Australian Critical Care 26 (2013) 193–196

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Australian Critical Care

journal homepage:www.elsevier.com/locate/aucc

Ensuring cultural sensitivity for Muslim patients in the Australian ICU:

Considerations for care
∗
Melissa J. Bloomer MN(HONS), MPET, MNP, RN ,

Abbas Al-Mutair MN, CCN Post Grad Dip, RN

Monash University, School of Nursing and Midwifery, PO Box 527, Frankston VIC 3199, Australia
articleinformation abstract

Article history: Australia is a diverse

Received 29 January 2013 and multicultural
Received in revised form 11 March 2013 Accepted 16 April 2013
nation, made up of a
population with a
Keywords:
predominant Christian
Islam
Muslim
faith. Islam, the second
Cultural sensitivity largest religion in the
Death and dying world, has
ICU demonstrated
Terminally ill significant growth in
Australia in the last
decade. Coming from
various countries of
origin and cultural
backgrounds, Muslim
beliefs can range from
what is considered
‘traditional’ to very
‘liberal’.

It is neither possible
nor practical for every
intensive care clinician
to have an intimate
understand-ing of Islam
and Muslim practices,
and cultural variations
amongst Muslims will
mean that not all
beliefs/practices will be
applicable to all
Muslims. However,
being open and flexible
in the way that care is
provided and respectful
of the needs of Muslim
patients and their
families is essential to
providing culturally
sensitive care.

This discussion
paper aims to describe
the Islamic faith in
terms of Islamic
teachings, beliefs and
com-mon practices,
considering how this
impacts upon the
perception of illness,
the family unit and how
it functions, decision-
making and care
preferences,
particularly at the end
of life in the intensive
care unit.
© 2013 Australian College of Critical Care Nurses Ltd.
Published by
Elsevier
Australia (a
division of Reed
International
Books Australia
Pty Ltd). All
rights reserved.
Introduction people in Australia
2
following Islam.
1 Statistics from 2011
In Australia today, the population is diverse and multicultural, with migrants making up a large component of the population.
reveal that the
In 2011, more than one quarter of Australia’s population were born overseas, and while the majority of the migrant population in proportion of people
Australia has historically come from Europe, the proportion of migrants coming from Asia and the subcontinent as well as other in Australia
1 following Islam has
parts of the world in increasing steadily. This diversity is reflected in the number of languages spoken and religions practiced.
Chris-tianity is the dominant faith in Australia with the latest Census results indicating that 61% of Australians identified as having increased by 69% in
1 the decade up to
a Christian faith, 7.2% of people identified with a non-Christian faith and 22.3% stating they had no religion. 1,2
2011.
With increasing
2,3
Worldwide, Islam is the fastest growing religion, accounting for 22% of the world’s population. Countries with the largest cultural diversity,
2 and more
Muslim populations include Indonesia, Pakistan, Bangladesh, India, Turkey, Iran, Egypt and Nigeria. In Australia, Islam has been
evident for some time, but it was the shift in the government’s migration policies in the 1970s that triggered an increase in the specifically as a
number of result of the growth
of Islam in
Australia, there is a
growing need for
∗ clinicians to ensure
Corresponding author. Tel.: +61 3 9904 4203. holistic care is
E-mail addresses: melissa.bloomer@monash.edu (M.J. Bloomer), provided that is also
abbas.almutair@monash.edu (A. Al-Mutair).
cultur-ally
congruent,
particularly for those
from minority or
marginalised ethnic
4
backgrounds. This
has been recognised
by the Royal Col-
lege of Nursing
Australia and the
Australian Nursing
and Midwifery
Board both of which
promote that nursing
care should respect
the values and
beliefs of various
5
cultures, be
culturally inclusive,
empowering and
meaningful to
various cultures;
and, that it should
meet the diverse
needs of the
Australian
6
Community.

The purpose of
this discussion paper
is to consider the
cultural and
religious perspective
of Muslims in
Australia, and how
inten-sive care
clinicians can
provide culturally
sensitive care for
Muslim patients and
their families in the
intensive care unit
(ICU). Before this is
possible, a deeper
understanding of
Islam is essential.

Islam
 The word Islam means “peace” and when it is used within the religious context it means the active submission to one God
(called Allah in Arabic), who is believed to be the sole creator of the humankind and the universe. A Muslim believes in one God
and
1036-7314/$ – see front matter © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
http://dx.doi.org/10.1016/j.aucc.2013.04.003
194 M.J. Bloomer, A. Al-Mutair / Australian Critical Care 26 (2013) 193–196
 is unable to participate in Car
7
in Muhammad as the final messenger of God, the life after death (hereafter) mortality rates are higher care decisions as a result of
8 than most other care their illness. ing
and resurrection of the body. Muslims are divided into two major sects, the
Sunni and Shi’a, and while there are some differences between the two sects
15
settings, and as many as For the Islamic patient, for an
9 one in five patients die in the
in relation to interpretation, methodology and authoritative systems, both
16
maintaining a family- Islami
sects share many commonalities in their religious and cultural beliefs and ICU. While care of the centred approach, where the
practices. ICU patient is complex and family is included in c
The teaching and laws of Islam are essentially derived from two sources, multifactorial, involving aspects of care planning is patien
the Noble Qur’an (the Holy Book revealed to Allah’s last messenger) and complex treatment plans and of high importance as it
10 interventions, clinicians must recognises the importance t in
Sunnah (sayings, deeds and sanctions of the Prophet Mohammed).
According to these sources, there are five pillars of Islam, which are
remain ever cognisant that 20
of the family unit. In this itself
beyond the waveforms and
considered the foundations of Muslim faith,
10
detailed in Table 1. technology, is an individual
way, the trend
Australian ICUs to focus on
for can
in the bed with not only
physical needs, but also
family-centred care is not in be
contrast with the needs of
The family in Islam psychosocial, social, cul-
the Islamic patient and their
diffic
17
tural and spiritual needs. family, however, ensuring ult if
Islam focuses on every aspect of human lives, and the family unit is Holistic care is dependent on care is perceived in this
viewed as the foundation of Islamic society. Islam encourages gender equity, the nurse building positive way can still be
the
and men and women are considered complemen-tary to each other, and
11 working relationships with problematic. This is nurse
the patient and their families because effective family-
within the family unit, all family members have duties towards each other. For
that allows for their specific centred care is also reliant is
example, Islamic teachings dictate that parents are required to care for and
educate their chil-dren, and similarly, children are expected to look after their
needs to be incorporated into on establishing rapport and unfa
the care, interventions and open effective
2
parents as they age. The mother in a Muslim family holds a particularly treatment provided in the communication between miliar
important position and in accordance with the Qur’an and Prophet 17
12
ICU. families and clinicians.
17,21 with
Mohammed sayings, she must be honoured.
Ensuring care is sensitive
Where language and what
cultural differences exist,
to the varying cultural needs effective communication is
Concept of illness in Islam of patients is imperative in
every clinical setting, but the
can be difficult imped-ing cultur
the establishment of
For Muslims, life is sacred because God is considered its origin and its nature of intensive care and rapport. Communication ally
the patient’s critical illness can be further hampered
destiny, and life is a divine trust and an opportunity for spir-itual refinement.
8
creates a heightened need, when, for some Muslim
unacc
Muslims therefore believe that illness is a test of person’s faith in God, and a and is dependent on nurses’ eptabl
12
women, they are required to
form of atonement for sins of the past. Illness is viewed as an opportunity to attitudes, values and belief cover their faces and
enhance a person’s spiritual connection, and as a result, the Muslim person sys-tems, particularly when 22
e. In
heads. For some
will respond to ill-ness with stoicism, become more engaged in prayer and it comes to providing holistic
Muslims, their beliefs also Austr
reading the Qur’an, in remembrance of God and asking for forgiveness. care for those who come
from diverse or minority
stipulate that a male alian
member of the family is
Muslims also believe that God is the ultimate healer of any phys-ical and ethnic or cultural groups. It
4
designated as the family ICUs,
3
psychological illness, and that the illness itself and cure are at God’s will. is therefore important to spokesperson, even if he is like
13 consider the ‘usual’ practices not the direct next-of-kin,
They believe that death does not happen, except by God’s permission, and
in Australian ICUs and the medi-ating the many
while saving a life and caring for someone is considered one of the highest
8
imperatives in Islam. Any treat-ment or care provided to the ill person are
impact these practices may communication between other
have on the provision of clinicians and any female
simply a means used to do God’s will.
3
culturally sensitive patient family members.
10
The
Weste
care. right or power to make or rn
Australian intensive care units (ICUs) contribute to decisions is care
also often allocated to a
male family member above settin
The Australian population is served by more than 140 gen-eral intensive The challenges all others, and in-keeping
14 with Islamic practices, this
gs,
care units (ICUs), which manage more than 119,000 admissions per year.
Patients in the ICU are often gravely ill,
Model of care delivery nominated ‘decision-maker’ physi
may even hold more
Typically, the Australian influence in decision-
cal
Table 1
The five pillars of Islam. ICU nurse spends more time making than the patient, a touch
at the patient’s bedside than practice in discordance with
1. Declaration of faith (Shahadtain in Arabic); 18 usual Australian beliefs. For is
any clinician. The way that
There is no God but Allah, and Mohammad is the Messenger of Allah;
the ICU nurse provides care
others, decision-making is con-
2. Prayer; considered to be the right of
Muslims are obligated to pray five times a day, and prayer is a combination of intellectual, is influenced by several 10 sidere
meditation, spiritual and physical exercise, performed with physical cleanliness (ablution) factors including the ICU’s the whole family, and
and in a standing position facing Mecca (the Islamic holy city); model of care delivery and clinicians should liaise with d
the nurse’s personal the family spokesperson in integr
3. Charity (Zakat); philosophy of car-ing for the order to determine their
Muslims must share their personal wealth with the poor and needy ;
7
patient and the family.
17,19 particular beliefs. al to
4. Fasting;
Muslims fast during month of Ramadan from sunrise to sunset during this 30 day period, Family-centred care, an caring
approach to care that is
which is the ninth month of the Muslim lunar year; and
5. Pilgrimage (Hajj); common to Australian ICUs, and
At least once in every Muslim person’s life span this must occur, if they are physically is founded on respect and the
and financially able. partnership amongst patients,
17 The nature of caring nurse
families and clinicians and
is essential when the patient –
patient relationship.23 It is used as a way of
providing comfort to a patient and/or the family
M.J. Bloomer, A. Al-Mutair / Australian Critical Care 26 (2013) 193–196 195
 expected to receive death Mecca,
24 Considerations at the end of with self-control, patience located
and as a demonstration of empathy and sensitivity. Islamic teach-ings
life and prayer; because they towards
however, forbid unnecessary touch, even the shaking of hands between
10 believe that a Mus-lim can the West-
unrelated adults of opposite sexes is prohibited. This means that the use of Death in ICU is be closer to God through North-
touch as a comfort measure when it is not directly related to performing a task 16,29 prayer and reading of the West in
is not valued amongst those of the Islamic faith and should be avoided. When common and providing Australia
Qur’an. Prayer and reading
touch is necessary, consideration should also be given for which hand is used. care for patients at the end of 31
life is undertaken with the Qur’an will become a , and
Muslims reserve the right hand for performing clean tasks such as consum-ing
3 sensitivity and compassion, priority, even more so than where
food and drink, while the left hand is reserved for unclean tasks. So where the usual practice of prayer possible,
taking into consideration the
possible, nurses should use their right hand in care tasks such as to distribute 8 five times a day, and this is acknowle
medication or when touching the Muslim patient, as a sign of respect. patient’s needs, and
believed to be the best way dging the
supporting the family constrain
for the family to overcome
through the death of a loved ts that
19,21 depression, anxi-ety,
10 one. For Muslims, helplessness and may
Modesty is also a core value of Islam, and while maintaining patient
17
every-thing possible must be disappointment. In caring exist in
dignity and modesty is also a core value in Australian ICUs, how modesty is done to prevent premature for a dying Muslim patient, the
interpreted by ICU clinicians and the Muslim patients and their family can death, but when medical clinicians need to physical
vary greatly. Even amongst Muslims, the degree/extent to which modesty is experts believe death is acknowledge and respect bed
observed can vary greatly. For Muslim women, some interpret ‘hijab’ as inevitable and it is space
the patient and family’s
covering a woman’s body including her hair and face, for others it is determined that treatment and the
religious beliefs,
interpreted as means covering the entire body except the face and hands, and will not improve the patient’s positioni
2 acknowledging that even
for others it is interpreted as choosing modest clothing. This mod-esty also condition or qual-ity of life, ng of
withdrawal or withholding amongst Mus-lims, there
applies for Muslim men who are required to cover their bodies at least from equipme
13 can be great variation on
2 treatment is acceptable, nt, this
‘navel to knee’, and are practices that should be continued in the ICU where beliefs and practices.
7
should
possible. The need for modestly will also result in some families insisting on because this is seen as
allowing death to take its When an appropriate be
the presence of another female during the examination of a female Muslim facilitate
9 religious or spiritual leader
patient and husbands may insist on being present while their wives are being natural course. However d
25 is not available from within
examined. Islamic beliefs dictate that wherever
the hospital, or when the
nutrition should not be possible,
ceased as this is considered a family indicate a
preference, they should be as a sign
crime according to Islam. of
Gender can create further considerations for care. In many Mus-lim Pain relief and sedation are encouraged to invite in their
countries, the custom is to have separate wards for opposite genders and it own religious/spiritual respect
acceptable under Islam, even
would be considered totally unacceptable to have patients of opposite genders for the
if these pharmacological leader to visit with the
10 patient
in the one room. In Australian ICUs, issues of nurse–patient ratios, patient interventions may hasten dying patient and their
and their
dependency, nurse skill mix and education are important considerations in the death.
13 family, and to be included
family,
26 in end of life discussions, at
allocation of staff to patients, but for the Muslim patient, the gender of cli- and their
30
nicians and the proximity to other patients of the opposite gender are For Muslims, religious the family’s discretion. religion.
significant issues and, where possible, these issues should also be considered. faith is core to coping with Ensuring that the patient
22 30 and family’s religious needs After
The preference for Muslims is for carers to be of the same sex, and a male death. Mus-lims believe
clinician should never attempt to inter-view or examine a female patient that death is God’s will and a are met must be a high pri- death,
10 test to the dying person, ority leading up to death,
30 just as
without another of her adult relatives or a female nurse being present. clinician
Obviously, this may not be possible or practical in an ICU, particularly when family and community, and even if that means delaying
that no one can escape death s in
the unit has an open-plan designed to maximise surveillance, but bear-ing this some care tasks until after
7 Australia
strong custom in mind, the use of single rooms where possible, and/or closed when it comes. The Qur’an the religious needs have
n ICUs
bedside curtains could assist to allay dis-tress caused by the co-location of details how no one can die been observed. would
other patients of the opposite gender. except by per-mission of already
Allah, and they will die do, the
12 Some Muslim families
when their time has come. body of a
Consequently, Muslims view may prefer to be with their Muslim
death as a bridge to an loved one dur-ing the last patient
eternal after-life (hereafter) moments such as during should
Family presence in the ICU and a journey towards resuscitation or withdrawal be
resurrection and meeting of life sustaining handled
Muslim families are often close-knit, with a strong sense of commitment 3 equipment, to ensure that with high
God.
amongst family members, especially at a time of illness or death, and religious rituals are respect
hospitalisation of a family member in the ICU may result in disequilibrium For the ICU clinician, observed. Muslims believe and
27 ensuring that the specific in Shahadtain, a testimony gentlenes
within the family. Regard-less of age or gender of the patient, all family 31
cultural/religious needs of of faith, as a declaration s as
members are expected to visit and participate in the caregiving process to the Muslim patient and their
3 that signifies the person Muslims
varying degrees, and provide emotional, financial and spiritual support. family are acknowledged entering paradise as if it believe
Visiting the sick represents a favourable social act, an obligation and a way to will significantly assist was the last statement the
honour the patient. Visiting is cultur-ally encouraged in Islam, as sick people coping up to and after death. 31 person’s
7,28 before death, and while it
are considered to be very close to God. As a result, it is very common that As well as Muslim soul can
may not be possible for the
dur-ing illness a large number of family and friends might gather in the preferences for still feel
critically ill patient in ICU
hospital to visit, and some may choose to stay in the hospital at all times to communication, decision pain until
to deliver the Shahadtain, 3,3
closely monitor the condition of the patient.
27 making and care delivery as burial.
spiritual preparation for
discussed previously, there death can be achieved in 2
are other ways in which the Some
other ways. Fam-ilies may families
ICU clin-ician can provide place a high priority on
culturally sensitive care at may
facing or orientating the
the end of life. As the end of dying patient towards
life approaches, Muslims are
wish to perform a special washing ritual known as a Ghusul, be shrouded with
a
196 M.J. Bloomer, A. Al-Mutair / Australian Critical Care 26 (2013) 193–196
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