دانش پرستاری: از کلاس درس تا جامعه

خانواده همچنان اصرار بر بردن بیمار به منزل دارند تا در منزل فوت نماید. آنها می‌گویند: "نمی‌خواهیم پدرمان بیشتر از این اذیت شود". حدس پزشکان معالج این است که خانواده با در نظر گرفتن شرایط کهولت، بیماری مزمن، خستگی از نگهداری بیمار، هزینه‌های درمان بیمار و در نهایت احتمال بالای فوت در بیمارستان به چنین تصمیمی رسیده‌اند.

ISLAMIC PERSPECTIVE: DEROVED FROM ISLAMIC BIOETHICS PROBLEMS AND PERSPECTIVES BY DARIUSCH ATIGHETCHI:

Some Muslim “scholars” believe that every possible effort should be made for the survival of the patient whilst others introduce the categories of unnecessary, ineffective or inappropriate measures when the patient is in the final throes in order to avoid invasive, painful or, in any case useless interventions.

The expression living will indicates a declaration made by a person in possession of his mental faculties, in which he specifies the limits within which he wants to be treated in the event of being in an extremely critical condition, without the possibility of recovery.

The term al-wasiya in Muslim law indicates the last wishes and, by extension, also a will (even if the latter is not strictly correct). Their regulation is present in Koran 5.106: “O ye who believe! When death approaches any of you, (take) witnesses among yourselves when making bequests, two just men of your own (brotherhood) or others from outside if ye are journeying through the earth, and the chance of death befalls you (thus).”, a Muslim can draw up an alternative living will, without a binding value and which can be defined a wasiya mubahah (admissible document) and includes the following elements64:

a) Request to suspend treatment if this does not improve the quality of life according to the principle “la darar wa la dirar” (no harm and no harassment).

In this case death is not accelerated as only excessive treatment is refused. However, hygiene and nutrition should be maintained.

(b) Instructions to switch off life-supporting equipment after brain stem death has been diagnosed. This was allowed by the Council of the Islamic Jurisprudence Academy of the OIC in Amman, 1996, 5th Resolution.

(c) Inclusion of the wish to donate organs according to the principle of public benefit (maslaha).

(d) It is worthwhile appointing an attorney, Arabic wakalah (pl.), to be expressly mentioned. When the patient’s mental faculties are compromised, his legal representative (wakil) is morally obliged to communicate the dying patient’s wishes to his relatives and Doctors.

Lastly, the living will must be signed by the author, by his legal representative (wakil) and by two witnesses, according to Koran 2.282: “The witnesses should not refuse when they are called on (for evidence)”. If none of the requests contained in the living will contradicts the teachings of the Shari’a, there is no justification for ignoring the directives it contains.

The Islamic Medical Association of North America (IMANA) recommends that all Muslims sign a kind of “Living Will” or “Advance Directive”. On the point of interest here, the sample declaration presented by the IMANA is similar to the content shown by Ebrahim. In the event of fatal illness or injury where the doctor certifies in writing that the use of life-prolonging procedures only artificially prolongs the agony, the patient asks that “such procedures be withheld or withdrawn, . . . with only the provision of appropriate nutrition and hydration and the administration of essential medications and the performances of any medical procedures . . . to alleviate pain”.

A model of “health care proxy and living will” was drawn up by the Connecticut (USA) Council of Masajid (Mosques) in November 2000 and differs from the previous two. In this, 67 the future dying patient explicitly authorises his agent “to direct that no treatment be conducted or withheld from me if to do so is against the teachings of Islam. . . . I direct that medication be judiciously administered to me to alleviate pain”. The subject refuses the possibility of anyone voluntarily interrupting his life and requests that “the ‘life support systems’ [may] be used in a judicious manner and their use discontinued . . . if it becomes reasonably apparent that they have no curative value”. Furthermore, the “life support systems” must “include but are not limited to artificial respiration, cardiopulmonary resuscitation, artificial means of providing nutrition and hydration, and any pharmaceutical drugs”.


Although as it is well-established in this case, patient being in state of ↓LOC, has no capacity in making decision and it is the physician ethical responsibility to do in the best interest of patient (beneficence) but another important aspect to be considered is to respect the patient autonomy in making his/her own decision. This (autonomy) can be justified by 1)-using patient preferences if any has been in the form of advance directive (living will) either in the form of written or communicated to a designated substitute (surrogate). 2-If these advance directives are unavailable, then surrogate (equivalent to patient’s autonomy) can choose if knows well enough what patient would choose if he or she were still decisional. 3- If there are multiple surrogates and they are not reached a common view, either a majority decision can be respected or physician can mediate between them to reach a decision.

4-If patient preferences are not known and physician conceives taking into account the patient’s best interest (based on diagnosis, prognosis, known cultural and religious values) that surrogate’s decision is either futile or inappropriate(e.g. forbidding specific treatment) ,then the case can be referred to hospital ethical committee or challenged in a legal institution. 5-As already mentioned in the case-scenario, it is the physician responsibility to continue attempts to know the reasons for forbidding extended treatment. For example, surrogates has no established relationship with medical team and lacks complete information pertaining to patient status and consequences or despite knowing the consequences (informed rejections),they might have past negative experiences that have weakened the confidence .Although desire to continue but they may have lack of resources and social support. In this way it is physician’s role to request the appropriate consult for mentioned aspects and in doing so he might be easily resolve their refusal.