97 CFI: 0.99; IFI: 0.99; RFI: 0.96; AGFI: 0.87; GFI 0/90; standardized RMR: 0.02). Cronbach alpha and ICC were 0.72-0.94 and 0.85-0.96, respectively.

CONCLUSION

The Persian version of the advance care planning questionnaire has desirable psychometric properties for measuring the advanced care planning of the elderly population. In addition, healthcare providers in Iran can employ this questionnaire in their practice and research.

Muslim Jurisprudence on Withdrawing Treatment from Incurable Patients: A Directed Content Analysis of the Papers of the Islamic Fiqh Council of the Muslim World League

This study investigates the views of contemporary Muslim jurists about withdrawing treatment of the terminally ill. Its aim is threefold. Firstly, it analyses jurists' views concerning core themes within the process of withdrawing treatment. Secondly, it provides insight into fatwas about withdrawing treatment. Thirdly, it compares these views with current medical standards in Europe and the Atlantic world on withdrawing treatment. The data consisted of six papers by Muslim jurists presented at the conference of the Islamic Fiqh Council in 2015. We conducted a directed content analysis (DCA) through a predetermined framework and compiled an overview of all previous fatwas referred to in the papers, which are also analysed. The results show that the general consensus is that if health cannot be restored, treatment may be withdrawn at the request of the patient and/or his family or on the initiative of the doctor. The accompanying fatwa emphasizes the importance of life-prolonging treatment if this does not harm the patient. It becomes apparent in the fatwa that the doctor has the monopoly in decision-making, which is inconsistent with current medical standards in Europe. Managing disclosure in view of the importance of maintaining the hope of Muslim patients may challenge the doctor's obligation to share a diagnosis with them.

Islamic perspectives on preconception, prenatal, and perinatal counseling

With advances in prenatal imaging, genetic testing, and medical treatment of premature neonates, new bioethical challenges have arisen. Many Muslims turn to their faith and religious leaders to help navigate these novel challenges. This article briefly discusses the factors that are involved in religious leaders issuing a fatwa, or religious opinion. Using clinical scenarios, this article reviews the current discourse amongst Islamic scholars and laws in Muslim-majority countries regarding challenging bioethical topics surrounding preconception counseling, antenatal testing and termination of pregnancy, as well as Islamic scholars' attempts to determine a minimum gestational age of viability using primary religious texts, the Quran and hadith. Challenges and shortcomings in the Islamic perspective on these issues are also addressed to highlight areas in which further research should be pursued. A deeper understanding of Islamic religious perspectives on these topics can help clinicians in providing care that is informed by patients' cultural and religious values.

A Pilot Efficacy Trial to Educate Muslim Americans about the Islamic Bioethical Perspectives in End-of-Life Healthcare

In the US, end-of-life health care (EOLHC) is often intensive and invasive, and at times may involve care that is inconsistent with patient values. US Muslims may not receive appropriate religious support, experience uncertainty around end-of-life decision-making, and under-utilize palliative and hospice care. As technological advancements and treatment options rise in EOLHC, Muslim American patients and their families need to understand more about the treatment options that are consistent with their beliefs. The objective of this study was to determine the efficacy of a pilot mosque-based educational workshop focused on increasing Muslim Americans' religious bioethics knowledge about end-of-life healthcare. Intervention sites were four mosques with racially and ethnically diverse members, two in the Chicago metropolitan area and two in the Washington, D.C. area. Eligible participants were self-reported Muslims, aged 18 years or older, who were proficient in English. The intervention included a pre and post-test survey and a workshop focused on the Islamic bioethical perspectives on EOLHC. Knowledge was measured with six true-false questions. Baseline and post-intervention scores were analyzed by McNemar's test and bivariate correlation. Overall, the analysis showed a significant improvement in post-intervention participant knowledge. There was increased knowledge of Islamic bioethical views on the moral status of seeking healthcare, brain death controversies, and religious perspectives on withholding or withdrawing life support near the end of life. Our pilot intervention successfully increased participant knowledge and underscores the need to improve the Muslim community's knowledge about the bioethical dimensions of EOLHC.

Review of Muslim Patient Needs and Its Implications on Healthcare Delivery

BACKGROUND

In the rapidly changing environment of healthcare, striving toward health equity and providing patient-centered care is imperative to the patient's experience. To achieve these goals, a comprehensive understanding of the diverse patient populations seeking these services, their needs, and the multitude of religious, cultural, and structural elements that impact their well-being is required. Muslim patients represent a considerable demographic, both in number and complexity of religious and cultural beliefs and practices. This scoping review examines the intersection of religion and cultural values with healthcare delivery in the context of the Muslim patient experience.

OBJECTIVES

The objective of this review is to identify key concepts and challenges that impact the Muslim patient experience.

SEARCH METHODS

The research databases Cochrane Library, OVID Medline, and PubMED were used to conduct a comprehensive systemic review of original, empirical peer-reviewed publications with the following search terms: "Muslim healthcare," "Muslim patient," and "Muslim experience."

SELECTION CRITERIA

Inclusion and exclusion criteria were used to narrow down articles to those that addressed Muslim patient needs and their healthcare experience.

RESULTS

A total of 21 articles met the criteria of this scoping review. Five central topics were identified during thematic analysis: Ramadan and Fasting, Barriers in the Patient-Physician Relationship, Trauma and Perceived Discrimination, Mental Health Awareness and Stigma, and Awareness of Advanced Care Planning.

CONCLUSION

This scoping review demonstrates that in order to provide patient-centered care addressing the unique needs of Muslim patients, religious and cultural values need to be explored under the frameworks of cultural humility and structural competency.

Arabic version of the Palliative Care Self-Efficacy Scale: Translation, adaptation, and validation

OBJECTIVES

A lack of confidence among oncology nurses might be problematic when providing palliative care. No valid and reliable tool is currently available in Saudi Arabia to assess oncology nurses' confidence in providing palliative care. This study aims to explain the process of translation, adaptation, and validation of the Palliative Care Self-Efficacy Scale (PCSS) to support its use in the Saudi context.

METHODS

This was a methodological study of translation, cultural adaptation, and content validation of PCSS. The process of translation and adaptation was conducted according to the World Health Organization guidelines, including forward and backward translations, an expert panel review, and pretesting and cognitive interviewing, resulting in a final version. Two independent bilingual oncology nurses familiar with palliative care terminology translated the PCSS from English to Modern Standard Arabic. Next, the concise PCSS translation developed from the 2 translations was back-translated to English by 2 English-speaking translators and then compared to the original PCSS. The Arabic version PCSS was evaluated by Saudi professionals (N = 5) in oncology and palliative care nursing using a Likert scale for essentiality, relevance, clarity, and appropriateness. The content validity was examined using the calculation of the content validity ratio, item-level content validity index (I-CVI), and modified kappa statistics. The thinking aloud method was also used to interview Saudi oncology nurses (N = 8) who had palliative care experience.

RESULTS

The relevance, clarity, and appropriateness of the first Arabic version PCSS were validated. It had a level of content validity index of 1.00 for all items after improvements were made based on the recommendations of experts and oncology nurses.

SIGNIFICANCE OF RESULTS

The PCSS demonstrated face and content validity in the assessment of oncology nurses' confidence in providing palliative care. The PCSS is suitable for use in palliative cancer care units in Saudi Arabia to identify the educational needs of nurses to promote their confidence and improve the quality of care. Additional reliable and valid language versions of the PCSS allow for international and national comparisons, which may be useful for oncology nursing administrators or managers who are accountable for the quality of palliative care during the strategic health-care planning process in cancer services.

Muslim perspectives on palliative care in perinatal and neonatal patients: a mini-review

Muslims comprise nearly a quarter of the worldwide population, with significant populations in the United States, Canada, and Europe. As clinicians, it is important to be familiar with Islamic religious and cultural perspectives on medical treatment, life-prolonging measures and comfort and palliative care, but historically, this has been a gap in the literature. Recently, there have been multiple papers discussing Islamic bioethics, particularly in regards to end of life care in adults; however, there has been a lack of literature discussing the Islamic perspective on issues related to neonatal and perinatal end of life care. This paper uses clinical scenarios to review key relevant principles of Islamic law, discussing the primary and secondary sources used in formulating fatawa, including the Quran, hadith, qiyas, and 'urf, and the importance of preservation of life and upholding of human dignity (karamah). Neonatal and perinatal scenarios are used to specifically explore the Islamic perspective on withholding and withdrawal of life-sustaining measures and determining what constitutes an acceptable quality of life. In some Islamic cultures the expertise of the patient's physician is given significant weight in making these judgments, and as such, families may appreciate frank assessment of the situation by the clinical team. Because of the various factors involved in issuing religious ruling, or fatwa, there is a wide spectrum of opinions on these rulings, and physicians should be aware of these differences, seek counsel and guidance from local Islamic leaders, and support families in their decision-making process.

Death Be Not Proud: A Commentary on Muslim Acceptance of Death in the Intensive Care Unit

Technologies used in medicine have meant that treatments can keep people biologically alive but often fail to provide meaningful recovery and quality of life. Many of those from the Islamic faith have relied on these technologies for recovery on religious grounds, even when it may be against clinical advice. This commentary seeks to challenge this notion among many Muslims and suggests there is a psycho-spiritual motivation within the Islamic tradition in not pursuing intensive care treatment that is deemed futile by clinicians. A wish to embrace death in these situations should be expressed to loved ones, and the dying person's loved ones should be encouraged to embrace death, in order to minimise harm from disagreements between clinical staff and family.

Current state of ethical challenges reported in Saudi Arabia: a systematic review & bibliometric analysis from 2010 to 2021

Background

Over the past few years, five domains of importance about the current state of bioethics in Saudi Arabia have shaped the perspective of most research: doctor-patient relationship, informed consent, do-not-resuscitate, organ donation, and transplantation, medical students’ knowledge and attitudes about medical ethics curriculum. This systematic review aimed to systematically identify, compile, describe and discuss ethical arguments and concepts in the best-studied domains of bioethics in Saudi Arabia and to present cultural, social, educational, and humane perspectives.

Methods

Six databases were searched using Boolean operators (PubMed, Embase, Web of Science, Scopus, CINAHL, Google Scholar) from December 2020–June 2021. The search and report process followed the statement and flowchart of preferred reporting items for systematic reviews and meta-analyses (PRISMA).

Resutls

The search resulted in 1651 articles, of which 82 studies were selected for a final review and assessment. There is a gradual increase in research, whereby a substantial increase was observed from 2017. Most of the published articles focused on ‘Organ Donation & Transplantation’ with 33 articles, followed by ‘Doctor-Patient Relations’ with 18 publications. Most of the published articles were from Central Province (33), followed by Western Province (16). The authorship pattern showed a collaborative approach among researchers. The thematic analysis of keywords analysis showed that ‘Saudi Arabia,’ ‘attitude PHC,’ ‘organ donation,’ ‘knowledge and education,’ and ‘donation’ have been used the most commonly.

Conclusion

This systematic quantitative synthesis is expected to guide researchers, stakeholders, and policymakers about the strengths and gaps in knowledge and attitudes regarding medical ethics in Saudi Arabia, both among the general public and health professionals.

Comparison of Clinical Characteristics and End-of-Life Care Between COVID-19 and Non-COVID-19 Muslim Patients During the 2020 Pandemic

Background:

Little is known about end-of-life care among Muslim patients, particularly during Coronavirus disease 2019 (COVID) pandemic, which we report here.

Methods:

The clinical characteristics, end-of-life care and resuscitation status of Muslim patients who died in the ICU of our tertiary care hospital in year 2020 from COVID were compared to Non-COVID patients.

Results:

There were 32 patients in COVID and 64 in the Non-COVID group. A major proportion, mainly of Non-COVID patients, already had a hospice eligible terminal disease at baseline (p=.002). COVID patients were admitted to the ICU sooner after hospitalization (2.2 vs. 17 days), had prolonged duration of mechanical ventilation (18.5 vs. 6 days) and longer ICU stay (24 vs. 8 days) than non-COVID patients, respectively (p<.001). Almost all patients were “Full Code” initially. However, status was eventually changed to ‘do-not-attempt resuscitation’ (DNAR) in about 60% of the cohort. COVID patients were made DNAR late in their ICU stay, predominantly in the last 24 hours of life (p=.04). Until the very end, patients in both groups were on tube feeds, underwent blood draws and imaging, required high dose vasopressors, with few limitations or withdrawal of therapies. Family members were usually not present at bedside at time of death. There was minimal involvement of chaplain and palliative care services.

Conclusions:

Muslim COVID-19 patients had prolonged mechanical ventilation and ICU stay and a delayed decision to DNAR status than non-COVID Muslim patients. Limitation or withdrawal of therapy occurred infrequently. The utilization of chaplain and palliative care service needs improvement.

Pediatric End of Life Care: Impact of Islamic Faith

Studies investigating children and families' experiences at end of life in Saudi Arabia are limited. However, one factor found to have an impact on patient and primary caregiver end of life care is Islam. Since women are the primary caregivers for children in Saudi Arabia, the purpose of this study was to explore the perceptions of Muslim women caring for a child at end of life. Using a qualitative approach, interviews were conducted with 24 female primary caregivers caring for a child at end of life. Thematic analysis was used to analyze the data. The researchers found that Islamic beliefs and practices had a positive influence on primary caregivers' experiences. Islamic beliefs and practices helped support participants through their child's end of life experience. Results have implications for health care education, practice, policy, and future research on end of life in Saudi Arabia other Muslim countries.

Honouring Wishes of Patients: An Islamic View on the Implementation of the Advance Medical Directive in Malaysia

An Advance Medical Directive (AMD) is a document in which competent patients express their wishes regarding their preferred choice of future medical plans in the event they become incompetent. AMD is important in relation to the patient's right to refuse treatment. However, they must also consider cultural and religious values of different communities. In Islam, there are several concerns that need to be addressed, namely the validity of the AMD according to Islamic jurisprudence and patients' right to end-of-life decision-making. To address these concerns, this article refers to multiple sources of Islamic jurisprudence, such as the Quran, the tradition of Prophet Muhammad and the works of Islamic scholars related to this topic. Based on the findings, Islam does not forbid the use of AMD as a method to honour patients' wishes in their end-of-life care. Islamic jurisprudence emphasises on the importance of seeking patients' consent before carrying out any medical procedures. However, several conditions need to be given due attention, such as: i) a patient's cognitive capacity during the process of drawing up an AMD; ii) the professional views of medical experts; iii) the involvement of family members in end-of-life care and iv) the limitations of a patient's decision-making in creating an AMD.

Nurses' perceived knowledge and benefits of artificial nutrition and hydration for patients nearing death: A survey among Jordanian nurses

OBJECTIVE

Existing research highlights the importance of nurses' knowledge and attitudes towards the provision of artificial nutrition and hydration (ANH) for patients with advanced cancer; however, the perspectives of Arabic and Islamic nurses have not yet been investigated. Therefore, we aimed to examine Jordanian nurses' knowledge, attitudes and perceived benefits in providing ANH for patients with advanced cancer.

METHOD

A descriptive cross-sectional design was employed.

RESULTS

Participants comprised 183 nurses (93.5% response rate). Around 80% received no training on ANH. Nurses had poor knowledge regarding ANH, with a mean score of 5.12 (SD=2.27) out of 15. Overall, nurses had positive attitudes towards ANH care (M = 3.09, SD = 0.29); however, the subscale analysis showed that nurses held inconspicuous beliefs about ANH benefits (M = 2.67, SD = 0.71) and strongly believed that ANH places a high burden on patients (M = 3.50, SD = 0.69). Nurses from government hospitals showed significantly higher ANH knowledge, as well as positive beliefs regarding ANH benefits, compared to less educated nurses.

CONCLUSION

Jordanian nurses have limited knowledge of ANH. Their positive attitude regarding ANH for terminally ill patients could be driven by cultural norms and beliefs, rather than education. Introducing ANH in nursing curricula and in-hospital services could have a positive impact on nurses' knowledge.

White lie during patient care: a qualitative study of nurses' perspectives

BACKGROUND

Keeping the patients well and fully informed about diagnosis, prognosis, and treatments is one of the patient's rights in any healthcare system. Although all healthcare providers have the same viewpoint about rendering the truth in treatment process, sometimes the truth is not told to the patients; that is why the healthcare staff tell "white lie" instead. This study aimed to explore the nurses' experience of white lies during patient care.

METHODS

This qualitative study was conducted from June to December 2018. Eighteen hospital nurses were recruited with maximum variation from ten state-run educational hospitals affiliated to Tehran University of Medical Sciences. Purposeful sampling was used and data were collected by semi-structured interviews that were continued until data saturation. Data were classified and analyzed by content analysis approach.

RESULTS

The data analysis in this study resulted in four main categories and 11 subcategories. The main categories included hope crisis, bad news, cultural diversity, and nurses' limited professional competences.

CONCLUSION

Results of the present study showed that, white lie told by nurses during patient care may be due to a wide range of patient, nurse and/or organizational related factors. Communication was the main factor that influenced information rendering. Nurses' communication with patients should be based on mutual respect, trust and adequate cultural knowledge, and also nurses should provide precise information to patients, so that they can make accurate decisions regarding their health care.

Top Ethical Issues Concerning Healthcare Providers Working in Saudi Arabia

Background: Healthcare providers working in Saudi Arabia come from various nationalities, cultures, and training backgrounds. This study aimed to assess the perceptions of healthcare providers working in Riyadh hospitals about ethical dilemmas and solutions.

Methods: This is a cross-sectional study among physicians working in Riyadh’s private and governmental hospitals between June and December 2017. The study collected information on demographics, knowledge about medical ethics, the sources of such knowledge, and common ethical issues in general and the top ethical issues and dilemmas encountered in their daily practice.

Results: A total of 455 physicians from government and private hospitals were enrolled in the study. The mean age of the participants was 34.29 ± 10.5 years, females were 29.7% and mean years of practice was 13.0 ± 11.5. The top ethical issues identified by the participants were “disagreement with the patients’ relatives about treatment” (91%), patient disagreement with decisions made by professionals (84%), treating the incompetent patient (79%), conflict with administration policy and procedures (77%), scarcity of resources (72%), and making decision about do-not-resuscitate or life-sustaining treatment (68%). There were significant differences in dealing with ethical issues in relation to gender, confidence about ethical knowledge, nationality, seniority, training site, and private or government hospitals academic and nonacademic.

Conclusion: Healthcare providers in Riyadh hospitals face multiple ethical challenges. In addition to improvement in ethics knowledge through educational program among healthcare professional, there is a valid need for healthcare professionals and other sectors within society to engage in serious and continuous dialogue to address these issues and propose recommendations.

Worldwide end-of-life practice for patients in ICUs

PURPOSE OF REVIEW

Published data and practice recommendations on end-of-life (EOL) generally reflect Western practice frameworks. Understanding worldwide practices is important because improving economic conditions are promoting rapid expansion of intensive care services in many previously disadvantaged regions, and increasing migration has promoted a new cultural diversity previously predominantly unicultural societies. This review explores current knowledge of similarities and differences in EOL practice between regions and possible causes and implications of these differences.

RECENT FINDINGS

Recent observational and survey data shows a marked variability in the practice of withholding and withdrawing life sustaining therapy worldwide. Some evidence supports the view that culture, religion, and socioeconomic factors influence EOL practice, and individually or together account for differences observed. There are also likely to be commonly desired values and expectations for EOL practice, and recent attempts at establishing where worldwide consensus may lie have improved our understanding of shared values and practices.

SUMMARY

Awareness of differences, understanding their likely complex causes, and using this knowledge to inform individualized care at EOL is likely to improve the quality of care for patients. Further research should clarify the causes of EOL practice variability, monitor trends, and objectively evaluate the quality of EOL practice worldwide.

Islamic Considerations on the Application of Patient's Autonomy in End-of-Life Decision

In end-of-life situation, the need for patient's preference comes into the picture with the intention of guiding physicians in the direction of patient care. Preference in medical directive is made by a person with full mental capacity outlining what actions should be taken for his health should he loses his competency. This is based on the reality of universal paradigm in medical practice that emphasises patient's autonomy. A specific directive is produced according to a patient's wish that might include some ethically and religiously controversial directives such as mercy killing, physician-assisted suicide, forgoing life-supporting treatments and do-not-resuscitate. In the future, patient autonomy is expected to become prevalent. The extent of patient autonomy has not been widely discussed among Muslim scholars. In Islam, there are certain considerations that must be adhered to.

The do-not-resuscitate order for terminal cancer patients in mainland China: A retrospective study

With the development of palliative care, a signed do-not-resuscitate (DNR) order has become increasingly popular worldwide. However, there is no legal guarantee of a signed DNR order for patients with cancer in mainland China. This study aimed to estimate the status of DNR order signing before patient death in the cancer center of a large tertiary affiliated teaching hospital in western China. Patient demographics and disease-related characteristics were also analyzed.This was a retrospective chart analysis. We screened all charts from a large-scale tertiary teaching hospital in China for patients who died of cancer from January 2010 to February 2015. Analysis included a total of 365 records. The details of DNR order forms, patient demographics, and disease-related characteristics were recorded.The DNR order signing rate was 80%. Only 2 patients signed the DNR order themselves, while the majority of DNR orders were signed by patients' surrogates. The median time for signing the DNR order was 1 day before the patients' death. Most DNR decisions were made within the last 3 days before death. The time at which DNR orders were signed was related to disease severity and the rate of disease progression.Our findings indicate that signing a DNR order for patients with terminal cancer has become common in mainland China in recent years. Decisions about a DNR order are usually made by patients' surrogates when patients are severely ill. Palliative care in mainland China still needs to be improved.