Culturally competent care is contingent on knowledge of the unique values and attributes of diverse communities. This article focuses on Islamic perspectives of suffering and meaning in illness as they relate to cancer care. Personal narrative and evidence-based information are integrated to inform a holistic nursing approach to the care of Muslim patients, particularly when supporting them and their families through suffering in the context of malignancy or significant illness.
AT A GLANCE
- For Muslim patients, the teachings of Islam offer ways to accept and find meaning in pain and suffering experienced through illness.
- Understanding Muslim beliefs about illness and medical treatment can help oncology nurses support patients and families through suffering in the context of malignancy or significant illness.
- Awareness of cultural and religious practices, including prayer, modesty, cleanliness, and diet, can help nurses provide holistic care to Muslim patients and families.
Understanding the unique cultural practices and health beliefs of different populations is important to providing culturally sensitive, evidence-based care. When caring for Muslim patients and their families, addressing needs related to privacy and modesty, dietary needs, and spiritual support is fundamental to integrating Muslim cultural practices into the context of cancer care (Mataoui & Kennedy Sheldon, 2016). An estimated 3.45 million Muslim individuals were living in the United States in 2017, representing diversity in race, country of origin, and sociodemographics (Pew Research Center, 2017). In the context of cultural and religious considerations, Muslim patient care has been explored concerning cancer screening (Lofters, Slater, & Vahabi, 2018), active treatment (Rasheed et al., 2017), advanced illness (Boucher, Siddiqui, & Koenig, 2017), and palliative care (Al-Shahri, 2016; Al-Shahri & Al-Khenaizan, 2005). Personal narrative and evidence-based information are integrated in this article to inform a holistic nursing approach to the care of the Muslim population, particularly when supporting patients and their families through suffering in the context of malignancy or significant illness.
As an Abrahamic faith, Islam shares aspects of belief and practice with other faiths that have a person’s relationship with God as a primary focus. Islam emphasizes worshiping God with love, devotion, and gratitude, and living according to His guidance. God is seen as the cherisher and sustainer of all creation. Muslims believe the events that happen in a person’s life are part of God’s plan to nurture and develop him or her and that each challenge comes with opportunity for benefit and spiritual growth. Illness and suffering are seen as part of the human condition by God’s design, but Islam does not view illness itself as either good or bad. Rather, illness is seen as a state prescribed by God that has the potential to bring a person closer to Him.
Muslims are encouraged to seek treatment for illness and relief from distress. However, when pain or illness remains after treatment options have been exhausted, Muslims believe there is wisdom behind this. Part of a Muslim’s approach to accepting the pain and suffering that exist in the world is accepting that God has reasons for what happens and trusting in this wisdom. The Prophet Muhammad taught that, for believers, all the conditions they face are good and offer opportunity for benefit. If believers are in prosperity and are grateful, they are rewarded by God for their gratitude. If they are in hardship and remain patient, they are rewarded for their patience (Al-Shahri, 2016). Therefore, all situations are good for people of faith. In fact, Islamic teachings state that God tests the people He loves most with more difficult hardships (Al-Shahri, 2016). However, not everyone will benefit from the experience of suffering; some will become bitter and reject God. Benefiting from hardship is not a given but an opportunity, depending on the faithfulness of people’s responses.
Islam teaches that going through hardship can be good in the following ways:
• The experience helps people appreciate their dependence on God.
• It increases sincerity in worship, bringing people closer to God.
• It expiates sins, teaches patience, and increases gratitude for times of ease.
To connect with God, Muslim patients likely will spend time in prayer. In addition to communicating with God informally, Muslims also observe more formal prayer, salah, that includes mental focus and physical movements, like bowing. Intentionality, cleanliness, modesty, and adherence to the specific mode ordained for the prayer are important aspects of the etiquette of salah. However, as important as they are, the rules are relaxed and the structure is modified if strict observance is not possible because of patients’ medical condition or ability.
Implications for Cancer Care
The experience of cancer can pose emotional, psychosocial, and spiritual challenges to patients, regardless of their religious affiliation. A cancer diagnosis, particularly in the context of advanced illness, can pose unique spiritual challenges as individuals seek to find meaning in life and suffering and contemplate what happens after death (Al-Shahri, 2016). Despite nurses acknowledging spiritual care as part of their role, gaps remain in the discussion and delivery of such care because of several barriers, including lack of specific training in spiritual care and discomfort with discussing personal beliefs (Rassouli et al., 2015). For healthcare providers, achieving a better understanding of their patients’ worldview and beliefs can increase understanding and rapport, improve patient care, and potentially reduce moral distress in providers.
Prayer is an integral component of Islamic spiritual life and often a means through which Muslim patients with cancer contemplate the meaning of illness and suffering, as well as find comfort and relief (Boucher et al., 2017; Mataoui & Kennedy Sheldon, 2016; Rassouli et al., 2015). An important way to support Muslim patients’ spiritual needs is by supporting personal and environmental cleanliness, which is essential to prayer (Al-Shahri & Al-Khenaizan, 2005). Prayer usually is preceded by a ritual washing, wudu, which includes wetting the hands, forearms, face, and feet. Cleanliness for prayer also involves avoiding having unclean, impure materials in contact with individuals’ bodies, their clothes, or the prayer space (Al-Shahri & Al-Khenaizan, 2005). Clothing or bedding that is soiled with urine or feces would render the space ritually unclean. Vomit or blood also may be of concern. Patients who are bedridden or who have limited mobility face challenges in maintaining cleanliness for prayer and may appreciate caregivers’ assistance with these needs. Muslims also will seek solace and well-being by reading, reciting, and listening to the Quran, which is considered a source of healing and spiritual guidance. Medical staff may hear audio recitations of the Quran being played in patient rooms.
In terms of pain control, it is appropriate for Muslims to be treated with medications to help relieve their pain, because they are not supposed to seek out or tolerate suffering for the sake of experiencing the suffering itself (Al-Shahri, 2016; Al-Shahri & Al-Khenaizan, 2005). However, some Muslim patients may choose to partially forego pain medication and prefer to tolerate some discomfort to be alert for prayer times (Al-Shahri & Al-Khenaizan, 2005; Tayeb, Al-Zamel, Fareed, & Abouellail, 2010). This may introduce conflict into decision making about treatment with medications that relieve pain but cause sedation. If healthcare providers are not aware of the values behind this type of choice, they may feel distress that their patients’ pain is not being adequately controlled. Another challenge could occur if surrogate decision makers are the ones deciding to forego pain medication on behalf of patients whose own preferences are unclear. When possible, goals for pain management should be discussed with patients while they have decisional capacity to help clarify their preferences in this area for staff and family members.
For Muslim patients, the teachings of Islam offer ways to accept and find meaning in pain and suffering experienced through illness. Even in times of extreme suffering, religious teachings instruct the faithful on how to approach God for relief. The Prophet Muhammad taught that someone suffering should not pray for death but should pray, “O God! Keep me alive as long as life is better for me, and let me die if death is better for me.” Muslims often wish to use their time at the end of life to continue to seek God’s favor and forgiveness. Even without a cure, the experience of suffering can bring healing. Supporting holistic care for Muslim patients, as with all patients, emerges from a place of cultural respect that ultimately may support not only patients and their family members, but also nurses’ understanding and experience of patient suffering in the context of cancer care.
About the Author(s)
Asma Mobin-Uddin, MD, FAAP, is a clinical bioethicist in the Center for Bioethics at the Ohio State University Wexner Medical Center and a pediatrician at Nationwide Children’s Hospital, both in Columbus. The author takes full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Mobin-Uddin can be reached at email@example.com, with copy to CJONEditor@ons.org.
Al-Shahri, M.Z. (2016). Islamic theology and the principles of palliative care. Palliative and Supportive Care, 14, 635–640.
Al-Shahri, M.Z., & Al-Khenaizan, A. (2005). Palliative care for Muslim patients. Journal of Supportive Oncology, 3, 432–436.
Boucher, N.A., Siddiqui, E.A., & Koenig, H.G. (2017). Supporting Muslim patients during advanced illness. Permanente Journal, 21, 16–190. https://doi.org/10.7812/TPP/16-190
Lofters, A.K., Slater, M., & Vahabi, M. (2018). Cancer screening among patients who self-identify as Muslim: Combining self-reported data with medical records in a family practice setting. Journal of Immigrant and Minority Health, 20, 44–50. https://doi.org/10.1007/s10903-016-0508-x
Mataoui, F., & Kennedy Sheldon, L. (2016). Providing culturally appropriate care to American Muslims with cancer. Clinical Journal of Oncology Nursing, 20, 11–12. https://doi.org/10.1188/16.CJON.11-12
Pew Research Center. (2017). U.S. Muslims concerned about their place in society, but continue to believe in the American dream. Retrieved from https://pewrsr.ch/2tYjcky
Rasheed, A.A., Rashid, Y.A., Pirzada, F.T., Haroon, F., Jabbar, A.A., & Rahim, A. (2017). Knowledge, attitude and perceptions of Muslim cancer patients regarding cancer treatment during Ramadan: Results from a tertiary care hospital Karachi. Journal of the Pakistan Medical Association, 67, 1144–1150.
Rassouli, M., Zamanzadeh, V., Ghahramanian, A., Abbaszadeh, A., Alavi-Majd, H., & Nikanfar, A. (2015). Experiences of patients with cancer and their nurses on the conditions of spiritual care and spiritual interventions in oncology units. Iranian Journal of Nursing and Midwifery Research, 20, 25–33.
Tayeb, M.A., Al-Zamel, E., Fareed, M.M., & Abouellail, H.A. (2010). A “good death”: Perspectives of Muslim patients and health care providers. Annals of Saudi Medicine, 30, 215–221. https://doi.org/10.4103/0256-4947.62836