Spirituality and Healing: A Spirituality and Healing: A Relationship between Faith and Relationship between Faith and

MedicineMedicine Topic: Futile Care at End of Life.& Natural Topic: Futile Care at End of Life.& Natural

Disasters—Katrina, Sandy, Jeddah Floods.Disasters—Katrina, Sandy, Jeddah Floods.

Prof. Faroque A Khan. MB(kmr), MACP.Prof. Faroque A Khan. MB(kmr), MACP. Director IMANA International Collaboration.Director IMANA International Collaboration. IMC/IMANA Conference –Jeddah. KSA IMC/IMANA Conference –Jeddah. KSA

Dec 29-30 2013.Shaaban 26,1435Dec 29-30 2013.Shaaban 26,1435

With respect to personal With respect to personal financial relationshipsfinancial relationships, , contracted contracted researchresearch includes research funding where the institution gets includes research funding where the institution gets the grant and manages the funds and the person is the the grant and manages the funds and the person is the principal or named investigator on the grant.principal or named investigator on the grant.

Conflict of Interest: Conflict of Interest: Circumstances create a conflict of Circumstances create a conflict of interest when an individual has an opportunity to affect CME interest when an individual has an opportunity to affect CME content about products or services of a commercial interest content about products or services of a commercial interest with which he/she has a financial relationship.with which he/she has a financial relationship.

The ACCME considers The ACCME considers financial relationshipsfinancial relationships to create to create actual conflicts of interest in CME when individuals have both actual conflicts of interest in CME when individuals have both a financial relationship with a commercial interest and the a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or opportunity to affect the content of CME about the products or services of that commercial interest. The ACCME considers services of that commercial interest. The ACCME considers “content of CME about the products or services of that “content of CME about the products or services of that commercial interest” to include content about specific commercial interest” to include content about specific agents/devices, but not necessarily about the class of agents/devices, but not necessarily about the class of agents/devices, and not necessarily content about the whole agents/devices, and not necessarily content about the whole disease class in which those agents/devices are used.disease class in which those agents/devices are used.

With respect to With respect to financial relationshipsfinancial relationships with commercial with commercial interests, when a person divests themselves of a relationship interests, when a person divests themselves of a relationship it is immediately not relevant to conflicts of interest but it must it is immediately not relevant to conflicts of interest but it must be disclosed to the learners for 12 months.be disclosed to the learners for 12 months.

The provider collects disclosure information from all The provider collects disclosure information from all Individuals in control of content. Those who refuse to disclose Individuals in control of content. Those who refuse to disclose

this this information are disqualified from participating. For any person information are disqualified from participating. For any person who reports a relevant financial relationship, the provider uses who reports a relevant financial relationship, the provider uses a peer review process to resolve the potential conflict of a peer review process to resolve the potential conflict of interest. For presentations that have the greatest potential for interest. For presentations that have the greatest potential for bias, the provider asks an independent third party reviewer to bias, the provider asks an independent third party reviewer to conduct a second peer review as an additional mechanism to conduct a second peer review as an additional mechanism to resolve conflicts of interest. (SCS 2.1, SCS 2.2, SCS 2.3) resolve conflicts of interest. (SCS 2.1, SCS 2.2, SCS 2.3)

disclose relevant financial relationships to me and to the disclose relevant financial relationships to me and to the learners who participate in my activities?learners who participate in my activities?

Disclosure InformationDisclosure Information

In compliance with the guidelines established by ACCME

I have NO actual or potential conflict of interest in relation.

I have no relevant financial interest

to this program or presentation.

IntroductionIntroduction

• All mandates of Islam aim at preserving:All mandates of Islam aim at preserving:– Life Life النفسالنفس– Faith Faith الدينالدين– Mind Mind العقلالعقل– Possessions (money/wealth) Possessions (money/wealth) المالالمال– Parentage Parentage النسبالنسب

IntroductionIntroduction• Ultimately, cure is by AllahUltimately, cure is by Allah

– ““And when I am ill, it is He (Allah) who cures And when I am ill, it is He (Allah) who cures me” Ash-shuraa, verse 80me” Ash-shuraa, verse 80

• Individual responsibilityIndividual responsibility– ““On no soul does Allah place a burden greater On no soul does Allah place a burden greater

than it can bear. It gets every good that it than it can bear. It gets every good that it earns, and it suffers every ill that it earns” earns, and it suffers every ill that it earns” AlBakarah, verse 286AlBakarah, verse 286

DYING CAN GET DYING CAN GET COMPLICATED-- COMPLICATED--

1)Permanent cardiopulmonary death-cpd1)Permanent cardiopulmonary death-cpd 2) CPD, possibly not yet permanent.2) CPD, possibly not yet permanent. 3)CPD with cessation of cellular activity.3)CPD with cessation of cellular activity. 4)Dead but mechanically functioning.4)Dead but mechanically functioning. 5)Brain death with no detected activity5)Brain death with no detected activity 6)Brain dead, but not entirely.6)Brain dead, but not entirely. 7)Life is gift from Allah-God-and it is to be 7)Life is gift from Allah-God-and it is to be

revered until it ends by itself—Soul & Body revered until it ends by itself—Soul & Body separation:Q 3:145- 39:42- 45:26-, 23:100separation:Q 3:145- 39:42- 45:26-, 23:100

Grandma Martha’s Dilemma: Grandma Martha’s Dilemma: Surveyed Cross Section of Surveyed Cross Section of Community. 52 Responded.Community. 52 Responded.

Scholars, imams, MD, Scholars, imams, MD, homemakers etc.homemakers etc.

10 women and 42 10 women and 42 men responded.men responded.

52% –prohibited, 33% 52% –prohibited, 33% OK,15%-no opinion.OK,15%-no opinion.

IMANA Newsletter: IMANA Newsletter: Vol XXIII, Issue 3.Vol XXIII, Issue 3.

Yes:-Milk-mother-Yes:-Milk-mother-Surrogacy for ailment.Surrogacy for ailment.

No: Birthing No: Birthing mother(58:2)-mother(58:2)-Adultery.Adultery.

Others: Get fatwa, Others: Get fatwa, Not a scholar, Not a scholar, concerns regarding concerns regarding family dynamics. family dynamics.

Futile CareFutile Care

Definition: Prevalence: Two Examples- Definition: Prevalence: Two Examples- Terri Schiavo and Prof. Jeffrey Butler.Terri Schiavo and Prof. Jeffrey Butler.

Religious GuidelinesReligious Guidelines Incorporating Religious Guidelines in Incorporating Religious Guidelines in

Curriculum.Curriculum. Resource Allocation-Rationing : Two Resource Allocation-Rationing : Two

Examples- Katrina(2005) Sandy (2012)Examples- Katrina(2005) Sandy (2012)

Futile Care: References.Futile Care: References. FK: JIMA 18:20.1986-Brain DeathFK: JIMA 18:20.1986-Brain Death FK: Fordham Law Jour. xxx Nov 2002 page 267-FK: Fordham Law Jour. xxx Nov 2002 page 267-

277—DNR & Bioethics.277—DNR & Bioethics. Badawi G, Smith F, Davidson, FK: PanelBadawi G, Smith F, Davidson, FK: Panel JIMA 43,113-133 Dec 2011.JIMA 43,113-133 Dec 2011. FK: JIMA (Ed) 38:6-9 March 2006-TS.FK: JIMA (Ed) 38:6-9 March 2006-TS. Huynh TN et al: JAMA Sept 9, 2013-FutileHuynh TN et al: JAMA Sept 9, 2013-Futile Butler-K: Knocking on Heaven’s Gate: Book-Butler-K: Knocking on Heaven’s Gate: Book-

Scribner Sept 2013.Scribner Sept 2013.

WHAT IS FUTILE CARE?WHAT IS FUTILE CARE?JAMA Sept 9 2013-Huynh TNJAMA Sept 9 2013-Huynh TN

DEF: 1)Burden> Benefit—58% DEF: 1)Burden> Benefit—58% 2)Treatment goals could never reach pt 2)Treatment goals could never reach pt goals 51 % 3)Death imminent 37%4) goals 51 % 3)Death imminent 37%4) Survival outside ICU not likely 36%Survival outside ICU not likely 36%

3month prospective study in five ICU’s.3month prospective study in five ICU’s. 1136 pts, 6916 assessed by 36 1136 pts, 6916 assessed by 36

consultants.—80%appropriate care, 9% consultants.—80%appropriate care, 9% probably futile, 11% futile care.probably futile, 11% futile care.

FUTILE CARE-Contd.FUTILE CARE-Contd. Six month mortality for the 123 pts who Six month mortality for the 123 pts who

received futile care was 85%, survivors quality received futile care was 85%, survivors quality of life very poor.of life very poor.

Cost was 2.6 million $$ =9.75SR Cost was 2.6 million $$ =9.75SR Suggest: Early transition to palliative care.Suggest: Early transition to palliative care. NYT Wed Nov 20,2013-How Doctors Die.NYT Wed Nov 20,2013-How Doctors Die. Identify FC in ICU-first step toward refocussing Identify FC in ICU-first step toward refocussing

care on patients more likely to benefit.care on patients more likely to benefit.

What To Expect? Chest Vol What To Expect? Chest Vol 144, Nov 2013-page 1707-1709144, Nov 2013-page 1707-1709 Three Step Approach:Three Step Approach: 1) Physicians decide care is futile1) Physicians decide care is futile 2) Appropriate committee agrees.2) Appropriate committee agrees. 3)Clinical outcome that often is, but not always, 3)Clinical outcome that often is, but not always,

pt death.pt death. Future futility guidelines need to incorporate Future futility guidelines need to incorporate

prospective data on its appl.prospective data on its appl. ATS, SCCM,ACCP, AACCN, ESICM preparing ATS, SCCM,ACCP, AACCN, ESICM preparing

guidelines.guidelines.

Source of Islamic Guidelines-Source of Islamic Guidelines-

Quran—God’s commands. Quran—God’s commands. Hadith—Prophet Mohd.(pbuh)-words & Hadith—Prophet Mohd.(pbuh)-words &

deeds.-deeds.- Ijma (Group consultation)Ijma (Group consultation) Qiyas (Personal opinion)Qiyas (Personal opinion) Other Sources.Other Sources.

What is Sharia?What is Sharia? Shariah means a road—travel spiritually very Shariah means a road—travel spiritually very

quickly without accident.quickly without accident. Operative formula by which Muslim Operative formula by which Muslim

determines what is good and ethical.determines what is good and ethical. Objectives: Objectives: 1) Criminal law:—murder, larceny,libel etc1) Criminal law:—murder, larceny,libel etc 2)Family—Marriage, divorce, inheritance, 2)Family—Marriage, divorce, inheritance,

custody, ?surrogacy.custody, ?surrogacy. 3)Transactions-Property, contracts, gifts,3)Transactions-Property, contracts, gifts,

Sharia--ObjectivesSharia--Objectives

Protection of life—Quran 5:32.Protection of life—Quran 5:32. Protection of religionProtection of religion Protection of property or wealthProtection of property or wealth Lineage and offspringLineage and offspring Protection of mind—sanity, Protection of mind—sanity,

reasons/intellect.reasons/intellect.

Courtesy of Dr. Aasim I. PadelaCourtesy of Dr. Aasim I. Padelaapadela@uchicago.eduapadela@uchicago.edu

Considerations Inputs

Maslaha

Hurma

Courtesy of Dr. Aasim I. PadelaCourtesy of Dr. Aasim I. Padelaapadela@uchicago.eduapadela@uchicago.edu

Islamic ethico-legal deliberationIslamic ethico-legal deliberation

Courtesy of Dr. Aasim I. PadelaCourtesy of Dr. Aasim I. Padelaapadela@uchicago.eduapadela@uchicago.edu

SocialScience

Medical Sciences

Philosophy &Bioethics

HealthPolicy

Ethics(Adab)

Moral Theology

(usul al fiqh)

IslamicLaw

(fiqh, hukm)

ClinicalPractice

AnIslamicBioethics

DiscursivePartners

Inputs

What Broke my Fathers Heart-NYT What Broke my Fathers Heart-NYT June 14,2010 by Katy Butler--1June 14,2010 by Katy Butler--1

85 male, retired professor, had stroke at age 85 male, retired professor, had stroke at age 79, had some cognitive & mobility problems.79, had some cognitive & mobility problems.

Wife became constant caregiver, lost wt, Wife became constant caregiver, lost wt, became depressed.became depressed.

Jeff developed painful inguinal hernia, for long Jeff developed painful inguinal hernia, for long standing bradycardia, pacemaker was placed standing bradycardia, pacemaker was placed preop—wife consented.(Jeff had refused it a preop—wife consented.(Jeff had refused it a year earlier--overtreatment)year earlier--overtreatment)

What Broke my Fathers Heart-NYT What Broke my Fathers Heart-NYT June 14,2010 by Katy Butler-2June 14,2010 by Katy Butler-2

Hernia was fixed. Pacemaker continued Hernia was fixed. Pacemaker continued ticking over next few yrs. ticking over next few yrs.

Jeff developed dementia, macular Jeff developed dementia, macular degeneration, and became incontinent.degeneration, and became incontinent.

Wife wanted to have pacemaker deactivated.Wife wanted to have pacemaker deactivated. Family felt Jeff did not want to live in this Family felt Jeff did not want to live in this

state.state. Living will does not address dementia or Living will does not address dementia or

pacemaker as life support.pacemaker as life support.

What Broke my Fathers Heart-NYT What Broke my Fathers Heart-NYT June 14,2010 by Katy Butler-3June 14,2010 by Katy Butler-3

A)Should Jeff’s pacemaker be turned off?A)Should Jeff’s pacemaker be turned off? B)Who decides when pt is mentally B)Who decides when pt is mentally

incapable?incapable? C) Doctors are trained as healers, what C) Doctors are trained as healers, what

responsibility do/should they have in responsibility do/should they have in presenting life sustaining versus alternative presenting life sustaining versus alternative therapies?.therapies?.

D) Medicare rewards far better for doing D) Medicare rewards far better for doing procedures than for assessing whether they procedures than for assessing whether they should be done at all.should be done at all.

Islamic(Muslim) Physician What Islamic(Muslim) Physician What does it mean?.does it mean?.

Birth. Free Will.Birth. Free Will. Predetermined life span.Predetermined life span. Book—Quran.Book—Quran. Death.Death. Afterlife.Afterlife. Accountabilty.( Key factor—Intention) Accountabilty.( Key factor—Intention)

Guidelines:Sharia—Key PointsGuidelines:Sharia—Key Points

Necessity overrides Necessity overrides prohibition.prohibition.

Harm to be removed Harm to be removed Accept the lesser of Accept the lesser of

two harms if both can two harms if both can not be avoidednot be avoided

Public interest Public interest overrides the overrides the individual interest.individual interest.

Ex:Starvation-Pork Ex:Starvation-Pork etc.etc.

Make things easier—Make things easier—combine hajj and combine hajj and umrah rituals—one umrah rituals—one intention-(niyyah).intention-(niyyah).

Use of scarce Use of scarce resources—ICU/transresources—ICU/transplant etc.plant etc.

Key Questions @ EOLCKey Questions @ EOLC

Ventilatory Support.—Air.Ventilatory Support.—Air. Hydration—WaterHydration—Water Nutrition—Food.Nutrition—Food.

COST !!!!!.COST !!!!!.

Ms TS: 26 female, suffered cardiac Ms TS: 26 female, suffered cardiac arrest on Feb 25,1990. arrest on Feb 25,1990.

Remained in persistent vegetative Remained in persistent vegetative state for 15 years. state for 15 years.

Died from dehydration on March Died from dehydration on March 31,2005, two wks after court ordered 31,2005, two wks after court ordered removal of feeding tube.removal of feeding tube.

   Ethical Dilemmas Related to Ethical Dilemmas Related to Terri Schiavo’s Health CareTerri Schiavo’s Health Care

Questions:Questions:   1)1) Was TS condition hopeless? Was TS condition hopeless? 2)2) Would she have wanted her feeding Would she have wanted her feeding

tube removed? tube removed? 3)3) Who is responsible for the cost of Who is responsible for the cost of

care, estimated to be in millions. care, estimated to be in millions. 4)4) Recommendations regarding—Vent Recommendations regarding—Vent

support, Fluid, Nutrition in support, Fluid, Nutrition in hopelessly sick pts.hopelessly sick pts.

Health Care Costs? –Terri Schiavo Case.Health Care Costs? –Terri Schiavo Case. Who is responsible ? individual ? family ? Who is responsible ? individual ? family ?

society society Any religious guidelines? Any religious guidelines? Khan F: JIMA Editorial: Vol 38(No 1) page Khan F: JIMA Editorial: Vol 38(No 1) page

6-9, March 2006.6-9, March 2006.

VENTILATION—FUTILE CAREVENTILATION—FUTILE CARENUMC EXPERIENCE.NUMC EXPERIENCE.

““Terminal Weaning”(Palliative) after Terminal Weaning”(Palliative) after appropriate family and staff agreement.appropriate family and staff agreement.

Thirty plus patients weaned “terminally”Thirty plus patients weaned “terminally” Three “survived” and transferred.Three “survived” and transferred. Karnik A, Khan F: Ethical Issues in Karnik A, Khan F: Ethical Issues in

Ventilated Patients-Hospital Practice Nov Ventilated Patients-Hospital Practice Nov 1997,43(11) 11-18.1997,43(11) 11-18.

EOLC--CostsEOLC--Costs Top 5% account for nearly half of Top 5% account for nearly half of

spending(>600 billion/yr).spending(>600 billion/yr). 17% of Medicare’s $550 billion annual budget 17% of Medicare’s $550 billion annual budget

spent on pt’s last six months.spent on pt’s last six months. Early use of palliative care significantly Early use of palliative care significantly

reduces these costs.reduces these costs. Big ticket items: Dialysis, ICU, Transplant, CV Big ticket items: Dialysis, ICU, Transplant, CV

procedures and medications.procedures and medications. NYT: January 10NYT: January 10thth 2013 & Nov 20, 2013. 2013 & Nov 20, 2013.

TWO RECENT BEST TWO RECENT BEST SELLERS.SELLERS.

1)Butler K: Knocking on Heaven’s Door: The 1)Butler K: Knocking on Heaven’s Door: The Path to a Better Way of Death—Scribner Path to a Better Way of Death—Scribner 2013.2013.

Daughter describes her father’s EOL Daughter describes her father’s EOL struggle.struggle.

Fink S: Five Days at Memorial: Life and Fink S: Five Days at Memorial: Life and death in a Storm Ravaged Hospital—death in a Storm Ravaged Hospital—Memorial Hospital in New Orleans after Memorial Hospital in New Orleans after Hurricane Katrina-Aug 2005Hurricane Katrina-Aug 2005

KATRINA—NEW ORLEANS:KATRINA—NEW ORLEANS:Dr. Anna Maria Pou—Labor Day Dr. Anna Maria Pou—Labor Day

Weekend-Aug 2005.Weekend-Aug 2005.

Hurricane Katrina-Aug Hurricane Katrina-Aug 2005.2005.

Abdulrahman and Kathy Zeitoun’s Abdulrahman and Kathy Zeitoun’s –Jihad—during Hurricane Katrina.–Jihad—during Hurricane Katrina.

Tragedy of Katrina.Tragedy of Katrina.Post 9/11 life for Arabs/Muslims.Post 9/11 life for Arabs/Muslims.Xenophobia and Racial Profiling. Xenophobia and Racial Profiling.

Beautiful nature of American Beautiful nature of American multicultural society.multicultural society.

Natural Disasters.Natural Disasters.Pres. Bush: “The worst moment of Pres. Bush: “The worst moment of my presidency”.my presidency”.

Below: Hyatt Hotel in New Orleans.Below: Hyatt Hotel in New Orleans.

WHAT IF?—No Lights. No Heat. WHAT IF?—No Lights. No Heat. No Water: NYU-Sandy Oct No Water: NYU-Sandy Oct

29/30/12-29/30/12- You were in a hospital in the midst of a You were in a hospital in the midst of a

natural catastrophe—hurricane, snow storm, natural catastrophe—hurricane, snow storm, sand storm and the power failed, and the sand storm and the power failed, and the heat climbed, all outside access was lost and heat climbed, all outside access was lost and you were providing care to very frail patients.you were providing care to very frail patients.

How would you react ???.How would you react ???. Memorial in New Orleans –Katrina Aug Memorial in New Orleans –Katrina Aug

2005.2005. NYU-Langone in NYC—Sandy—Oct NYU-Langone in NYC—Sandy—Oct

29/30/12.29/30/12.

Health Care Costs;Health Care Costs;

Federal-18% of GDP-Federal-18% of GDP- 2011-Medicare $554 billion—21% of total.2011-Medicare $554 billion—21% of total. Of the $554 billion 28% or about $170 Of the $554 billion 28% or about $170

billion on pts in last six months of life.billion on pts in last six months of life. Costs, Ethics & Concerns about EOLC will Costs, Ethics & Concerns about EOLC will

ensure continuing debate & scrutiny.ensure continuing debate & scrutiny. Kais. Health News: June 4Kais. Health News: June 4thth 2013 Daily 2013 Daily

Report.Report.

The Quality of Dying and Death: The Quality of Dying and Death: Outcome Measure ?Outcome Measure ?

If you can’t measure it, you can’t improve itIf you can’t measure it, you can’t improve it—Lord Kelvin.—Lord Kelvin.

Not everything that counts can be Not everything that counts can be measured. Not everything that can be measured. Not everything that can be measured counts: Albert Einstein.measured counts: Albert Einstein.

The Quality of Dying and Death—QODD?The Quality of Dying and Death—QODD? Chest: Editorial 143 Feb 2013-289-290. Chest: Editorial 143 Feb 2013-289-290.

Jeddah Floods-- Nov 2009.KAAU –Extensive Damage.

Nov 25,2009. Two yrs rainfall in 4 hrs-death, destruction-> billion riyals.

Hurricane Sandy—LI South Hurricane Sandy—LI South Shore-Oct 2012.Shore-Oct 2012.

Sandy-Oct 2012—NY.Sandy-Oct 2012—NY.

Jeddah Floods-- Nov 2009.KAAU –Extensive Damage.

Nov 25,2009. Two yrs rainfall in 4 hrs-death, destruction-> billion riyals.

TYPHOON- HAIYAN-Nov 2013TYPHOON- HAIYAN-Nov 2013

Natural Disasters: Public Health:Natural Disasters: Public Health: Leaning J, Guha-Sapir D, Nov 7Leaning J, Guha-Sapir D, Nov 7

N Engl J Med 2013; 369:1836-1842N Engl J Med 2013; 369:1836-1842..

The effects of armed conflict and natural disasters on The effects of armed conflict and natural disasters on global public health are widespread. global public health are widespread.

In the years ahead, the international community must In the years ahead, the international community must address the root causes of these crises. address the root causes of these crises.

Natural disasters, particularly floods and storms, will Natural disasters, particularly floods and storms, will become more frequent and severe because of climate become more frequent and severe because of climate change. change.

These events affect the mortality, morbidity, and well-These events affect the mortality, morbidity, and well-being of large populations. Humanitarian relief will being of large populations. Humanitarian relief will always be required, and there is a demonstrable need, always be required, and there is a demonstrable need, as in other areas of global health, to place greater as in other areas of global health, to place greater emphasis on prevention and mitigation.emphasis on prevention and mitigation.

CONCLUSIONSUnique opportunity to fathom the treasures and secrets of God’s creationAlong with it grave and unprecedented risksNevertheless, since we do not will unless God wills, can these breakthroughs be regarded as part of the divine will to afford humanity yet another opportunity for moral training and maturity (TARBIYAH) in our quest for excellence (IHSAN). WASATHIYAH “Thus we have appointed you a middle nation, that you may be witness against mankind, and that the messenger may be witness against you …” 2:143

ACP-Chair Elect 2014-Valedectorian GMC --Kashmir.

LIJMC-NUMC-NSUH-NYU.

Regent ACP.

ACP-NYS Laureatte.NDMF Awardee.Vice Chair ICLI BOT.

Parvez Mir—FCCP—Spouse

Kids: Tania-Natashe-Nabil.

KSA—KAAU 2001, Buraidah, KFMC.

Thank You—Shukriya.Thank You—Shukriya.