Introduction
Research area and methodology
Participants
Anonymous name | Birth year | Sex | Type of physician | Ethnic background |
---|---|---|---|---|
Yusuf | 1977 | Male | Trainee general practitioner | Moroccan |
Talha | 1985 | Male | General practitioner | Moroccan |
Omar | 1984 | Male | Trainee neurologist | Moroccan |
Anwar | 1983 | Male | Trainee internist | Turkish |
Amin | 1959 | Male | Geriatrician | Afghan |
Khalid | 1974 | Male | Anaesthetist | Moroccan |
Farid | 1980 | Male | Acute medicine specialist | Moroccan |
Nabila | 1977 | Female | General practitioner | Moroccan |
Muhammad | 1970 | Male | General practitioner | Turkish |
Khadidja | 1982 | Female | Trainee internist | Moroccan |
Research team
Data collection
Personal information/background | |
Year of birth | |
Sex | |
Medical education | |
Motivation to study medicine | |
Current employment | |
Professional experience | |
Main questions | |
1. Would you like to think of a case in which palliative sedation was used? | |
2. What was (in this case) the reason to commence sedation? | |
3. How was the decision to sedate made? ... ..Who were involved? ...... What was the response? | |
4. Can you tell me how you communicated the suggestion for palliative sedation? Who were involved (present)? | |
5. What was the response to your suggestion to switch to palliative sedation (patient / family)? | |
6. Can you describe its course (until death?) | |
7. How did those who were closely involved with the patient (family, relatives, etc.) respond? | |
8. Can you tell me about the contact with those involved after the patient died? | |
*(Questions 1 to 8 can be applied to multiple cases.) | |
Palliative sedation and good death | |
9. What do you see as the objective of palliative sedation? | |
10. What do you mean by a good death ... for a patient ...for his / her family (for yourself)? | |
11. What do you feel about pain relief (in the form of medication) at the end of life? (Would you use it yourself if you were a patient ... based on what considerations.) | |
12. How do you think the application of pain management relates to a good death, and what part does palliative sedation play? | |
13. What, in your opinion, does the use of palliative sedation at the end of life mean for the ‘quality’ of life? | |
Religious background | |
14. In what kind of religious environment did you grow up (home & environment)? | |
15. Do you consider yourself a Muslim? Can you tell me something about that? | |
16. May I ask if you consider yourself to belong to a certain branch of Islam? | |
17. What is the current role and meaning of your religion in your daily life? | |
18. What is the significance of religion in your professional life (as a physician)? | |
19. Do you think your beliefs play a role in the considerations and choices you make as a professional? | |
20. What do the pronouncements of imams or Islamic scholars mean to you? | |
21. Are there any of pronouncements about palliative sedation to guide you? | |
Are there things you find important to say but have not been addressed? |
Data analysis and validation
Results
Super-ordinate theme | Subtheme | Quote |
---|---|---|
I: professional self-concept | ||
Primacy of individual moral decision as a physician | 1: ‘However, an Imam or Islamic scholar cannot simply dictate to me what I should do, because a physician is personally responsible for his own, Islamically as well right? Because you take action as you see fit’. (Yusuf) 2: ‘I am also a human being, but I think that we as Muslim or as physician are permitted by God to make a decision’. (Amin) 3: ‘If you are treating a patient to whom the imam’s opinion is important. In that case, in the interests of the patient you have to pay heed to it’. (Anwar) 4: ‘You say: well now, what is said about this in the literature or what sort of pronouncements have a bearing on it. And, well that this or that applies to the person dear to you. We can go ahead and do this. Nothing is standing in our way. I think that this would clear up a great deal of uncertainty’. (Omar) | |
Alleviating suffering as moral duty | 5: ‘Yes and if a patient is truly suffering physically, this is obvious from the state he is in, from his facial expressions, and then, of course, you have to do something about it’. (Farid). 6: ‘I think you have to see pain management as a separate issue. It is something detached from the stage of life a person is in. In short, if someone needs it then it must be used’. (Anwar) 7: ‘I see it as ‘li kulli dāin dawā’ (every disease has a cure, GM) [23], that’s what I think. Am I interpreting this properly? I’m not really sure. But I see a eh a disease, eh and I interpret it as such. So, if there’s a dawā’ (medicine, GM) for it, then I see it as my calling to go ahead and use it like this’. (Talha) | |
Pain relief as professional medical task | 8: ‘Well then, as I have already said, giving a patient pain relief is part and parcel of your duties as a physician’. (Khalid) 9: ‘As far as I am concerned, as a physician I am there to put the patient first and also to protect them, and in this pain relief is a must’. (Khadidja) |
Super-ordinate theme | Subtheme | Quote |
---|---|---|
II: attitudes towards death and dying | ||
II a: Islamic perspectives on a good death and the dying process | Importance of awareness | 10: ‘(…) that a person can’t perform his prayers, yes that is also an argument. How should you tackle this situation? As physician you are the one in the position of responsibility. Because you have unnecessarily lowered the state of someone’s consciousness’. (Yusuf) 11: ‘And that at your very end your last words should be the shahāda (Islamic testimony of faith, GM). That you are in a state to be able to pronounce this. Well, it’s not clear what you are experiencing when you are sedated, how much of this you can absorb’. (Khalid) 12: ‘And I don’t think it matters to God whether you are awake, clear in the head, you are unconscious (…) If He wishes, He can make contact with you. So, who am I to say: if you are asleep you are not able to communicate with God or to recite the shahāda for Allah’. (Amin) 13: ‘(…) that I can also concentrate as fully as possible on Allah, can pray, I would think that was wonderful. That my last words were Allah’s words, you know, that would be the most wonderful of all, of course. Or to die as I prayed, I think that would be tremendous. Well, naturally, you can’t do that if you are heavily sedated’. (Nabila) |
Expiation of sins through suffering | 14: ‘What they have said to me is that suffering at this stage, that is very important. Because it can work as an act of atonement for the sins you have committed throughout your life. And, when it’s all said and done, this is indeed an argument: to endure this now is good for him because he has a chance of going to Heaven, to Janna (Paradise, GM)’. (Omar) 15: ‘Some ideas prevalent Islam say: suffering is a sort of penance, a means by which you can atone for your sins. But this clashes a bit with your own actions as a physician’. (Khalid) 16: ‘It is a contradiction that someone who is suffering, um – let’s make no bones about it – um, should bear this with patience. Er, that they obtain blessings through this. We are aware of this. Therefore, I think: What should we do to accommodate it. You try being in my place when someone is suffering from cancer. One that has metastasized. And that person is told: Bear up, because this is a blessing and it can also be a blessing for you…..with every pang you feel your sins are being forgiven. There is no discomfort at all, says the Prophet, peace be unto him, if this is borne patiently, um, sins are forgiven [26]’. (Muhammad) | |
Medical intervention until death | 17: ‘They wanted to do everything that could be done. Saying then: Allah decides whether he lives or dies from this. And if you have said: If we operate and he dies all the same, youhave done your best but Allah had decided not the physician, not a human being (…) and had we not allowed this chance it would be tantamount to murder’. (Omar) 18 ‘Then indeed a specific ḥadīth (Traditions from the Prophet Muhammad, GM) or a certain āya (verse, GM) in the Koran, that somebody had once heard of is referred to. But nothing concrete, and it remains up in the air’. (Yusuf) 19: ‘Well, many also believe that as the physician says: Yes, we are going to stop treatment as medically we have reached the end of the road (…) That is immediately translated as: euthanasia, an active ending of a life or pulling out the plug. It gives rise to so many misconceptions. It is, of course, very difficult to explain. When it’s all said and done a person is losing someone dear to them, and this makes explanations very difficult’. (Anwar) | |
Giving the patient a chance | 20: ‘I think that everybody deserves a chance. I’ve sent someone who is ninety to intensive care because I didn’t think that his case was hopeless’. (Anwar) 21: ‘I am absolutely convinced that I as a physician, a Muslim doctor, must pull out all the stops. That you should never give up easily on someone. This is the reason that you are always just a little bit on the defensive side’. (Omar) | |
II b: palliative sedation in relation to Islamic perspectives on a good death | Palliative sedation as possibly life-shortening | 22: ‘Often, after I had given an injection I have had to pronounce life extinct. The thought frequently crossed my mind: well that’s a bit too much of a coincidence. Then I felt a little awkward, I’ve thought: have I really not been doing something wrong?’ (Nabila) 23: ‘But then again, I think about my own situation, if I had COPD and I knew there was medication, I would say: Begin palliative sedation. I would also be thinking about my family, about those closest to me’. (Farid) 24: ‘As Muslims we believe that of course there is a certain time at which it will happen. Nothing you can do will make it a second earlier or a second later. And this time is already fixed. It’s just that your mind wanders along these lines: I’m doing something and if I didn’t do it, the result would be different’. (Muhammad) |
Proportionate use of palliative sedation | 25: ‘I think that you have to adjust this discreetly. You must always be aware of what you are doing. In other words, that you do not overshoot the mark’. (Khalid) 26: ‘Certainly, just go ahead. I always compare it to a situation in which a person has a bad slipped disc, and the nerve pain is awful. As long, and I reiterate this over and over, it does not speed death up or shorten the length of life, it can be done’. (Nabila) | |
Palliative sedation versus cause of death | 27: ‘But in the eyes of many other people and if one is realistic one can understand their point of view, someone does not eat, does not drink’. (Amin) 28: ‘One matter I always think important is to explain to these people is that she did not die because of the medicines. That they, hum, go home understanding this. The woman had an illness and she died from it. I was not the cause, it happened to her. Now and then you can say that Allah has foreordained that it be so’. (Omar) |