0811-Nursing Standard Operating Procedures: An Islamic Perspective

The paper does not pretend to rewrite existing nursing SOPs but rather tries to provide an Islamic perspective to them so that they can be relevant to an Islamically oriented nursing environment and practice. The general ethico-legal guidelines for nursing practice can be summarized as maqasid al shari’at, the general purposes of the Law; qawa’id al shari’at, the general principles of the Law, and specific legal rulings, ahkaam al shari’at. Islam has a parsimonious and rigorously defined ethical theory of medical practice based on the 5 purposes of the Law. The five purposes are preservation of ddiin, life, progeny, intellect, and wealth. Any medical action must fulfill one of the above purposes if it is to be considered ethical. Legal axioms or principles, qawa’id al shari’at, guide reasoning about specific ethico-legal issues and are listed as intention, qasd; certainty, yaqiin; injury, dharar; hardship, mashaqqat; and custom or precedent, ‘urf or ‘aadat. The nurse must have a general knowledge of specific legal rulings, hukum, that relate to nursing practice so that she can advise her patients accordingly. Regarding patient hygiene, the nurse must know what body products are considered impurities, najs, and advise the patients accordingly regarding their wudhu and salat. The paper gives details of both physiological and pathological secretions and fluids with special emphasis that fresh blood is not najs. The paper describes how a nurse can help patients perform their ‘ibadat obligations under various disease conditions. It explains regulations of puasa for the sick and what medical procedures can be carried out without nullifying puasa. The regulations of foods and drinks for the sick are reviewed. The Islamic viewpoint is given on ethico-legal issues of artificial life support, euthanasia, privacy, confidentiality, and consent. Legal guidelines are provided on how to navigate the fine line between benefit and injury in medical interventions. The paper the covers issues of general nursing etiquette of: bed-side visits, etiquette of medical / surgical procedures, interaction with patients of the opposite gender, interaction with healthcare givers of the opposite gender, interaction between genders in nursing education, covering awrat, dealing with the family, teaching & learning in the health care team, care delivery in the health care team, and health care team group dynamics. Islamic guidelines are discussed regarding the etiquette of clinical history taking and examination, nursing care and counseling for specific diseases, nursing the terminally ill, and coping with stress in nursing practice.

This paper was inspired by slides prepared by nurses at the Kampung Baru Medical Center (KBMC) in Kuala Lumpur on the integration of Islamic values in nursing. Basing on the presentations, the author added material he had used in teaching physician etiquette and medical jurisprudence to produce this paper. The paper does not pretend to rewrite existing nursing SOPs but rather tries to provide an Islamic perspective to them so that they can be relevant to an Islamically-oriented nursing environment and practice.

KBMC was established by Dr Ishak Masud and his colleagues as a hospital that would implement Islamic values in 1998. After operating successfully for 10 years and inspiring the start of several other Islamic hospitals it changed is name to Islam Hospital in 2008 and continues its mission of providing Islamic holistic care. The author is of the opinion that in the next 10-15 years, hospitals like KBMC will increase in number as a response to the demand for an Islamically-oriented healthcare system.

In her presentation titled ‘Peranan Jururawat Dalam Melaksanakan Hospital Mesra Ibadah (HMI), Sn. Naziah Bt. Abd Rasib explained that a hospital mesra ibadat integrated Islamic values in nursing practice. It provided high quality service reflecting the Islamic paradigm of quality as well as practicing practical d’awa bi al hal. Nurses in such a hospital served with a smile and talked to patients with respect. They assisted patients in their ‘ibadat obligations. The ward was organized to facilitate ‘ibadat with the direction of qiblat being indicated. Open wards had only one gender and private rooms allowed only close family members to enter. Female wards had closed doors for privacy and dignity. Male healthcare providers did not enter female wards without a chaperone. Dhikir, doa, and Qur’an recitations were encouraged.

In her presentation titled ‘Peranan Jururawat Melaksanakan Hospital Ibadah’, Mastura Bt Ahmad talked about care for terminally ill patients. They needed to be visited by religious officers to administer to their spiritual needs. They must be reminded about salat and dhikir. They should repeat the shahadat from time to time. They should be allowed to have private time with their family members. Visitors can be allowed but the number in the room must be limited at any one time. The ‘awrat of the patients has to be covered all the time that they had visitors. Members of the family should be encouraged to be with the patients and to read Qur’an to them. When death approaches the patient should be encouraged to repeat the shahadat. On death the face should be turned towards qiblat and surat yasin should be be recited through the PA system.

In her presentation titled ‘Peranan Jururawat Melaksanakan Hospital Mesra Ibadah’, Juinarah Mohideen discussed nursing principles. The nurse observes salat, dresses properly, is disciplined, is committed, and is good mannered. The nurse must fulfill the amanah of following the SOPs. Sn Juinarah emphasized the importance of knowledge, learning, planning, and skills in helping patients fulfill their ‘ibadat obligations. She then explained procedures for new admissions. New patients should be triaged quickly and assessments made for example their ‘ibadat needs. The following ‘ibadat facilities should be provided: prayer mat, prayer clothes, water spray bottle for wudhu, sand for tayammum, and Qur’an or tafsir. In preparation for salat, patients on intravenous drips can have the spigot closed temporarily for salat, diapers and dirty dressings changed, bladder catheters and colostomies emptied. Weak patients should be helped to make wudhu. Salat al jama’at must be encouraged where possible. Religious officers should be alerted to visit the patient. Reminders about entry of salat time should be made. The patient and accompanying family members should be taught the salat of the sick and those who cannot pray on their own must be given assistance. The clothes and the environment must be kept clean. Medical procedures should be started with the basmalah and ended with alhamdulilaah or inshallah. ‘Awrat must be covered as much as possible. A nurse of the same gender should take care of the patient. For long procedures salat should be combined. Kalimat shahadat should be pronounced before general anesthesia. The nurse should report to the treating doctor any disabilities that the patient has regarding ‘ibadat. Azan and iqamat are pronounced on the birth of a baby.

The general ethico-legal guidelines for nursing practice can be summarized as maqasid al shari’at, the general purposes of the Law; qawa’id al shari’at, the general principles of the Law, and specific legal rulings, ahkaam al shari’at. Islam has a parsimonious and rigorously defined ethical theory of medical practice based on the 5 purposes of the Law, maqasid al shari’at. The five purposes are preservation of ddiin, life, progeny, intellect, and wealth. Any medical action must fulfill one of the above purposes if it is to be considered ethical. Legal axioms or principles, qawa’id al shari’at, guide reasoning about specific ethico-legal issues and are listed as intention, qasd; certainty, yaqiin; injury, dharar; hardship, mashaqqat; and custom or precedent, ‘urf or ‘aadat.

Protection of ddiin, hifdh al ddiin, essentially involves ‘ibadat in the wide sense that every human endeavor is a form of ‘ibadat. Thus medical treatment makes a direct contribution to ‘ibadat by protecting and promoting good health so that the worshipper will have the energy to undertake all the responsibilities of ‘ibadat. A sick or a weak body cannot perform physical ‘ibadat properly. Balanced mental health is necessary for understanding ‘aqidat and avoiding false ideas that violate true ‘aqidat.

Protection of life, hifdh al nafs: The primary purpose of medicine is to fulfill the second purpose of the Law, the preservation of life, hifdh al nafs. Medicine cannot prevent or postpone death since such matters are in the hands of Allah alone. It however tries to maintain as high a quality of life until the appointed time of death arrives. Medicine contributes to the preservation and continuation of life by making sure that physiological functions are maintained. Medical knowledge is used in the prevention of disease that impairs human health. Disease treatment and rehabilitation lead to better quality health.

Protection of progeny, hifdh al nasl: Medicine contributes to the fulfillment of the progeny function by making sure that children are cared for well so that they grow into healthy adults who can bear children. The care for the pregnant woman, peri-natal medicine, and pediatric medicine all ensure that children are born and grow healthy. Intra-partum care, infant and child care ensure survival of healthy children.

Protection of the mind, hifdh al ‘aql: Medical treatment plays a very important role in protection of the mind. Treatment of physical illnesses removes stress that affects the mental state. Treatment of neuroses and psychoses restores intellectual and emotional functions. Medical treatment of alcohol and drug abuse prevents deterioration of the intellect.

Protection of wealth, hifdh al mal: The wealth of any community depends on the productive activities of its healthy citizens. Medicine contributes to wealth generation by prevention of disease, promotion of health, and treatment of any diseases and their sequelae. Communities with general poor health are less productive than healthy vibrant communities. The principles of protection of life and protection of wealth may conflict in cases of terminal illness. Care for the terminally ill consumes a lot of resources that could have been used to treat other persons with treatable conditions.

2.3 The 5 Principles of the Law in Medicine, qawa’id al shari’at fi al tibb

The principle of intention, qa’idat al qasd: The Principle of intention comprises several sub principles. The sub principle ‘each action is judged by the intention behind it’ calls upon the nurses to consult their inner conscience and make sure that their actions, seen or not seen, are based on good intentions. The sub principle ‘what matters is the intention and not the letter of the law’ rejects the wrong use of data to justify wrong or immoral actions. The sub principle ‘means are judged with the same criteria as the intentions’ implies that no useful medical purpose should be achieved by using immoral methods.

The principle of certainty, qa’idat al yaqeen: Medical interventions must be be based on certainty and must be evidence-based, the evidence being derived from history, physical examination, and investigations. The principle of certainty asserts that uncertainty cannot abrogate an existing certainty. Existing assertions should continue in force until there is compelling evidence to change them. All medical procedures are considered permissible unless there is certain evidence to prove their prohibition.

The principle of injury, qa’idat al dharar: Medical intervention is justified on the basic principle that injury, if it occurs, should be relieved. An injury should not be relieved by a medical procedure that leads to an injury of the same magnitude as a side effect. In a situation in which the proposed medical intervention has side effects, we follow the principle that prevention of an injury has priority over pursuit of a benefit of equal worth. If the benefit has far more importance and worth than the injury, then the pursuit of the benefit has priority. Physicians sometimes are confronted with medical interventions that are double edged; they have both prohibited and permitted effects. The guidance of the Law is that the prohibited has priority of recognition over the permitted if the two occur together and a choice has to be made. If confronted with 2 medical situations both of which are injurious and there is no way but to choose one of them, the lesser injury is committed. A lesser injury is committed in order to prevent a bigger injury. In the same way medical interventions that are in the public interest have priority over consideration of individual interest. The individual may have to sustain an injury in order to protect public interest. In many situations, the line between benefit and injury is very fine.

The principle of hardship, qaidat al mashaqqat: Medical interventions that would otherwise be prohibited actions are permitted under the principle of hardship if there is a necessity. Necessities legalize the prohibited, al daruuraat tubiihu al mahdhuuraat, and mitigate easing of legal rules and obligations. In the medical setting a hardship is defined as any condition that will seriously impair physical and mental health if not relieved promptly. Committing the otherwise prohibited action should not extend beyond the limits needed to preserve the purpose of the Law that is the basis for the legalization. The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place.

The principle of custom or precedent, qaidat al urf: The standard of medical care is defined by custom. The basic principle is that custom or precedent has legal force. What is considered customary is what is uniform, widespread, and predominant and not rare. The SOP is regarded by Law as customary and must be followed.

Overview: The nurse must have a general knowledge of specific legal rulings that relate to nursing practice so that she can advise her patients accordingly. She also needs to know the classification of these rulings as explained below. Nurses who have this knowledge will be able to communicate better with their patients because of their understanding of how sickness impacts on religious obligations. Their patients will be more satisfied and will be more compliant.

Obligatory, waajib, is the most important legal ruling. The shafi’e school considers waajib the same as faradh. Individual obligations, fardh aini, cannot be delegated. Performance of a collective obligation, fardh kifai, by any member of the community absolves the rest from sin.

Recommended, manduub, is also called sunnat, masnuun, nafilat, mustahabb, tatawu'u, ihsaan, fadhiilat. It is ordained without compulsion. The manduub has got the following levels of excellence: confirmed, sunnat muakkada; and not confirmed, sunnat ghayr muakkadat. The sunnat muakkadat is what the Prophet used to carry out continuously and left it only on rare occasions.

Prohibited, haraam, is defined as omission of the waajib or commission of the haraam. The original position for all human acts is permission and prohibition is the exception. Thus textual evidence is required to prove prohibition but is not required to prove permission. The situation is reversed in sexual matters in which the original position is prohibition and permission is the exception requiring textual evidence. Only Allah can make something haraam. Haraam is prohibited because it is impure and harmful. An act that aggravates disease is haraam. An act that leads to haraam is also haraam. An act that cures disease is waajib. A general principle is that the halaal is clear and the haraam is clear and between the two are inconclusive matters, mutashaabihaat For inconclusive matters what leads to bad or evil is makruuh and what leads to good is manduub.

Offensive, makruuuh: is an act that is discouraged by the Law giver without compulsion. It is better to avoid the makruh because it is usually an introduction to the haram.

Rewards and Punishments For Various Acts: The classification of acts can best be understood from the consequences of doing them or not doing them

Patients are concerned about their continuing ability to perform religious obligations. Salat can only be undertaken in a state of physical and ritual purity. It is therefore important for a nurse to distinguish what is an impurity, najs, from what is clean, taahir, and advise the patients accordingly. Presence of an najs requires repeat of wudhu before salat which for a patient may not be an easy ideal.

Eye secretions: Tears and the early morning eye discharge are not najs but should be wiped or washed away because they could be a nidus for infection.

Ear Secretions: The secretions of the external ear are najs but must be cleaned away. It is recommended in wudhu to clean the external meatus and the ear canal as deep as is safe.

Nasal Secretions: Nasal secretions are not an najs but should not be allowed to accumulate. The Prophet recommended blowing the nose three times on waking up to clear away secretions, accumulated infectious and toxic material. During wudhu washing the inside of the nostrils, instinshaaq, removes secretions and dirt.

Throat Secretions: Throat clearings are not najs but should be disposed of carefully because they transmit air-borne bacterial and viral infections.

Oral Cavity Secretions: Saliva is not najs. Spitting saliva should however be discouraged because it leads to spread of air-borne infection. Spitting in the hospital or the public highway is esthetically not acceptable. Islam teaches practical measures to ensure oral hygiene. The mouth is rinsed five times a day during wudhu. Use of the toothpick, siwaak, is especially emphasized and is recommended at every prayer, before entering a public place, after eating, and on waking up from sleep. The toothpick must be washed between uses.

Vaginal Secretions: The vagina excretes the menstrual flow in addition to several fluids of its own. The moisture inside the vaginal canal is not najs as long as it is inside the vaginal canal. Inter-menstrual vaginal discharges are not najs. Ghusl is needed when there is a vaginal discharge following a wet sexual dream although the fluid itself is not najs. All vaginal discharges and any other fluids in the perineal area should be washed away very quickly because of the high potential of infection. Menstrual blood is washed off the cloth or if dry it is scraped off the cloth. The cloth can then be used for prayer even if traces of the blood can be seen. Touching the perineal area of one self, of another person, or of an animal nullifies wudhu.

Penile Secretions: The Law recognizes three types of penile discharges: seminal fluid, mani; prostatic discharge, madhi; and urethral discharge, wadi. Semen is not najs because it contains sperms that are living human hereditary material. Dry semen on a cloth is scraped away while the wet one is washed with water and the cloth can be used for salat. Prostatic or urethral discharges that occur independently of semen are najs. Discharge of prostatic fluid or urethral fluid necessitates repeat of wudhu because of urinary contamination. Touching the penis by the person or by another person nullifies wudhu.

Circumcision: Circumcision, removal of the prepuce, is recommended for males. It is a hygienic measure to prevent accumulation of urethral discharges and urine under the prepuce that can lead to infection. Circumcision in females is symbolic and should not involve genital mutilation of any kind.

Interstitial Space Fluids: Membranous cavities have various secretions. Pleural, peritoneal, pericardial, and synovial fluids are not najs and must be washed away if they are outside their respective cavities.

Scalp Hair: Scalp hair can trap and accumulate infectious and toxic material because of its continuous exposure to the atmosphere. Wiping the hair with wet hands in wudhu helps remove accumulation of possible air-borne pathogens. Scalp hair must be washed and combed regularly to prevent any accumulation of filth. Dyeing and plaiting hair are permissible provided they do not prevent proper cleaning. Proper cleaning of hair requires that water reaches the root of the hair. Hair of both men and women can only be dyed with colors other than black. Black dyeing or plucking away white hair is considered deception about the age of a person. Shaving scalp hair is needed when lice and other ecto-parasites are feared to grow in it. It is however offensive, makruh, to shave only part of the head unless there is a medical indication.

The Moustache and the beard: It is recommended to trim the moustache and grow the beard. The beard should be trimmed and not left to grow beyond the size that can be maintained hygienically. Grey hair can be dyed with any color but black. The beard should be washed during wudhu and should be combed regularly to prevent accumulation of dirt. In a medical situation it may be necessary to shave the beard if infection is feared. Nurses should also be more careful with their beards because they could be a site of infections.

Armpit hair: Cutting axillary hair is recommended and is necessary for hygiene. Sweat accumulating under the arm-pit may give rise to pungent odors.

Pubic hair: Cutting and regular cleaning of pubic hair is recommended and ensures cleanliness.

Trunk hair: Skin hair can be shaved as needed for cleanliness. Regular washing and shaving of abdominal, chest hair, pubic hair, and axillary hair is recommended for hair hygiene. There is no prohibition for women to shave off excess body hair or face hair.

Skin Secretions: Sweat is najs but must be wiped or washed away to prevent accumulation. Fatty sweat secreted by apocrine glands associated with hairy parts of the skin such as the armpit, the scalp, and the perineum is broken down by bacteria producing a pungent odor. Body odors should be suppressed using perfume or deodorants.

Wudhu is regular washing of parts of the skin exposed to environmental pollution: the face, the forearm, hands, the feet, and the head. It is recommended to wash or wipe with a wet hand the nostrils, the ear, the back of the neck, bases of toes, and fingers to clear away collected secretions that can be a substrate for infection. Rings and other coverings on the body must be removed before washing to make sure that all parts of the body are washed.

Ghusl, bathing the whole body, is obligatory after menstruation, post-natal bleeding, and coitus. It is also undertaken before hajj and ‘umrah. The prophet recommended at least one bath a week preferably on Fridays.

Nails: It is recommended to trim fingernails and toenails at most every forty days and the cut nails should be thrown away. Letting nails overgrow is against the sunnat.

In hospital practice doctors come across many questions concerning patient hygiene and blood is the most often encountered intravascular fluid. Blood of epistaxis[1] and freshly spilled blood (venous or arterial) are not najs but must be cleaned away with water[2] [3]. Fresh bleeding from hemorrhoids and anal lesions does not nullify wudhu but must be washed away immediately and before salat commences. At the time of the prophet the therapeutic procedure of cupping, hijaamah, was common and the blood was not treated as najs[4].

Respiratory tract secretions: Respiratory discharges associated with the common cold, sinusitis, naso-pharyngitis, otitis media, and sputum are not najs but must be cleaned away quickly and disposed of.

Genito-urinary tract secretions: Discharges from urethritis, cystitis, prostatis, and pyelonephritis can be considered najs because of urinary contamination. Wudhu is valid in cases of continuous hematuria (microscopic and macroscopic). Salat must be performed immediately after making wudhu. Suitable urinary bags should be worn to prevent soling clothes and the place of salat. In urinary incontinence wudhu is made followed immediately by salat.

Diarrhea: Diarrhea is defined as excessive, frequent, and loose stool discharge. It is considered najs and nullifies wudhu.

Vomiting: Vomiting (emesis) is forcible ejection of stomach contents from the mouth. Upper GIT vomitus is not najs and does not nullify wudhu. This is because contents of the upper GIT are mostly recently ingested food. The lower GIT vomitus especially the lower intestine has fecal excretory material that is najs. Vomitus that is severe may contain intestinal contents and should always be considered najs. The vomitus of a baby is treated like its urine to be simply washed away.

Intubation: Tracheal, esophageal, gastric, and naso-gastric tubes are inserted for diagnostic or therapeutic purposes. The fluids involved are not najs but must be washed away to prevent their becoming nidi of infection. Catheterization of the bladder results in contamination by urine which is najs. Catheterization of the heart does not result in contamination because fresh blood is not najs.

Stoma: Colostomies and ileostomies are created to allow intestinal contents to exit to the exterior. Stoma have to be cleaned and covered and salat is done with them discharging. The colostomy site is kept as clean as possible all the time. Wudhu is made before each salat.

Wounds: The discharge from wounds must be cleaned away but does not constitute najs that nullifies wudhu.

If patients can move from the bed they can get wudhu in the usual way and pray with other patients in congregation. If they cannot move they can get wudhu while on the bed using a water spray bottle to avoid wetting the beddings. If they have wounds or bandages or plasters, they can carry out dry ablution, tayammum, instead. To avoid bringing pathogenic organisms in the hospital, only sterilized sand should be used or the patient can touch ‘earth’ on the wall of the hospital.

The Law considers 15 days the maximum duration of the menstrual flow. Salat and puasa are suspended during this time. Salat and other acts of ‘ibadat are resumed if the flow continues beyond 15 days since prolonged bleeding, istihaadhat, is not considered menstruation[5]. Dysfunctional uterine bleeding (DUB) does not stop the woman from salat or puasa and is treated in the same way as urinary incontinence. The woman washes her vagina and perineum, pads herself, gets wudhu and performs salat immediately to try to avoid being caught by more bleeding. Sexual relations are allowed in DUB unless there is a medical contra-indication[6]. The use of hormones to regulate the menstrual period in order to be able to complete the rituals of pilgrimage is widely used. The same cannot be done for puasa Ramadhan.

The patient may have the following physical handicaps: inability to face the qiblat, inability to stand, inability to sit, inability to read, inability to bow, and inability to prostrate. The following are solution alternatives: make-up salat, qadha al salat; resting for moments in a sitting position to regain energy for the next movement; praying in a sitting position; praying while sitting down and cross-legged; praying while lying down on one side of the body; resting on a staff in salat; Praying by gesturing with one part of the body e.g. finger; and finally praying in the mind with no motions. The sick stop qiyam al layl and try to fulfill only the 5 prescribed prayers. Salat can be interrupted for an urgent need that could be medical or otherwise.

Measures to prevent physiological harm in puasa: The prophet (PBUH) taught measures to ensure that puasa does not cause physiologic damage. Puasa continuously from day to day, wisaal, was forbidden[7]. Early iftaar was recommended[8]. Delaying suhuur was recommended[9].

Guidelines on diet in puasa. The aim should be maintaining normal body weight or actually reducing it if overweight. Over-eating at iftaar and suhuur should be avoided because of weight gain and indigestion. The diet should contain sufficient fiber to prevent constipation and to delay the onset of feeling hunger because of a longer stomach transit time. Enough water should be taken at night to prevent dehydration and constipation. Adequate fluid and salt intake prevents lethargy in the afternoon caused by low blood pressure. Inadequate sleep is a cause of headaches. Intake of adequate calcium, magnesium, and potassium will prevent muscle cramps. Hot places should be avoided because they aggravate the dehydration. Cooling the body such as tepid sponging, tabarrud, is allowed[10] during puasa.

Puasa in certain physiological conditions: Old age is considered an excuse from puasa[11] because of physiological fragility and delicate nutritional requirements. The pregnant woman, al hublah, is allowed to break puasa[12] if puasa is a health risk. The breast-feeding woman or nursing woman'[13], is allowed to break puasa if there is health risk. The exemption from puasa is obligatory for the menstruating woman[14] and for a woman in the post partum period. Any fasting undertaken in haidh and nifaas is invalid.

Puasa with diabetes mellitus: Diabetes has special consideration in puasa because of its direct relationship with food intake. Insulin-dependent diabetics have to reduce their insulin dose because of reduced food intake during the day. In some cases this is not possible and they have to be exempted from puasa altogether especially if their diabetic control is brittle. Insulin-dependent diabetics should be monitored very carefully because hypoglycemia may arise due to insulin injections with inadequate dietary intake. Non-insulin diabetics can undertake puasa under medical supervision. This will generally require changing times of medication, close monitoring of blood sugar levels, and being alert to any hyperglycemic or hypoglycemic crises. Pregnant diabetics are exempted from puasa because diabetic control is more difficult in pregnant women making puasa doubly hazardous for both the mother and the fetus.

Puasa in other conditions of illness: The sick are allowed to break puasa[15] if trusted nurses fear that puasa will be deleterious to good health. The missed puasa is made up later[16]. If the illness is chronic, maradh muzmin, then there will be no opportunity for making up. The puasa of a sick person is valid but is makruh. The heirs can perform make-up fasting, qadha al puasa, for days missed by a deceased disabled by disease in terminal illness[17]. Based on the clinical condition puasa could be exempted for peptic ulcers and kidney stones. Peptic ulcers are aggravated by raised acid levels and could be a reason for exemption from puasa. Low fluid intake could encourage growth of kidney stones and joint problems due to deposition of excess solutes.

Concept of jawf: Any potentially nutritious substance that enters and stays the inside cavity of the body, al jawf, nullifies puasa. The term jawf has to be reinterpreted in view of modern anatomical and physiological knowledge. In my understanding jawf means the alimentary canal from the mouth to the anus.

Oral intake: Deliberate eating and drinking and eating nullify puasa. Incidental smelling food or any other pleasant odor does not nullify puasa Use of snuff or tobacco in the nose nullifies puasa. Deliberate smelling of tobacco or any other type of smoking material nullifies puasa. If the smelling is non intentional it does not nullify the puasa. Madhmadhat and istinshaaq in wudhu are permitted during puasa[18] it is however offensive to exaggerate them[19]. The decision of what is normal and what is excessive requires more discussion. More discussion is needed on swallowing saliva and swallowing phlegm during puasa. The mouth can be rinsed with pure water without nullifying puasa. Care must be taken to avoid swallowing. Siwaak is permitted all through the day of puasa[20]. Use of a tooth brush with toothpaste is allowed if care is taken to rinse out the mouth fully such that none of the toothpaste remains in the mouth. Entrance of water into the ear canal and reaching the ear-drum was traditionally considered a nullifier of puasa but unless the eardrum is perforated there is no direct connection between the ear and the jawf. Eye drops enter the nostrils and may eventually reach the pharynx probably reaching the jawf. Kohl applied to the eye does not nullify puasa if its smell is not felt in the mouth.

Medical examination and investigations: Taking blood, urine, and stool samples for investigation does not nullify puasa. Diagnostic enemas and barium meal examinations nullify puasa. Esophagoscopes, gastroscopes, and sigmoidoscopes that have lubricants or other substances that will remain in the jawf nullifies puasa. Digital rectal examination involves inserting substances into the jawf and may nullify puasa. Vaginal examination may nullify puasa but the reasoning involved is more complicated. Examination of the external auditory canal, endoscopy and catheterization of the urethra and the urinary bladder should in normal circumstances not nullify puasa because they do not involve entry into the jawf. Imaging that does not involve using contrast media in the jawf does not nullify puasa. IVP uses contract media injected in the blood stream and not the jawf.

Medical treatments: The general rule is that any substance that enters the body through any of its openings, manfadh, nullifies fasting. The openings are the two ends of the alimentary canal, the mouth and the anus. Drugs of whatever form taken orally, per anus, nullify puasa. The medication schedule can be modified such that drugs are taken only during the night hours. Sub-lingual medication absorbed from the oral cavity with none entering the esophagus may not nullify puasa. All drugs that are applied externally on the skin do not nullify puasa. Use of eye drops does not nullify puasa. Nose drops may nullify fasting because they could drop into the pharynx and be swallowed. Inhalants may nullify puasa if they have droplets of water that can enter the jawf. Injections (sub-cutaneous, intra-muscular, and intra-venous) do not nullify puasa because they do not involve putting substances into the jawf. However nourishing and rehydrating injections nullify the purpose of puasa. Hormonal preparations should not be used to delay menstruation in order to avoid interrupting puasa of Ramadhan.

The physically disabled can circumbulate the ka’aba riding on a vehicle or being carried by another person. The weak can leave Muzdalifat earlier to avoid the crowds. The very old and those with debilitating chronic diseases can ask another person to perform hajj on their behalf. However if the disease is curable it is better to delay hajj until the next year. In case of a fracture, hajj is stopped and is repeated the next year. If disease occurs during hajj, the sick can be carried to Arafat because al hajj Arafat and missing Arafat is missing the whole hajj. They are assisted to complete the other rites as much as is possible

Standing up, bowing, prostration, and sitting down in salat may be difficult for a woman in advanced pregnancy. It may also be difficult for her to put her hands on her abdomen. Bleeding in early pregnancy and the bleeding of threatened abortion are not considered haidh. Post abortal bleeding is considered nifaas. A pregnant woman may be excused from puasa. If the excuse is based on fear of nutritional deficiency in the mother or in both the mother and the fetus, the missed puasa must be made up. If the exemption is based on fear of harm to the fetus alone, expiation is by feeding the poor. The hustles of movement in hajj may be too strenuous for a pregnant woman

The haram foods are specified. The rest are halal. Haram foods can be eaten in situations of necessity, darurat. Refusing to eat the halal for no valid reason is a hated innovation.

Halal foods are all plants, all land animals not specifically forbidden, and products of halal animals, and all aquatic life except frogs and crocodiles.

Haram foods are dead animals, animals not slaughtered according to the Law, animals that prey/hunt with fangs or talons, mules, donkeys, flowing blood, pork, and any food that is harmful to health as shown by customary experience or scientific investigation.

Animals must be slaughtered by a sane adult who mentions God’s name when slaughtering. Any meat is treated as haram if the butcher is unknown. Meat sold in markets in a Muslim community is considered halal even if the butcher is unknown. Meat in the markets of a non-Muslim community is haram unless the butcher is known

We should eat only when hungry and when we should not eat to fill the belly. Hand washing is necessary even if spoons and forks are used in eating. It is recommended to eat in a group. It is forbidden to eat at a table where alcohol is served. It is recommended to eating with the right hand even if the person is left-handed. Eating should be in haste with the objective of finishing and going on to do other things. The meal should generally not be treated as entertainment. It is an obligatory act for the purpose of giving the body energy.

It is recommended to eat from the top of the dish and eat only the food next to you. Eating while reclining or standing is prohibited. Eating hot food is forbidden. Food served should be finished so care must be taken not to over-serve food. Certain foods like onions should not be eaten when planning to be in a public place because of their obnoxious smell. It is forbidden to blow over food. A tooth-pick should be used to remove impacted pieces of food. Hands are washed and the mouth is rinsed at the end of the meal. The host is praised and is thanked at the end of the meal.

Satiety can be described in three states: the necessary, the needed, and the excess. The necessary is the minimum nutritional intake necessary to maintain health in the best status. The needed is intake that is more than necessary but which prevents the feeling of hunger. Excess intake is beyond the need.

Obesity is a social and medical disease due to excess food intake. It interferes with physical acts of worship such as puasa, salat, and pilgrimage. Puasa (obligatory or voluntary) helps in controlling excess intake. Puasa is also training in appetite control during the ensuing non-puasa period.

Legal definitions of terminal illness and death: Terminal illness is defined as illness from which recovery is not expected. The manner in which death is defined affects the ruling, hukm, about life support. If death is defined in the traditional way as cardio-respiratory arrest, life support cannot be withdrawn at any stage. If the definition of higher brain death is accepted, life support will be removed from persons who still have many life functions (like respiration, circulation, sensation). The consensus is to define death as brainstem death.

Principles of certainty and autonomy: When the determination of death and the exact time of its occurrence are still matters of dispute, a major irreversible decision like withdrawing life support cannot be taken. Islamic law strictly forbids action based on uncertainty, shakk.

The purposes of life and wealth: The purpose of preserving life may contradict the purpose of preserving wealth. Life comes before wealth in order of priorities. This however applies to expenditure on ordinary medical procedures and not heroic ones of doubtful value because that would be waste of wealth.

Withholding vs withdrawal: A psychological distinction in Law exists between withholding life support and withdrawing it. The issue is legally easier if life support is not started at all according to a pre-set policy and criteria. Once it is started, discontinuation raises more legal or ethical issues.

Concepts: Euthanasia is carried out illegally for patients in terminal illness with a lot of pain and suffering. Active euthanasia, an act of commission that causes death, is taking some action that leads to death like a fatal injection. Passive euthanasia, an act of omission, is letting a person die by taking no action to maintain life. Terminal sedation with very high doses has the dual effect of controlling pain and causing respiratory failure. Islamic Law views all forms of euthanasia, active and passive, as homicide. Those who give advice and those who assist in any way with suicide are guilty of homicide. A nurse is legally liable for any euthanasia actions performed even if instructed by the patient or the physician.

Analysis using purposes of the law, maqasid al shariat: Euthanasia violates the Purpose of the Law to preserve Life by taking life and it leads to cheapening human life making genocide more acceptable. It violates the purpose of religion by assuming Allah’s prerogative of causing death.

Analysis using principles of the law, qawaid al shari’at: According to the principle of intention, there is no distinction between active and passive euthanasia because the end-result is the same. The principle of injury makes euthanasia illegal because it tries to resolve the pain and suffering of terminal illness by causing a bigger injury which is killing. Continuation of pain in terminal illness is a lesser evil than euthanasia. According to the legal principle of sadd al dhari’at, prohibition of euthanasia closes the door to corrupt relatives and nurses killing patients for the sake of inheritance by claiming euthanasia. Euthanasia reverses the customary role of the nurse as a preserver into a destroyer of life. Euthanasia like other controversial issues is better prevented than waiting to resolve its attendant problems. The patient cannot legally agree to termination of life because life belongs to Allah and humans are mere temporary custodians. The determination of ajal is in the hands of Allah.

General conclusions: Our analysis has shown that there is no legal basis for euthanasia. Nurses have no right to interfere with ajal that was fixed by Allah. Disease will take its natural course until death. Nurses for each individual patient do not know this course. It is therefore necessary that they concentrate on the quality of the remaining life and not reversal of death. Life support measures should be taken with the intention of quality in mind. Instead of discussing euthanasia, we should undertake research to find out how to make the remaining life of as high a quality as is possible. The most that can be done is not to undertake any heroic measures for a terminally ill patient. However ordinary medical care and nutrition cannot be stopped. This can best be achieved by the hospital having a clear and public policy on life support with clear admission criteria and application to all patients without regard for age, gender, socio-economic status, race, or diagnosis.

Privacy and confidentiality are often confused. Privacy is the right to make decisions about personal or private matters and blocking access to private information. The patient voluntarily allows the nurse access to private information in the trust that it will not be disclosed to others. This confidentiality must be maintained within the confines of the Law even after death of the patient. Confidentiality falls under the teaching of the prophet about keeping secrets.

In routine hospital practice, many persons have access to confidential information but all are enjoined to keep such information confidential. The patient should not make unnecessary revelation of negative things about himself or herself. The nurse can not disclose confidential information to a third party without the consent of the patient. Information can be released without the consent of the patient for purposes of medical care, for criminal investigations, and in the public interest. Release is not justified without patient consent for the following purposes: education, research, medical audit, employment or insurance purposes.

Confidentiality includes medical records of any form. The ownership of the records is not clear. Do they belong to the patient, the caregiver that wrote them, or the institution? Using the law of property, a product belongs to the person who made it. In this case, the doctor is the 'maker' of all the medical facts that are written and should be the acknowledged owner of the records. However the patient is the owner of the facts in the record. The patient is also the only person involved who has most to lose if records are misused and therefore should have control in the form of ownership. The contents of the medical records cannot be revealed without the express permission of the owner of the information. Although the patient owns records in the sense that their contents cannot be disclosed without consent, the physician has physical custody of the records.

Privacy and confidentiality of medical records are balanced against the need for timely information by caregivers. In a modern medical environment, many records are generated about each patient. These prove a challenge as far as keeping of secrets is concerned because many people can access them. Besides their use in medical care, the records can be used for medical education, medical research, and for legal purposes. Specific legal and ethical guidelines govern the release of these records.

Medical records have to be retained because they may be referred later for purposes of medical treatment or for litigation. They however cannot be retained for ever because that is costly. There are therefore regulations on how long each type of record can be kept.

No medical procedures can be carried out without informed consent of the patient except in cases of legal incompetence. The patient has the purest intentions in decisions in the best interests of his or her life. Others may have bias in their decision-making. The patient is free to make decisions regarding the choice of nurses and treatments. Consent can be by proxy in the form of the patient delegating decision making or by means of a living will.

The patient must be free and capable of giving informed consent. Informed consent requires disclosure by the nurse, understanding by the patient, voluntariness of the decision, legal competence of the patient, explanation of all alternatives, recommendation of the nurse on the best course of action, decision by the patient, and authorization by the patient to carry out the procedures. Consent is limited to what was explained to the patient except in an emergency.

Refusal to consent must be an informed refusal (patient understands what he is doing). Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission of the court. Doubts about consent are resolved in favor of preserving life.

Spouses and family members do not have an automatic right to consent for a competent patient. A spouse cannot overrule the patient’s choice. Advance directives and proxy informed consent by the family are made for the unconscious terminal patient on withholding or withdrawal of treatment. Nurse assisted suicide, active euthanasia, and voluntary euthanasia are illegal even if the patient consented.

The living will has the following advantages: (a) reassuring the patient that terminal care will be carried out as he or she desires (b) providing guidance and legal protection and thus relieving the nurses of the burden of decision making and legal liabilities (c) relieving the family of the mental stress involved in making decisions about terminal care.

The disadvantage of a living will is that it may not anticipate all developments of the future thus limiting the options available to the nurses and the family. The device of the power of attorney can be used instead of the living will. Decision by a proxy can work in two ways: (a) decide what the patient would have decided if able (b) decide in the best interests of the patient.

Competent children can consent to treatment but cannot refuse treatment; parental endorsement is still necessary. The consent of one parent is sufficient if the other one disagrees. Parental choice takes precedence over the child’s choice. The courts can overrule parents. Life-saving treatment of minors is given even if parents refuse. Parental choice is final in therapeutic or non-therapeutic research on children.

Mental patients cannot consent to treatment, research, or sterilization because of their intellectual incompetence. They are admitted, detained, and treated voluntarily or involuntarily for their own benefit, in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order.

For patients in coma, proxy consent by family members can be resorted to. If no family members are available and it is an emergency, nurses do what they as professionals think is in the best interest of the patient.

Labor and delivery are emergencies that require immediate decisions but the woman may not be competent and proxies are used. Forced medical intervention and cesarean section may be ordered in the fetal interest. Birth plans can be treated as an advance statement.

Ordinary medical care is a delicate balance between beneficial treatment and harmful side-effects of the methods used. No therapeutic modality is free of risk. If we were to consider any risk as unacceptable there would be no medicine. The consideration of balance includes costs, health risks, and medical benefits. In many situations, the line between benefit and injury is so fine that the physician may have to seek another opinion or consult his conscience to reach a solution since no empirical methods can be used.

The Law gives us very clear guidelines on the balance between risks and benefits. Attempts at prevention are made before disease occurrence. A disease, considered an injury, should be relieved. The injury should however not be relieved by inflicting an injury of the same or higher degree. In cases of doubt about the relative importance of the benefits of treatment and the side-effects of the treatment, we follow the principle that prevention of injury has priority over pursuit of a benefit of equal worth. If the benefit has far more importance and worth than the injury, then the pursuit of the benefit has priority.

If we cannot empirically compare the harm of continuing untreated disease and the possible harm from medical care, we follow the principle of selecting the lesser of two evils. If confronted with 2 actions both of which are harmful and there is no way but to choose one of them, the lesser harm is committed in order to prevent the bigger harm.

This also implies that an individual could suffer in the interest of preventing a public harm since public interest has priority over individual interest. The individual may have to sustain an injury in order to protect public interest. This could occur in a situation of a contagious disease treated with potentially toxic medication in order to prevent its spread in the community.

Physicians sometimes are confronted with medical interventions that are double edged; they have both prohibited and permitted effects. The guidance of the Law is that the prohibited has priority of recognition over the permitted if the two occur together and a choice has to be made

The nurse-patient interaction is both professional and social. The bedside visit fulfills the social obligation of visiting the sick. The human relationship with the patient comes before the professional technical relationship. It involves reassurance, psychological and social support, show of fraternal love, and sharing. A psychologically satisfied patient is more likely to be cooperative in taking medication, eating, or drinking. The following are recommended during a visit: greeting the patient, good encouraging words, asking about the patient’s feelings, doing good/pleasing things for the patient, making the patient happy, encouraging the patient to be patient, discouraging the patient from wishing for death, nasiihat for the patient, and reminding the patient about dhikr. Nurses should not engage in secret conversations that do not involve the patient. Nurses must make dua for the patients because qadar can only be changed by dua. They can make ruqya for the patients by reciting the two mu’awadhatain or any other verses of the Qur’an.

The nurse should respect the rights of the patient regarding advance directives on treatment, privacy, access to information, informed consent, and protection from nosocomial infections. Nurses must be clean and dress appropriately to look serious, organized and disciplined. They must be cheerful, lenient, merciful, and kind. They must enjoin the good, have good thoughts about the patients and avoid evil or obscene words. They must observe the rules of lowering the gaze, and seclusion. Nurses must have an attitude of humbleness. They cannot be emotionally-detached in the mistaken impression that they are being professional. They must be loving and empathetic and show mercifulness but the emotional involvement must not go to the extreme of being so engrossed that rational professional judgment is impaired.

Caregivers must seek permission when approaching or examining patients. Medical care must be professional, competent, and considerate. Medical decisions should consider the balance of benefits and risks. The general position of the Law is to give priority to minimizing risk over maximizing benefit. Any procedures carried out must be explained very well to the patient in advance. The caregiver must never promise cure or improvement. Every action of the caregiver must be preceded by basmalah. Everything should be predicated with the formula inshallah, if Allah wishes. The caregivers must listen to the felt needs and problems of the patients. They should ask about both medical and non-medical problems. Supportive care such as nursing care, cleanliness, physical comfort, nutrition, treatment of fever and pain are as important as the medical procedures themselves and are all what can be offered in terminal illness. Nurses must reassure the patients not to give up hope. Measures should be taken to prevent nosocomial infections.

Taking history, physical examination, diagnostic procedures, and operations should preferably be by a nurse of the same gender. In conditions of necessity a nurse of the opposite gender can be used and may have to look at the ‘awrat or touch a patient. The preference between a Muslim of opposite gender vs non-Muslim of same gender depends on the local situation.

Healthcare givers of opposite genders should wear gender-specific garments during surgical operations because Islam frowns at any attempt to look like the opposite gender. Shari’at guidelines on interaction with patients of the opposite gender should be followed.

Medical co-education involves intense interaction between genders: teacher-student, student-student, and teacher-teacher. Interacting with colleagues of the opposite gender raises special problems: norms of dress, speaking, and general conduct; class-room etiquette; social interaction; laboratory experiments on fellow students; learning clinical skills by examining other students; and the operation theatre. The Law will allow all of these under the doctrine of necessity, dharurat.

Both the caregiver and patient must cover awrat as much as possible. However, the rules of covering are relaxed because of the necessity, dharurat, of medical examination and treatment. The benefit of medical care takes precedence over preventing the harm inherent in uncovering awrat. When it is necessary to uncover awrat, no more than what is absolutely necessary should be uncovered. To avoid any doubts, patients of the opposite gender should be examined and treated in the presence of others of the same gender. The caregivers should be sensitive to the psychological stress of patients, including children, when their awrat is uncovered. They should seek permission from the patient before they uncover their awrat. Nurses who have never been patients may not realize the depth of the embarrassment of being naked in front of others.

Visits by the family fulfill the social obligation of joining kindred relations and should be encouraged. Family members are honored guests of the hospital with all the shari’at rights of a guest. The nurse must provide psychological support to family because they are also victims of the illness because they are anxious and worried. They need reassurance about the condition of the patient within the limits allowed by the rules of confidentiality. The family can be involved in some aspects of supportive care so that they feel they are helping and are involved. They should however not be allowed to interrupt medical procedures. Nurses must be careful not to be involved in family conflicts that arise from the stresses of illness.

The hospital health care team is complex and multi-disciplinary with complementary and inter-dependent roles. Members have dual functions of teaching and delivering health care. Most teaching is passive learning of attitudes, skills, and facts by observation. Teachers must be humble. They must make the learning process easy and interesting. Their actions, attitudes, and words can be emulated. They should have appropriate emotional expression, encourage student questions, repeat to ensure understanding, and not hide knowledge. The student should respect the teacher for the knowledge they have. They should listen quietly and respectfully, teach one another, ask questions to clarify, and take notes for understanding and retention. They should stay around in the hospital and with their teachers all the time to maximize learning.

Each member of the team carries personal responsibility with leaders carrying more responsibility. Leaders must be obeyed except in illegal acts, corruption, or oppression. Rufaidah, the first Muslim nurse, was a good model of etiquette. She was kind, empathetic, a capable leader and organizer, clinically competent, and a trainer of others. Besides clinical activities, she was a public health nurse and a social worker assisting all in need. The human touch is unfortunately being forgotten in modern medicine as the balance is increasingly tilted in favor of technology.

Basic duties of brotherhood and best of manners must be observed. Encouraged are positive behaviors: mutual love, empathy, caring for one another; leniency, generosity, patience, modesty, a cheerful disposition, calling others by their favorite names, recognizing the rights of the older members, and self control in anger. Discouraged are negative attributes: harshness in speech, rumor mongering, excessive praise, mutual jealousy, turning away from other for more than 3 days, and spying on the privacy of others.

Gender-specific identity should be maintained in dress, walking, and speaking. Free mixing of the genders is forbidden but professional contact within the limits of necessity, dharurat, is allowed. Patients of the opposite gender are examined in the presence of a chaperone. The gaze should be lowered. Modest covering must be observed. Display of adornments that enhance natural beauty must be minimized.

11.0 ETIQUETTE OF CLINICAL HISTORY TAKING and EXAMINATION

Patients have to consent before their medical history can be taken otherwise the nurse will be trespassing on privacy and may be accused of spying, tajassus. The permission to take history is needed even if a proxy such as a spouse or a parent volunteers the history. The same applies to information collected from previous records. Any information obtained from or about a patient is confidential and its unauthorized disclosure is a breach of confidentiality.

The purpose of history taking is to discover the social or personal antecedents of disease as well as the natural history of the disease. This involves considerable probing into personal life and privacy. It provides a golden opportunity for both nurse and patient to face spiritual diseases that affect physical health. There is an opportunity for the nurse to exercise the function of da’wah and for the patient to make repentance, taubat.

History taking is also an opportunity for discovery of legal complications such as foster relations that prohibit marriage and defective marriages concluded during ‘iddat. In complicated medical conditions, history taking may be an opportunity for discussing costs of medical care with the patient. The nurse taking history may face a major ethical dilemma when in the course of taking history, the patient volunteers information about a criminal action that should be prosecuted. If the nurse keeps the information to himself, he is not fulfilling the duty required of him as a citizen to report crime to the authorities.

Successful history taking requires good communication skills and careful observation of non-verbal clues. Accurate history depends on the honesty and memory of the patient. Patients may not want to reveal some information that they consider embarrassing or that they mistakenly consider irrelevant to the presenting disease condition. Patients may forget some information or confuse it. The interviewer must be tactful and sensitive in probing for relevant information and may have to adopt various strategies to help the patient’s memory. Questions may be open-ended or closed. Sometimes the interviewer may just have to keep quiet and listen actively as the patient talks to be able to pick up useful clues. Interrupting patients is a frequent problem of interviewers who pressed for time would like to keep the interview as short as possible. Patients with underlying emotional problems may only verbalize physical symptoms and it requires tact and establishment of rapport to get them to talk about their inner worries and feelings.

11.5 Etiquette of the clinical state examination

The issues of consent and confidentiality discussed above for history taking are also relevant to clinical or mental examinations. A patient can only be examined against his or her consent only if there is a necessity, dharuurat. The necessity may relate to the life of the patient or may be in public interest such as examining a suspected criminal for evidence about the crime. Mental patients are not legally competent to give consent; the necessary consent could be obtained from a guardian, wali. Examination by a caregiver of the opposite gender requires special consideration. It is always preferable that nurses of the same gender carry out the examination. A nurse of the opposite gender can be used only if a situation of necessity arises. A chaperone must be present. Examination is limited to what is necessary. The nurse should allay the anxiety of patients being examined.

Disorders of the urinary tract, amraadh al jihaaz al bawli: In urinary incontinence or hematuria, wudhu is followed immediately by salat with no delay. Suitable urinary bags should be worn to prevent soling clothes and the place of prayer. Hematuria causing anemia exempts from puasa. Patients with renal failure not in coma perform salat as much as they can but are exempt from puasa in order to control fluids and electrolytes. In urolithiasis, movements are restricted if they trigger pain and salat is delayed while patients are under sedation to control pain. Stress of hajj movements and change in meals in a hot and dry climate may trigger pain. Patients prone to stone formation have to be careful while fasting to make sure they take plenty of fluid and avoid hot environments that lead to excessive fluid loss.

Disorders of the male genital tract, amraadh al jihaaz al tanaasuli al rijaali: Circumcision, partial or complete excision of the prepuce, is a hygienic measure highly recommended but those who cannot be circumcised should be careful to clean properly under the prepuce during istinjah.

Disorders of the female genital tract, amraadh al jihaaz al tanaasuli al nisawi: In cases of prolonged menstruation or dysfunctional uterine bleeding, it suffices to pad the perineum, make wudhu, and pray immediately without waiting. Menstruation exempts from puasa and not DUB. Hormonal regulation of menstruation is allowed for hajj but not for puasa of Ramadhan. Sexual relation can be undertaken in prolonged DUB if care is taken to prevent ascending infection. DUB is ignored in computation of ‘iddat in both pre-menopausal and post-menopausal women. The period of post-abortion bleeding is recognized as nifaas. In cases of hemostatic disorders and ecclampsia, termination of the pregnancy may be the best way to save the mother’s life but it will adversely affect the fetus who may not yet be viable extra-uterine. Delivery complication may lead to difficult choices between saving losing two lives versus losing one life.

Upper respiratory disorders, amraadh jihaaz al tanaffus al ‘uliyat: A person with URTI can be excused from leading salat because of difficulty in recitation of the Qur’an. Infectious patients should not pray in the mosque and should restrict their social interactions.

Lower respiratory disorders, amraadh jihaaz al tanaffus al suflah: Dypnoeic patients should limit their physical movements in salat and hajj. Repetitive cough may make recitation in salat difficult. Hemoptysis does not void wudhu and puasa. Patients with pneumonia or pneumonitis will experience pain on recitation and prostration. Patients on respiratory support cannot recite Qur’an during salat.

Vascular disorders, amraadh ‘uruuq al ddam: Orthostatic hypotension is avoided by shortening the recitation to avoid standing for a long time, prolonged sitting between prostrations, frequent periods of rest, and sitting down during rites of hajj like tawaaf. Syncope necessitates delay of salat, hajj rites, and judicial proceedings. Caution must be taken because physical exertion in salat, hajj and coitus may trigger a coronary attack or rupture of an aneurysm. Patients with intermittent claudification, varicose veins, phlebitis, and thrombophlebitis should make tayammum and avoid using water for wudhu and must be cautious in salat movements or sitting down for tashahhud. In DVT, movements of the lower limb in salat and hajj are limited for fear or dislodging an embolus. Prior prolonged sitting predisposes to embolus formation.

Diseases of the heart, amraadh al qalb: In cases of mitral stenosis, mitral incompetence, and restrictive pericarditis, physical exertion in salat and hajj can lead to more severe decompensation.

Circulatory disorders, amraadh al dawrat al damawiyat: Patients in CCF may be too weak to pray. Standing up for prolonged periods in salat may worsen the lower leg edema and compromise venous return even further. The muscle movements of salat may however have a beneficial effect in venous return. Puasa in CCF is not recommended. Hajj is better postponed in CCF because the patient may not be able to withstand the extra physical exertion involved. In states of shock the physical movements of salat and hajj are not possible and puasa is not allowed because of the need to replace body fluids.

Disorders of the hematopoietic system, amraadh al dam: It is obligatory for the mother to take hematinics as directed in the interests of the fetus. It is obligatory on parents to provide sufficient nutrition to the infant to prevent anemia. Although breast-feeding is recommended for 2 years, it is not sufficient by itself after the 6^th month. The father is obliged by Law to provide sufficient nutrition to the nursing mother and the infant to prevent anemia.

Disorders of the bony skeleton: Congenital and acquired disorders of the bony skeleton may limit the range of movements in salat: sideways movement of the neck in tasliim, prostration on the floor, raising the hands in takbir, and pointing with the finger in tashahhud, and bowing. Tawaaf in hajj may be difficult with lower limb pathology. Use of an artificial limb is no bar to hajj and tawaaf. Patients can support themselves on a stick or a pillar during salat. Pain and restricted movements of the vertebral column make bowing more difficult. Standing for prolonged periods may also be difficult. Prostration may be completely impossible. The requirement to straighten the back after bowing may be relaxed. Back pain may also interfere with sexual function. Restricted bending of the knees interferes with sitting properly. Knee problems may make tawaaf and sa’ay in hajj difficult. In case of foot problems, a pilgrim may wear sandals if he has disease that makes it impossible to walk barefoot around the ka’aba. If shoes are needed for orthopedic conditions they can be worn in hajj and salat. Wudhu may not be possible with open wounds and compound fractures and resort is made to tayammum. Pain due to sprains and fractures may limit movements in salat. Movements will not be possible at all when the limbs are immobilized. When a pilgrim has a fracture or becomes lame for any other reason, he is discharged from the rites of hajj and has to repeat the hajj later. Orthopedic fixation of some joints like the hip or knee joints may limit the range of movements possible in salat. In hajj tawaaf may have to be done in a wheelchair. Wudhu can be made on a limb stump preferably washing. If washing is difficult the stump can be wiped with a wet hand. If a leg is in a cast, the rest of the organs are washed with water and tayammum is carried out for the limb in a cast. In osteomyelitis, pain may limit movements in salat. If there is a discharging wound, tayammum will be needed instead of wudhu. Care is exercised in salat and hajj to avoid pathological fractures that are common in bones with neoplastic disease. In osteoporosis care has to be taken in movements in salat and hajj to avoid fractures. Treatment of osteoporosis with hormone and mineral replacement is obligatory for postmenopausal women so that they can lead a normal life.

Cartilage and ligament disorders, amraadh al mafaasil: Laryngeal, pharyngeal, or other oral diseases may impair the ability to recite the Qur’an. Patients with such conditions cannot be prayer leaders, imaam al salat. Public duties like leadership that require communication may be impaired. Pleas and evidence in court may also be affected. Salat is intimately related to joints because of the physical movements involved. Osteoarthritis and rheumatoid arthritis cause pain and limitation of movement. These limit the physical actions needed for salat and hajj. Degenerative disorders of the vertebral column such as spondylosis (arthritis of the spine), intervertebral disc disease (herniation), spondylolisthesis (anterior displacement) impair ability to stand for long periods in salat as well as tawaaf and sa’ay. Tayammum is carried out in cases in which either hot or cold water worsen the pain of rheumatism.

Muscular disorders: Injury to muscles will necessitate limitation of movements in salat while they heal. Some diseases of muscle weakness like myasthenia make it impossible to make the full range of movements required in salat.

Skin disorders, amraadh al jild: Skin lesions such as eczema, dermatitis, itches, discharges, rashes, and chronic ulcers are a reason for tayammum. If the skin is bandaged, the bandage is wiped with the wet hand. Shaving or cutting hair is forbidden in hajj. An exemption is made for those with lice in their hair but a fidyat has to be paid. Injury to ligaments may limit movements in salat.

Gastro-intestinal tract (GIT) disorders, amraadh jihaaz al ta ‘am: Patients with an acute abdomen are immediately excused from the obligation of puasa until full recovery. Salat can be performed as much as their physical condition allows. Puasa may not be possible in advanced stages of peptic ulcer disease. The impact of GIT neoplasms on puasa and salat is variable depending on the complications. Conditions of the oropharynx interfere with eating and drinking as well as recitation of the Qur’an in salat. Esophageal disorders may have implications for patients performing puasa. Esophageal varices may lead to hematemesis that voids puasa. Patients with malabsorption may be exempted from puasa while they are on treatment with special diets that have to be taken during the day or if their nutritional status requires regular food intake. Use of a hernia belt is allowed in hajj for those whose small intestine herniates. Diseases of the large intestine interfere directly with puasa if they are associated with vomiting which voids fasting. Stoma created after operation for cancer of the colon do not normally interfere with puasa, salat, or hajj. The colostomy site is kept as clean as possible all the time. Wudhu is made before each salat. Normally there is no interference with puasa. In cases of bleeding due to hemorrhoids and anal fissures, wudhu will have to be made immediately before the salat and for that salat only. It has to be repeated for every salat. Care must be taken during instinjah not to cause undue pain in case of anal fissures. Extreme obesity makes salat difficult because of body weight, physical weakness, and restricted movements. Puasa is good for the obese.

Gastro-intestinal tract symptoms & ‘ibaadat: Salat is delayed while anticipating vomiting because vomiting is najs and will nullify the salat anyway. Vomiting nullifies puasa; it is recommended to continue puasa even after an episode of vomiting but make up the day after. Hiccup in salat may make recitation of the Qur’an impossible. If the hiccup persists it is preferable to terminate the salat and wait until it subsides. In extreme cases of peptic ulcer disease the patient is exempted from fasting. Any incidence of audible smelt flatus nullifies wudhu. A general feeling of flatulence does not nullify wudhu. Salat should not be terminated on mere suspicion of passing flatus. Constant flatulence may make maintenance of wudhu difficult. It is recommended that salat is performed immediately after wudhu. If flatulence is continuous it can be ignored but efforts at finding a treatment should be continued. A situation of continuous diarrhea makes it difficult to maintain a state of wudhu or to pray in congregation. When an episode of diarrhea is impending, salat is terminated by tasliim at any stage and is resumed after defecation and a new wudhu. In cases of anal incontinence, wudhu is made immediately before each prayer. Upper GIT bleeding that does not cause visible blood at the anal opening does not nullify wudhu. If it leads to hematemesis, puasa is void and has to be made up later. Fresh bleeding from hemorrhoids and anal lesions does not nullify wudhu but must be washed away immediately and before salat commences. Any cause of abdominal discomfort such as pain, cramps, spasms, and digestive disorders make it difficult to concentrate in salat. It is recommended to delay salat until the discomfort is treated. Pain of gallstones in an acute attack makes concentration in salat difficult. Associated vomiting may void puasa. Halitosis, bad oral smell due to caries, gingivitis, and oral ulcer; is a reason for keeping away from public assemblies until the condition is cured.

Vision disorders, amraadh al basar: A blind person is not obliged to attend salat al jama'at, salat al jumu'at, and hajj if he no guide. He can be a muaddhin only if someone to tell him the correct time. He can also be imaam. He can be a political leader if the visual impairment does not impair performance of leadership functions. He cannot be a judge because of inability to see witnesses and assess their demeanor. He can be a scholar or a mufti. He can testify if the evidence does not involve sight. He can marry if measures are taken ensure enough mutual knowledge of the future spouses based on other senses and information from third parties. He can be wali in marriage if he knew the spouses before getting blind and can recognize both using other senses. Selling and buying by a blind person can take place in transactions where fraud is unlikely. Blind persons can offer professional services if there is no possibility of harm due to their lack of sight.

Hearing and vestibular disorders, amraadh al sama’u: A deaf person is obliged to attend salat al jumu’at if others hear adhan and inform him. He can be muaddhin if others tell him the correct time. He can be imaam. He can follow the imaam by watching what the imam does. He can teach Qur’an but it is preferred he does not do so because he cannot hear and correct mispronunciations. He is not obliged to return greetings because he cannot hear but is obliged to respond to sign language of greeting if he is sighted. Deafness reduces competence as a leader but is not an absolute contra-indication. A deaf judge will not be able to discharge duties fully. A deaf person can be a scholar and can give religious rulings if he can read the questions and answer by writing or by sign language. He cannot be a witness over matters that require perfect hearing. He can contract a marriage by use of reading or sign language. He can declare divorce. He can buy and sell as long as he understands the transaction and can communicate in writing or by sign language. It is forbidden for a deaf person to engage in any professional work for which hearing is necessary. In vestibular disturbances standing up in salat or tawaaf may require support.

Olfactory disorders, amraadh al shumm: In hyposmia the victim may not be able to smell flatus and thus may continue praying with an invalid wudhu. Hyperosmia and parosmia may results in unnecessary concern about presence of najs where it is insignificant. The halitosis associated with puasa is due to reduced oral cleansing action of saliva. It can be reduced by increased oral hygiene. Impairment of the taste sensation may reduce enjoyment of food. It may also impair ability to discriminate dangerous things and avoiding swallowing them. Halitosis due to disease or poor oral hygiene may make social intercourse difficult. It is especially offensive in the masjid. Use of perfume to control body odor in public places like the mosque is mandatory to avoid annoying others. Body or oral odor may cause so much distress in a marriage that it may lead to divorce. Impaired smell may make transactions involving perfumes invalid because the buyer cannot identify what is being bought. Similarly impaired smell may lead to buying of rotten products without knowing their true state. Court evidence based on smell may not acceptable in situations of olfactory disorders.

Taste disorders, amraadh al dhawq: If taste is defective, it will not be possible to tell that water is polluted and is not suitable for wudhu. Enjoyment of food decreases when the sense of smell is defective. Dangerous food may also be consumed if it cannot be tasted. In selling food and drinks, the buyer may use taste to make sure the product is wholesome. This is not possible when the sense of taste is defective. Evidence in court based on taste of products may not be accepted in cases of a defective taste sense.

Other sensory disorders, amraadh al hawaas al ukhrah: Loss of tactile sensation does not affect wudhu and salat. It can lead to ingesting rough and dangerous materials. It impairs sexual sensation may lead to stresses in marital life. Loss of tactile sensation may be a cause of accidents at work. The integrity of the tactile sensation is considered when assessing certain types of court evidence. An impaired sensation of temperature may result in unnecessary exposure and heat stroke during hajj. Hot and therefore harmful food may be eaten when temperature sensation is impaired. Inability to adjust to extreme climatic conditions may be grounds for divorce if a promise was made in the marriage contract that the spouse will not be taken to another country. Workers must not be exposed to extremes of temperature. Extreme pain may prevent concentration in salat. Pain may cause insomnia. Chronic pain due to PID and other causes of dyspareunia may create marital stress. Chronic pain may lead to psychological stress. Severe pain may lead to criminal behavior. Salat is delayed in cases of extreme hunger sensation. Loss of the hunger sensation is dangerous to life. Inability to extinguish the feeling of hunger with food intake may lead to loss of appetite control. Children may be severely undernourished when they do not feel hungry and refuse to eat food. Extremes of pain may lead to crime. Concentration in salat is impaired in extreme thirst

General ill feeling and general weakness, al dhu’ufu al ‘aam: Non-obligatory duties are delayed but obligatory acts like salat, puasa, and hajj are delayed only for physical inability to perform. The physically disabled is allowed to pray sitting or lying down. Exemption from puasa is only for potential physiological harm. The weak can leave Muzdalifah earlier. Travelers may shorten and/or combine salat or break puasa and make up later. Salat, puasa, and hajj rites are delayed for high fever. Non-obligatory puasa is recommended for the obese but is discouraged for the under-weight and the pregnant. Obligatory puasa is delayed in cases of extreme malnutrition and cachexia. The obese are obliged to reduce weight especially if they have impairments in salat performance and sexual function. The underweight are obliged to seek dietary treatment. Extreme fatigue necessitates delay of salat for lack of concentration, delay of puasa, and delay of hajj rites except standing at Arafat. Acts of ‘ibadat cannot be delayed in the chronic fatigue syndrome. The victims of this condition should try to perform as many acts as are possible and in the meanwhile try to seek treatment. Supplications, doa, and recitation of the Qur’an are highly recommended because diseases of the heart may be an underlying cause of the chronic fatigue syndrome.

Fever, al humma: High fever may be reason for delaying salat because of generalized weakness and discomfort. Puasa with high fever aggravates dehydration and may have to be delayed. In cases of high fever, hajj may be difficult due to general weakness and lack of physical energy to complete the rites of pilgrimage. Fever aggravates dehydration in the dry climate of Hejaz. Care must be taken to prevent spread of contagious diseases because most cases of fever are due to infection.

Pain, al alam /al waja’u: Salat is delayed for severe acute headache, acute backache, and skin itch until the patient is able to concentrate. Salat is not delayed for chronic backache or skin itch but should be made as short as possible. Salat is interrupted for an anginal attack to rest and use medication and is continued after that with sujuud al sahaw at the end. Use of sub-lingual medication does not nullify the salat of a patient with chronic angina. Arthritic joint pain necessitates restricting movements during salat. If the pain is severe, the guidelines for the salat of the sick are followed. Patients with chronic pain on regular twice or thrice daily medication are exempted from fasting. Joint or back pain in hajj is an exemption to allow the pilgrim to be carried or to be put on wheeled transport during tawaaf and sa ay.

Disorders of high altitudes and space, amraadh al muratafa’aat wa al fadhaa: Concentration in salat at high altitude is impaired because of low oxygen concentration. Salat in weightless space is feasible but the physical movements may be restricted and the guidelines of the salat of the sick may have to be employed. Puasa at high altitudes is a challenge because of the cold that requires high and regular food intake to generate enough metabolic heat to keep the body warm in the cold atmosphere. The impact of weightless ness in space on puasa has not yet been studied.

Adverse environment, haalaat al taqas al qaasi: Salat is delayed on a hot day until the temperature cools down to what is reasonable. Tayammum is carried out on cold days even if water is available. Cooling the body is permitted in puasa. Puasa can be broken on very hot days for fear of severe dehydration. Special protection is needed against heat stroke and dehydration during hajj. Tayammum is prescribed if the extreme cold may aggravate peripheral vascular disease. If the floor is too cold to stand during prayer, wearing of sandals or khuff is allowed. If frostbite or hypothermia occur as a result of cold exposure, puasa is broken to eat food to generate enough metabolic heat to raise body temperature. Puasa may be broken on cold days for fear of severe dehydration and due to increased calorie requirements to maintain body temperature. Salat on a cold day is preferably offered in the home to avoid cold exposure in the external atmosphere. In case of fear of light injury it is recommended to pray inside a house, use a shelter, or wear special headgear and eye wear to avoid cosmic radiation. Photo dermatitis in hajj is avoided by avoiding going out during the middle of the day.

Endocrine disorders, amraadh ajhizat al hormonaat: In diabetes mellitus, blindness exempts from salat al jama’at. Diabetics with leg ulcers make yatammum instead of wudhu and adopt the most confortable salat position. Insulin-dependent diabetics and pregnant diabetics are exempted from puasa. Diabetics controlled on oral medication and diet can undertake puasa under physician supervision. Patients of anterior hypoparathyroidism and hypothyroidism offer salat and puasa depending on clinical severity. They are treated for sexual failure before marital dissolution is considered. They perform tayammum instead of wudhu for cold intolerance. The default age of 15 is used to define adulthood if puberty is delayed. Growth hormones can be used for growth retardation. Wet nurses, milk banks, or artificial formula are used for lactation failure. In cases of amenorrhoea, the presumptive period of 4 months + 10 days is used as the ‘iddat. Patients with diabetes insipidus are exempted from puasa until electrolyte and fluid imbalances are corrected. Patients with hyperthyroidism with restlessness preventing concentration offer brief salat with short recitation. Patients with Addison’s disease offer salat sitting down to avoid postural hypotension and delay puasa and hajj until correction of fluid and electrolyte imbalances. Patients with primary hyperaldosteronism are exempted from puasa until correction of electrolyte imbalances. In adreno-cortical excess standing and posture of salat are altered (because of myopathy and possibility of fractures due to osteoporosis), puasa is delayed during the treatment, hajj is delayed, and legal competence is impaired if psychotic symptoms are severe. Hormonal treatment of testicular and ovarian disorders, pseudohermaphroditism, gynecomastia, and hirsuitis is allowed if benefits outweigh risks. Legal liability is decreased if criminal behavior is due to hormonal derangement.

Infection, al ‘adwah: Infectious persons may be excluded from hajj and congregational salat. Under the principle of public interest superseding private interest, the following are allowed in an epidemic: restriction of movement, quarantines, involuntary measures (mass immunization, treatment, and prophylaxis), and destruction of property (eg infected animals). Premarital screening is obligatory in places with endemic infectious diseases. Conjugal sexual rights can be denied for fear of infection. Conviction for zina cannot be based on incidental finding of STD in an unmarried person. Seeking divorce or khulu’u can be based on discovery of STD in a spouse. A spouse is legally liable for transmitting STD. Islam gave detailed teachings on personal hygiene, food hygiene, excreta disposal, and waste disposal in order to keep the environment clean and healthy.

Neoplasia, al sarataan: Intervention against cancer risk factors is based on the principle that harm should be relieved, al dharar yuzaal. Laws on sexual, body, and environmental hygiene decrease risk exposure. The tobacco-cancer link is considered yaqeen by physicians making tobacco haram. It is considered ghalabat al dhann by jurists making tobacco makruuh. The diet-cancer link does not reach the level of yaqeen or ghalabat al dhann. The Law can regulate institutional but not home diets. Parents are liable for child malnutrition due to negligence. Early disease screening is obligatory if scientific evidence shows benefit. Treatment of advanced disease is based on the balance of harm and benefit, both immediate and long term.

Genetic conditions, amraadh wiraathiyyat: Jurists are not unanimous on the obligation of pre-nuptial genetic testing and advice. The case for testing is stronger in cases of cousin marriages or in cases with a family history of genetic disease. Results of genetic testing could be used as a basis for refusing marriage or refusing to get pregnant. Pre-natal genetic screening in the form of amniocentesis for sex selection may encourage illegal abortion. Amniocentesis for disease detection may be of benefit to the parents to make financial and other preparations to take care of sick newborns. Marriage of close relatives has to be considered in the light of the balance of disease risk due to consanguinity and social advantages of marrying within the family. Treatment by genetic engineering is allowed under the rubric of permissibility of change of fitra as long as it is not done with the purpose of defying Allah’s creation. Widespread genetic testing may introduce systematic social discrimination based on gene profile for diseases and provide a false scientific basis for ethnic discrimination

Traumatic injury, al juruuh: It is allowed to wash a patient in ablution. Tayammum is preferred for cases of profuse or active bleeding at sites of wudhu. In cases of wounds, a wet hand is rubbed on the bandage. Tayammum is carried out instead of ghusl in cases of burns or other conditions preventing use of water. Patients with physical disabilities pray in the most comfortable position. Impotence in paraplegia and physical disability preventing working to support the family are grounds for marriage nullification if the wife requests. The Law provides for financial compensation in cases of accidental injuries or work-related injuries.

Disturbance of consciousness, fuqdaan al shu’uur /al mughmi ‘alaihi: Forgetfulness in salat is remedied by the prostration of forgetting, sujuud al sahaw. A forgotten salat is offered when remembered. In complete loss of consciousness, there is no obligation to perform salat. In semi-coma, syncope, or stroke the patient tries to perform salat as much as he can. Stroke patients must be careful not to fall down during salat due to the limb paralysis or paresis. A dozing person stops salat, sleeps, and resumes when conscious of what he is reading. In fright or inability to concentrate, salat is shortened. A person who forgets and eats in Ramadhan just resumes puasa and completes the day. The obligation of puasa is dropped if the patient is in coma or is fully unconscious. Hajj is delayed if consciousness is impaired. Hajj rites are delayed in case of syncope following postural hypotension. Semi-conscious patients or those in coma are fed without their consent under the purpose of preserving life. Pronouncements of divorce or khulu’u, marriage, or contracts under psychosocial stress or impaired consciousness have no legal effect because of legal incompetence. However a guardian, wali, on behalf of the unconscious, can conclude valid contracts. Court testimony by a semi-conscious person is not allowed. There is reduced legal or civil liability for crimes and contracts under the influence of ordinary psychiatric medication. Liability is not reduced for crimes and contracts committed under the influence of alcohol or illegal drugs.

Personality disorders, amraadh al shakhsiyyat: Personality disorders not accompanied by cognitive effects have no impact on ‘ibadat. Severe personality disorders exempt from hajj for fear of crises. Preventive measures are needed to protect the public from psychopaths. Severe personality disorders are a contra indication for marriage. Personality disorder may be considered as legal incompetence in contracts and criminal prosecution.

Neurotic and psychotic disorders, amraadh al junuun: Obligatory salat is delayed in severe anxiety because of inability to concentrate. Compulsive-obsession about passing flatus in salat should be ignored. Psychiatric disease does not affect the obligation of paying zakat because zakat is related to the wealth and the not the individual. Psychiatric illness that affects legal competence exempts from salat, puasa, and hajj. Attempts are made to treat psychiatric illness before resort to divorce. A marriage contract is deemed void or irregular because of mental incompetence. Divorce pronouncements by an insane person have no immediate legal effect unless confirmed by a competent court. Contracts by a schizophrenic or a patient with mood disorders clouding clear thinking are void. Evidence by a psychiatric patient is evaluated in view of the type of cognitive or personality defects because some may be acceptable. The evidence of patients with mood disorders must be considered in the light of their clinical conditions.

Sexual disorders, amraadh al jimaa’e: Sexual disorders usually have no direct impact in ‘ibadat, aadaat, or mu’amalaat; they however are intimately related with marriage and divorce. Divorce or khuluu can be considered for lack of libido, sexual deviation (e.g. sadism or masochism), transsexual behavior, male impotence, and female vaginismus/frigidity. Fasting may help control sexual desire.

Stress disorders, amraadh dhiiq al nafs: Stress can be controlled internally by salat, dhikr, and i’tikaf. It may lead to wrong unintended decisions in transactions, produce adverse effects on marriage leading to divorce, affect appetite, and impair concentration in salat. Hajj and puasa may increase the stress level. Salat generally decreases stress levels.

Epilepsy: Epileptics under control can perform salat and puasa and undertake hajj but have to take medication and avoid triggers of attacks.

Degenerative conditions, amraadh talaf al dumaagh: Salat and hajj may be difficult in advanced Parkinson’s disease. Demented patients cannot be leaders in salat because of confabulation. Dementia that does not impair cognition does not exempt from salat, puasa or hajj. Court testimony of elderly demented patients is evaluated in light memory and cognition. Since dementia is incipient, special tests of competence are needed before court testimony.

Central neurological conditions, amraadh al a’aswaab: Head injury may be associated with paralysis, impaired consciousness, or loss of sensation affecting salat and hajj obligations. Brain tumors affect salat, hajj, marriage contracts, and judicial proceedings depending on the severity. Mental clouding from brain infection affects salat, puasa, hajj, and witnessing in court. Spinal cord injuries may lead to quadriplegia and paraplegia that limit movements in salat. Tawaaf is undertaken on a vehicle for patients with spinal problems.

Peripheral neurological conditions, amraadh a’aswaab al a’adha: Disease such as myasthenia gravis limits salat movements and may make hajj difficult. Pain from neuropathies may be increased during salat movements.

Other disorders, amraadh ukhrah: Aphasia and dysphasia affect conclusion of marriage contracts, witnessing in courts of law, and public leadership duties. Vestibular disturbances necessitate support to stand in salat and tawaaf.

Pregnancy & and delivery, amraadh al haml wa al wilaadat: Pre-natal diagnosis could be prohibited under the principle of closing the door to evil if it leads to abortion. Amniocentesis and other investigations to ascertain life and gender at time of the father’s death help determine fetal inheritance rights. Consideration of maternal interest has priority over consideration of fetal interests in medical and surgical interventions in pregnancy and delivery. Adhan and iqamat are required for the newborn. Circumcision can be delayed for fear of neonatal bleeding. Neonatal disease screening and immunization are encouraged by the Law. Breast-feeding is mandatory for 2 years according to Qur’anic injunction. Foster breast-feeding is allowed but it creates relations like those of a biological mother that restrict marriage. Use of artificial formulas is allowed but milk banks are discouraged. Payments are made to a divorced mother for breast-feeding their babies. Post-partum hemorrhage has the same legal rulings as menstruation. Post-natal depression may constitute deficient legal competence for making treatment decisions for the mother and baby.

Infancy, al khadhaanat: Nafaqat includes all material sustenance needed for the infant such as food, clothing, and medical care. The father is responsible for nafaqat during marriage and also after divorce. The extended family and the state are responsible for financial maintenance of single poor mothers. Child abuse and neglect can be physical, sexual, or psychological. Vaccination of infants is obligatory.

Childhood, al tufuulat: Hormonal treatment of slow growth is permitted. The age of 15 years indicates legal maturity even if sexual maturation is not complete. The rules of hijaab and male-female interaction are applied earlier in precocious growth to avoid transgression. Younger girls growing precociously are not married off because they are immature. Parents can consent on behalf of young children for urgent reconstructice surgery but should wait until children reach the age of consent for non-urgent surgery. Children who grow rapidly could be allowed to undertake some transactions if their cognitive skills are judged to be like those of adults.

Adolescence and youth, sinn al muraahaqat wa al shabaab: Adolescent and youth behavioral problems are best resolved by preventive tarbiyyat. Intervention when they are already grown up is sometimes too late.

Old age, al shaykhuukhat: The elderly, like the sick, are exempted from fulfilling all the acts and conditions of the physical acts of ‘ibadat, salat, puasa, and hajj. They pray sitting down or lying on the side. They can make tawaaf carried by a person or a vehicle. In cases of urinary or fecal incontinence, they wear a retainer, make wudhu and perform salat immediately without waiting. Mental competence of the elderly is considered in marriage, divorce, transactions, evidence, and criminal liability. Both males and females experience sexual problems.

Narcotics are given for severe pain. Drugs are used to allay anxiety and fears. The caregivers should maintain as much communication as possible with the dying. They should attend to needs and complaints and not give up in the supposition that the end was near. Attention should be paid to the patient's hygiene such as cutting nails, shaving hair, dressing in clean clothes. As much as possible the dying patient should be in a state of ritual purity, wudhu, all the time.

The dying patient should as far as is possible be helped to fulfill acts of worship especially the 5 canonical prayers. Tayammum can be performed if wudhu is impossible. Physical movements of salat should be restricted to what the patient's health condition will allow. The prophet gave guidelines on salat even for the semi-conscious patient. The terminal patient is exempted from puasa because of the medical condition. It is wrong for a patient in terminal illness to start puasa on the grounds that he will die anyway whether he ate enough food or not. Illness does not interfere with the payment of zakat since it is a duty related to the wealth and not the person. The terminal patient is excused from the obligation of hajj. It is also wrong for a patient in terminal illness to go for hajj with the sole intention of dying and being buried in Hejaz.

Spiritual preparation involves allaying anxiety, presenting death as a positive event, thinking of God, and repentance. Caregivers should allay fear and anxiety about impending death. Death of the believer is an easy process that should not be faced with fear or apprehension. Believers will look at death pleasantly as an opportunity to go to God. God loves to receive those who love going to Him. The patient should be told that God looks forward to meeting those who want to meet Him. Dying with God’s pleasure is the best of death and is a culmination of a life-time of good work. Thinking well of God is part of faith and is very necessary in the last moments when the pain and anxiety of the terminal illness may distract the patient's thoughts. Having hope in God at the moment of death makes the process of dying more acceptable. The dying patient should be encouraged to repent because God accepts repentance until the last moment.

During the long period of hospitalization, the nurses develop a close rapport with the patient. A relationship of mutual trust can develop. It is therefore not surprising that the patient turns to the nurses in confidential matters like drawing a will. The nurses as witnesses to the will must have some elementary knowledge of the Law of wills and the conditions of a valid will. One of these conditions is that the patient is mentally competent. The Law accepts clear signs by nodding or using any other sign language as valid expressions of the patient's wishes. Islamic Law allows bequeathing a maximum of one third of the total estate to charitable trusts, waqf, or gifts. More than one third of the estate can be bequeathed with consent of the inheritors.

A terminal patient can make a living will regarding donation of his organs for transplantation. The nurse must explain all what is involved so that an informed decision is made. The nurse may be a witness. It is however preferable that in addition some members of the family witness the will to ensure that there will be no disputes later.

The nurse may be a witness to pronouncement of divorce by a terminally ill patient. The pronouncement has no legal effect if the patient is judged legally incompetent on account of his illness. If the patient is legally competent, the divorce will be effective but the divorcee will not lose her inheritance rights.

The nurse should advise the terminal patient to remember all his outstanding debts and to settle them. If the deceased has some property, the debts are settled before any distribution of the property among the inheritor.

The last moments are very important. The patient should be instructed such that the last words pronounced are the testament of faith, shahadat. Once death has occurred the body is placed in such a way that it is facing Makka. Eyes are closed and the body is covered. Prayers are then recited. The nurse should take the initiative to inform the relatives and friends. They should be advised about the rules on mourning. Weeping is allowed. The following are not allowed: tearing garments, shaving the head, slapping the cheek, wailing, and crying aloud. Relatives are comforted by telling them hadiths about death. These talk about the reward of the person who loses his beloved one and he is patient.

The nursing team should practice total care by being involved and concerned about the processes of mourning, preparation for burial and the actual burial. They should participate along with relatives as much as is possible. The preparation of the body for burial can be carried out in the hospital. The body must be washed and shrouded before burial. Perfume can be put in the water used for washing the body. The washing should start with the right. The organs normally washed in wudhu are washed first then the rest of the body is washed. Perfume can be used except for those who died while in a state of ihram. Women's hair has to be undone. After washing, the body is shrouded, kafn, in 2 pieces of cloth preferably white in color. As many persons as possible should participate in the funeral prayer, salat al janazat. Burial should be hastened. Following the funeral procession is enjoined. There is more reward for accompanying the funeral procession and staying until burial is completed. Hurrying in marching to the grave is recommended. The body should be buried in a deep grave facing Makka. After burial, the relatives are consoled and food is made for them. Only good things should be said about the deceased.

Definition of stress: Stress is a psychological, emotional, and physiological reaction to a stressor. It is considered part of normal human adaptation if it is within certain limits. It becomes abnormal or pathological in situations of over-reaction such that the adverse consequences of the stress reaction cancel out the advantages. The stress threshold varies from person to person and from stressor to stressor. What stresses one person may not stress another one. The same individual could react to the same stressor in different ways depending on the social and personal context. The underlying cognitive and spiritual qualities modulate reaction to stressors.

Mention of stress in the Qur’an: The Qur'an has described stress as tightness of the chest, dhiiq al sadr[21]. It also has described stressful life as constricted life, ma’ishat dhankan[22]. The opposite of stress is breadth of the chest, inshiraah al sadr[23]. Stress involves psychological stress, dhiiq nafsi with physical symptoms and signs appearing later. Stress is breakdown of normal psychological equilibrium, i’itidaal

Causes of stress: Stressful events are traumatic, uncontrollable, and unpredictable. Examples are: trauma, temperature, and emotions. Travel is a cause of stress likened to punishment[24]. It is part of human nature to be inpatient, al ajalat fitrat insaniyat[25]. Thus when confronted by a problem that cannot be resolved quickly, they become stressed. Life is full of difficulties. Allah helps those in difficulty. Each difficulty, ‘usr, is accompanied by what makes it easy, yusr[26]. Patience is called for in moments of difficulty. However many people when in trouble forget this and fall into stress.

Reaction to stress: Psychological reactions to stress are: anxiety, anger, aggression, apathy and depression, cognitive impairment. The physiological reaction to stress manifests as the usual signs of adrenaline releases. Long-term stress affects good health.

Coping with stress: People cope with stress in different ways. Coping with stress may be by denial, projection, repression, rationalization, or reaction formation. The type of reaction also depends on the personality type, spiritual preparation, and experience in life.

The quickest treatment for stress is to remove the stressor. This however does not always succeed in returning the person to the normal state because memories of unpleasant stressors may continue eliciting stressful reactions for a longer time. Cognitive approach to stress is to make the person realize that there is no rational basis for the stress over-reaction. Spiritual approaches involve repairing the relation to the Creator so that the victim feels empowered to cope more effectively with the stressor or even ignore it altogether.

Eliminating the trigger: Emotional disequilibrium is a disease that must be treated. Every disease has a treatment. Once emotional disorders have occurred, the best approach is to remove the cause if it can be identified. Then we undertake the task of rebuilding, repairing, and restoring faith. This is supplemented by supplication,

Restoration of faith: The most effective approach to dealing with emotional disorders is to correct the faith. This requires clarifying certain relationships and clarifying the issues of causality. A person must know the correct relation with God, with his own body, with other humans, and with the eco-system. Any defect in any one of these relationships will lead to emotional disequilibrium. Understanding causality removes a big burden of guilt from a person for what has gone wrong. Nothing happens without God’s permission. This however does not remove personal responsibility for actions.

Cognitive approach: empirical analysis of the problem may lead us to conclude that it is not worth worrying over. We need to understand that problems are a test. The final result is not having a problem but knowing how to deal with it. Ignorance of human limitations (physical, cognitive, sensory) makes humans stress themselves over failures. If they were wiser they would not blame themselves because they would known that some tasks are beyond their ability. Human perception is not accurate. What is perceived as a problem may not be a significant problem or may not a problem at all and this would become obvious with passage of time.

Supplication / doa: Supplication is very effective in dealing with emotional disturbances. Its effects are dual. On one hand there is supplication to God to relieve the stress. On the other hand there is the feeling of relief because the problem has been referred to a higher and stronger power

[1] Ibn Majah

[2] Bukhari

[3] Bukhari

[4] Darqutni

[5] Bukhari

[6] Abu Daud

[7] Bukhari

[8] Bukhari

[9] Ahmad

[10] Bukhari

[11] Bukhari

[12] Bukhari

[13] Bukhari

[14] Bukhari

[15] Bukhari

[16] Qur’an 2:183-185

[17] Bukhari

[18] Bukhari

[19] Tirmidhi

[20] Abudaud

[21] Qur’an 11:12, 15:97)

[22] Qur’an 20:124

[23] Qur’an 94:1

[24] Bukhari

[25] Qur’an 17:11

[26] Qur’an 94:5-6