 Bismillahirrahmanirrahim And this medicalization of death, I argue, has robbed humanity, Muslims included, of what has been the most spiritual experience one can undertake in dying. Even Pharaoh called out to our Lord when he was dying. So that's how it's changed. Now I want to bring up some statistics to really lay out the landscape of death here in America in 2019 with this first question, how do we die? And this is a pretty pie chart showing the causes of death for people aged 65 and older. Heart disease and cancer always being one and two. But I think the more interesting pie chart is this one. At least 70% of older adults will die from chronic illnesses. This means diseases or illnesses that used to kill people over the order of days or weeks are now taking months or years. And I think it's done one of two things to people. Either they take that time to gain some perspective, to plan. I know you had to talk here by my dear friend, Diaz al Ali, about estate planning a few months ago. You take this time to plan. It's all nearer to Allah. Or I think, paradoxically, what has happened is that because we're living so long with chronic illness, we get into a mode of denial, where let's say a patient has heart failure and things are looking grim, they get hospitalized, doctors are great at seeing them up, fixing their medications, discharged home. A couple months later it happens again. A couple months later it happens again. So when it finally happens to where it's gotten to a point where the end is near, the patient, the family is in this mode of, no, it's just like last time. The doctor just gave this medication and she was fine. So we get in this habit of denial and delusion, unfortunately. The second question is when do we die? Does anybody want to take a guess? It's the average lifespan here in America in 2018. Yeah, 78.6, and this was 2016. It's fallen a little bit because of the opioid crisis, but still 78. Good. And if you make it to age 65, that actually increases. But once you make it to age 65, your average lifespan is 84.4. And the last question is where do we die? And I want to spend a few minutes on this. If you're age 65 or older, you have a 27.9% chance of dying in a hospital. 24.7 people die in nursing homes and 29.4% die at home. Now that 29.4%, I want to just take a minute here. That's increased over the couple of years and there's more of a push to die at home. Survey after survey among older adults, 70%, 80%. When asked where their preferred place of death would be, it's at home. People who are in and out of the hospital, and I'm sure everyone here has had some personal experience to one degree or another. Being in a hospital is not fun, right? So most people want to die at home when they're asked this. 29.4% is an overestimate, I'd say for two reasons. Number one, it's not accounting for the transitions at the end of life. What do I mean by transition? Well, a patient is home, then they get admitted to the hospital, spend some time in the ICU, get discharged to a skilled nursing facility, back home, back to the hospital. And if data shows that those transitions have actually increased over the last 10 years, and more and more people are spending more and more time in ICUs in their last three to six months of life. So it's not so much where we take our last breath, although that is important. It also comes into question where we're spending our last weeks or months of life. Second reason it's an overestimate is like with all medical literature, whites are overrepresented in studies. And we know from smaller studies among minorities, minorities are more likely to want to die in a hospital and more likely to die in a hospital. And that's for a couple of reasons. Like for example, when asking blacks here in America about end of life preferences, well, most have a gross mistrust, maybe not most, but a lot have a gross mistrust of the healthcare system founded in historical events. I mean, it wasn't that long ago that blacks here in America were experimented on against their own will in Tuskegee case of Henrietta Lacks. So there's that gross mistrust. But how about Muslims? What are our perspectives? What are our attitudes on end of life care, on these issues? And the short answer is we just, we don't know. There's no, haven't been any large formalized surveys to actually ask people in our communities what we think. I think as a Muslim coming from a Muslim family, as a doctor who's treated Muslim patients, I think we mirror other minorities in this country, that we push for more aggressive interventions, ICU stays, life support, etc. And we'll delve into what truly our faith, Islam says about that and where we can find some room in our faith to have these discussions. So I want to do a little practice first. I want you to imagine, you are your age right now, whether you're in your 30s, 40s, 50s, and you start to have a headache and then some vision changes. A week goes by and you realize the right side of your body is not keeping up with your left. And you go to the doctor. And the doctor, kind of shocked, she orders a CT scan of your brain. And the CT scan shows that you have what is most likely brain cancer. This brain cancer is the type that, even with surgery, has 100% recurrence rate and usually people live on the order of two years when diagnosed. And I want you to turn to the brother or the sister next to you. I want you to think about these questions. What are you feeling? What's most important to you right now? And your worries and hopes. And think about what is most important for you to do upon hearing this news. So go ahead and take just a few minutes and do this practice, Insha'Allah, with whoever's next to you. All right. Usually when I do this in small groups, I actually go around and ask everybody what they've said. But I do want to hear, in terms of what's most important, if anybody, a couple of volunteers are willing to share what came up in your conversation. All in the back. Inheritance, things like that, taking care of that. What up? I heard family and deans are big things. Anybody else on the sister's side? I've asked this question more than a few times. And I think most common things that come up are a bucket list kind of to-do, whether it's traveling or something like that. Family. They're spending time with family, mending broken relationships, you know. And then obviously dean, like when I was saying, going near to Allah. A lot of people say hi to you if they're able to, if they haven't done it yet. How many folks said I want to see second, third, fourth opinions from different doctors and seek out the best specialists on brain cancer? You said I want to live as long as possible, no matter what, even if machines have to keep me alive. That's the reason I do this exercise. I've yet to have somebody raise their hand and say that. When we're healthy, we have that perspective. We're going to die, right? We have that perspective in terms of what's important and what our dean teaches us about what's important. When we're really in that whirlwind, that emotional whirlwind, when we are confronted by illness, a lot of times those things, the doctor's opinions and treatment options and machines, etc., just overload us and overwhelm us. So that's just the practice that I wanted everyone to do. Okay. So now death and dying in Islam, and we'll spend a few minutes on this because I do think it's important. Sheikh Hamza, I'm able to preserve him, he wrote in his essay death, dying, and the afterlife in the Quran, and I'll read it. Without death, it is questionable whether we would have any need for religion at all. At a fundamental level, religion's greatest claim is making sense of the reality of death, which relentlessly impinges on our living consciousness. This is very true. No one's died and come back to tell us what awaits us. We rely on Allah. We rely on our faith to make sense of it all. So in the Quran, the word al-Maut and its virgins of it mention 166 times and almost as many verses. And when I looked at these verses, just as an exercise, I looked at what are the most often occurring themes in the Quran. Number one is, Allah is the soul authority on life and death. The bringer of life, the causer of death. We often use that truth, that reality as I would call it a cop-out almost. We have to make decisions and Allah is the authority on life and death. That's not mutually exclusive. Allah is our soul authority on our risk, on our provisions. We have a choice when we wake up every morning whether we're going to go to work or not. And just like that, Allah is the soul authority on life and death. And he knows what happened, what will happen, what is happening, and what would have happened. You still have to make decisions. The second often occurring theme is resurrection, that there is an afterlife. That's because the Arab at the time, they didn't believe in an afterlife. They believed they were mortal. They believed that Allah was the creator. They didn't believe that they'd be resurrected. They used to say that there is not but our life in this world. We die and we live and nothing destroys us except time. And Allah swt refutes this time and time again. How can you disbelieve in Allah when you were dead and He gave you life? And then He causes you to die and then He gives you life and then to Him is the final return. And Imam al-Haddad, Rahimullah, comments on this in his lives of man. This is the journey of the soul. We need to have this in our minds when we're facing our mortality. It is a spiritual experience. And before conception all of our souls were gathered in Al-Alam al-Arwah where we took the mithaq, the covenant. Al-astubi rabbikum, am I not your lord? Maulub ala shahidna, yes, and we are witnesses to that. And we come down to the dunya, the lower world where we're accountable for our deeds and misdeeds. Go back to Al-Alam al-Arwah where the soul departs. And then finally, judgment day in the final abode, Allahumma inna nasa laka ridaqa wal jannah wa na'udu bika minsaqitika wal na'ar. And then how about the hadith? I want to just take some hadith that the Prophet sallallahu alayhi wa sallam gave us to really think about death and dying. First is wisdom. He said, Those who remember death most often and are best in preparing for what's after it, those are the wisest. And I would argue that coming to this talk and preparing for it will classify you as wise by prophetic standards insha'Allah. We know that the Prophet sallallahu alayhi wa sallam suffered pretty agonizing deaths. The day before he died sallallahu alayhi he was wiping his face with cold water saying, Oh Allah, help me with the throes of death. And also redemptive suffering is another thing. There was a hadith where one man died and another man said, He was fortunate. He died without being tried by illness. And the Prophet sallallahu alayhi wa sallam he admonished him for saying this. How would you know if he wasn't tried by illness that Allah would have forgiven his sins? I want to take a second here and an expiation of sins is something that's very important to us. We know that it's a weak hadith but a thorn doesn't prick the skin of a Muslim except that he or she is forgiven. There is a big difference between suffering from illness and causing undue suffering from medical interventions that are around today. There is another hadith, Do no harm nor reciprocate it, nor reciprocate harm. And that is the principal axiom when it comes to Islamic ethics, Islamic biography. Do no harm. So there is a big difference between suffering from illness and suffering from interventions and we'll talk about it more later. And lastly is prayer. The Prophet sallallahu alayhi wa sallam taught us never to long for death but to ask for life as long as life is good for me and ask for death if death is good for me. And that's what he taught us sallallahu alayhi wa sallam. Do want to touch about spend the next five minutes or so about grief. Prophet sallallahu alayhi wa sallam grieved when he was confronted by death. When his son Ibrahim was taking his last breaths the Prophet sallallahu alayhi wa sallam was crying. And Abdulrahman ibn Awf he said, and you, messenger of Allah, you're crying too? He said, this is mercy and started to cry some more. Inna al'ayna tadmaa where the eye shed tears. And the heart is grieved and we don't say except which is pleasing to our Lord. And then he calls out to his dead son wa inna bifaraqika ya Ibrahim ala mahazoonoon and we are grieved by your separation o Ibrahim. I want to do another exercise on grief and this is the five stages of grief posed by psychiatrist Kubla Ross in her book On Death and Dying. Denial, anger, bargaining, depression and finally accepting. And I'm going to use an example that we know very well to walk us through these stages and that's of Umar ibn Khattab we know Umar he was strong physically, strong in his faith and conviction and his love for Allah and his messenger but when he was confronted by bad news that the Prophet died he said, some of the hypocrites alleged that the messenger of Allah is dead by Allah he is not dead but has gone to his Lord as Moses went and remained hidden from his people for many days running around with his sword out and what are these stages? he's denying it, he's not dead he's angry, he's calling people hypocrites he's yelling, he has a sword out and of course he's bargaining he's not dead, he only went the way Musa alayhi salam went right? and I always think I'm sure everybody here has watched a TV show or a movie where a doctor says something like you have cancer and they zone out, dramatic music and the muffled voice of the doctor in the background, that's real that happens when people are confronted by bad news but we know the rest of the story where Abu Bakr al-Dilan who finally comes out he tries to silence Umar twice and he couldn't and finally he did something that was very uncharacteristic of Abu Bakr al-Dilan who he speaks over him and says whoever worshiped Muhammad and whoever worshiped Allah know that Allah never died and he said the ayah Muhammad is not but a messenger and messengers have passed before him and reflecting on this on this moment years later Umar says by Allah as soon as I heard Abu Bakr recited my legs betrayed me so that I fell to the ground Umar man we all aspire to be like here he is breaking down and finally he says I knew then that the messenger of Allah had indeed died and he's finally accepted I bring this example for three reasons number one is if Umar felt these emotions who are we not to who are we not to number two is doctors and clinicians don't really do a good job addressing these emotions we don't we're just not trained in it hospice and palliative care the fellowship that I am in takes a whole year to get trained in this right so they do a poor job and usually what happens is we start to try to engage with the patient in their family intellectually Allah created us we have a test of creation we have intellect he also gave us F he gave us a Fuad that's capable of feeling a heart that's capable of feeling and as long as the Fuad is raging with emotion good luck trying to engage with patients in their families intellectually or cognitively and then lastly the way Umar relied on the Quran to bring them to that acceptance phase so should we and we need to be patient so now I'll spend the next section talking about advanced care planning but first I want to introduce what I do as a doctor does anybody here want to take a stab at what palliative care is the process of dying so palliative care is a specialty in medicine that focuses like some of the brothers were saying focusing on symptom relief and quality of life and patients with serious illness it is not only end of life care I have patients who are facing serious illness who have just been diagnosed with a life limiting illness or a serious illness like cancer like heart failure like COPD and they have tremendous amount of symptoms I help with those symptoms it doesn't mean that they are going to die months or what have you they still may be getting curative treatment for their cancer but palliative care can come at any point in time in a disease process so when other doctors are introducing palliative care know that it's not strictly end of life care hospice care on the other hand is and hospice care is an approach to care for patients where you focus solely on comfort and usually for hospice care there is a Medicare benefit most patients on hospice are at home although in some specific cases where home is not an option they can be in facilities or even in the hospital although that's rare and really it's a mode of care that again focuses on comfort so those are the differences between palliative and hospice care there are some overlap but that's some definitions for you guys so let's talk about advanced care planning advanced care planning is a big umbrella term for planning for the future in terms of your medical decisions some other people call it life care planning I kind of like that better and a lot of conversations have to happen with advanced care planning difficult conversations three of the things that I'm going to address today are something called a surrogate decision maker something that's been mentioned a couple times already quality of life and lastly code status where we have these discussions in advanced care planning they're often recorded or documented in something we call an advanced directive an advanced directive is a legal document this is the easy to read California advanced healthcare directive that you can find on preparefreeorcare.org I like the easy to read one and it asks people to go through certain scenarios and to really write down their wishes that happen but first it asks for the surrogate decision maker anybody want to take a stab at what a surrogate decision maker is yeah exactly also known as a healthcare proxy, a DPOA of health durable power of attorney of health this is someone who can make decisions on your behalf when you are no longer able to and I would say there are four main things that make a good surrogate decision maker number one they need to know they're a surrogate decision maker be surprised the patients that I have in clinic oh yeah it's my wife well does your wife know that she's going to be a surrogate decision maker should something happen no I haven't told her yet you got to do that first I've had patients who thought a family member would be their surrogate decision maker and the family member said I can't do that and that's good to know at that point rather than later on the second thing is that they're available if it's somebody that's really hard to get a hold of probably not a good idea to have them as a surrogate decision maker number three is they know your wishes and we'll talk about what those wishes may look like and lastly they need to have the emotional wherewithal to act on those wishes it could be a very high stress and very difficult situation where they're cull to make that decision and they may feel conflicted that's a surrogate decision but knowing what your wishes are they need to make it on your behalf it's called substituted judgment so that's what a surrogate decision maker is I want everyone here at least as a practice to think who that would be for you even if you're young and healthy you should have somebody in mind and have that conversation the second thing I want to talk about is quality of life a lot of times unfortunately in the medical arena quality of life almost is like an afterthought oh there's nothing to do now let's focus on quality of life I wish that weren't the case but when we ask about quality of life we ask things about what brings people joy very common things are being pain and symptom free being able to communicate with loved one and I do a research study interviewing imams in the muslim chaplains where I ask about quality vs quantity as a palliative care doc I want to make you live as well as possible for as long as possible that's my goal a lot of times at the end of life unfortunately because of the medical advancements that we have sometimes quality of life and quantity of life just cannot be addressed together but when I ask that when I ask that to the muslim chaplains and some of the imams all of them said quality they favor quality in a terminal patient and when I ask what quality is many of them mention that last piece the ability to worship a law having the capacity the mental capacity to communicate with loved one sure but also being able to carry out ibadah to carry about worship and that's very important for us as muslims and can I think can help contextualize so going to that advance directive this is how it kind of looks like put an X on this line where you would feel so sick that you may die soon what do you want to focus on? I want to live as long as possible no matter what or I want to focus on being comfortable and then it walks people through specific scenarios and this isn't written in stone we know that in the medical field there's a lot of nuance and a lot of gray area and that helps as a guide for clinicians who are reading this advance directive or you're sure a good decision maker that are reading this advance directive to kind of give guidance so advance directive that's that's important the next thing I'm going to talk about is code status which I think as we get older or if we're living with chronic illness is a very important topic to discuss and not an easy one but I want to give you an example of how it's discussed in today's hospitals and medicine let's say Mrs. Khan is a 74 year old woman and she has diabetes and hypertension but otherwise she's healthy and she falls and she breaks her hip very common in our an elderly woman she goes to the hospital they take her to surgery, they fix the hip and they discharge her to a skilled nursing facility to get rehab, to get stronger after her surgery, very common and in the skilled nursing facility also very common to get infection so she comes back to the hospital to the ER the fever with low blood pressures she's really sick and it turns out she has a raging urinary tract infection and so the doctor comes in whether it's the emergency room doctor or the admitting doctor at the hospital asks all these questions how are you feeling, what are the symptoms does a physical exam, runs some tests and says Mrs. Khan we need to admit you to the hospital in fact because your blood pressures are so low you have to take you to the ICU for closer monitoring and we have to give you IV antibiotics and then they end with this and we ask this to all patients that are coming into the hospital if your heart were to stop or you were to stop breathing for whatever reason would you want us to do CPR or hook you up to life support or allow you to die naturally that question took me three seconds to ask four seconds maybe my clinic is a palliative care doctor this question takes clinic visit after clinic visit hours to delve into but we just in today's medicine in US healthcare we do not have a system to address this question the way it's supposed to be so it ends up being a four second question at the end of a an intake from a doctor and on top of that don't do a good job asking that question the way I asked it I've learned from trial and error because you got to be quick because you know you got to get them they're sick but you have to be as objective as possible the way doctors ask it these days is well if your heart were to stop do you want us to do everything we can to bring it back of course why am I in the hospital do you want us to take heroic measures to do whatever we can do you want us to do everything so the way we phrase it is obviously important if a doctor feels within herself that she want a patient to not want that stuff sometimes they try to dissuade a patient from doing it breaking ribs or traumatic etc and I think that's wrong too it takes getting to know a patient and what's important to them lastly I'll say it does a very bad job at portraying what CPR looks like there have been studies around this in terms of the success rate for CPR but the reality is if you're in the hospital and your heart were to stop people come in doctors, nurses respiratory therapists, pharmacists and immediately begin doing compression on your chest and yes we do break ribs when we do them immediately they would put a mask or a tube down the wind pipe to push air into your lungs doctors they describe this as helping you breathe it's not helping you breathe it's literally pushing air into your lungs right and of course you're getting medications catheters put in during all this code it can last anywhere between 5 minutes to sometimes as long as an hour to see if they're able to get your pulse back and it can be pretty chaotic as many times as doctors try to practice it in simulated situations it's not always that way and immediately after they end with a patient if they're able to get the pulse back in the ICU and usually on blood pressure support medications and sedated and or paralyzed so that's how what a full code looks like and I like to spell it out because if you're asking about chemotherapy about the side effects and what to expect and you're also going to be asking about the outcomes how is it going to help so let's talk about the outcomes and this is geared towards older adults anybody want to take a guess in Hollywood what the success rate is in Hollywood 100% they got to make it a little realistic 75% according to one study at least for our older adults the younger folks may have a better chance at surviving this for older adults as we get older or as we get sicker our chances of surviving just become lower so if you take 100 people over the age of 65 49% will die during the actual they won't survive it another 34% will not leave the hospital another 7% after a year of discharge 10% chance of living after a year of this code in hospital arrest on top of that we have this phrase during a code that we say time is brain the brain needs a lot of oxygen every minute that goes by without adequate oxygen can cause some brain damage so it's not uncommon that after a code people can have neurological deficits and the older you get the more sensitive your brain is so this is data showing what your chances are depending on your age of what a good neurological outcome or at least just minimal deficits and as you can see if you look to the 85 year olds and older 4.5% chance 10% chance of surviving 4.5% chance of having good neurological outcome I don't present these numbers to dissuade anybody from being full code that's not my goal I've had patients elderly patients who I've had long conversations with I know what you're saying doc I've heard it I'm gonna be full code you've made an informed decision but I think we do a poor job at actually knowing what's out there so that's why I presented that for all comers at least as of 2009 data from anybody who's over 18 years old if your heart stops in the hospital all comers have a 22% chance of leaving the hospital so it's not too different from the over 65 but I say the thing to take away from this is that you need to have conversations with your doctors, with your loved ones around what you would want because a lot of times this is the last thing that happens to patients before they die the alternative is what we call DNR do not attempt to resuscitate also known as full no code also known as allow natural death and usually it's filled out on this pink form called a post form physician ordered for life sustaining treatment and the post form is pink and the reason it's pink, not pink is because it's easily accessible in times of emergency there have been cases where it's filled out patients do not want to be resuscitated but because paramedics can't find it the defaults the decision is already made for you if you haven't had these conversations it's to do it so there have been instances around that usually I have samples for you to look at but if you just look at capulse.org you can see it, it won't pull it up in the pink sheet but it asks three main questions the first is whether or not you'd like to be resuscitated the second is the level of treatment you would like so whether it's full everything including the code whether it's comfort based and just everything focused on comfort treatment somewhere in between and the last thing it asks is about artificial nutrition and hydration so two feeds in the thing, the like I would say this is very important for anybody who's older to fill out or at least talk about with their doctor for anybody who's in and out of a hospital for anybody at a skilled nursing facility for anybody with serious chronic illness or terminal illness to fill out this is where we plan so in conclusion looking at the advanced care planning continuum you can fill out an advance directive anytime, it also talks about now and it also talks about the future so you can complete an advance directive update it periodically if you are diagnosed with a serious illness that's when post forms come into play and hopefully the goal is that your treatment wishes are honored and all the while of course you're having these conversations with your loved ones with your doctors and everybody involved in your care a Hadith that the Prophet SAW said and I think Yasir mentioned this a few months ago when I was watching his live stream there's no intellect like planning and so we need to plan and that's what advanced care planning is about okay so now we'll switch gears again actually let me open it up to questions before I move into the thick of end of life care are there any questions that come up I can repeat the questions too yes brother so the brother asked it sounds like there's two choices to make full code versus DNR and what goes into making that decision how do you make that decision and I think it boils down to looking into the future and how you want to live the rest of your life knowing really well that if you have terminal illness if you do have if you are older that this may be the last moments of your life and if at the last moments of your life you want to allow to die naturally without those things that's one thing and if you want there's a lot medicine can do the question is should we so ventilators and ICU's and staying in the hospital I'm sure many people here have had experience weeks to months even years a little girl from Oakland passed away after four years of being on a ventilator so that's the question that you need to ask yourself is how important is that for you and also there's a degree of suffering that happens during it all is that something you're willing to go through knowing those outcomes and that's the question and it's a tough one there's no legal structure so as we'll talk about shortly western bioethics autonomy and informed consent is the most important meaning doctors will always ask a patient and their families what they want or are supposed to and so sorry I should repeat the question he's asking if there's any legal I guess anything legal that's out there that can really determine whether a patient is full code in DNR specifically in cases where patients are living like with dementia or quality of life may be low no there isn't so usually they need to turn to patients and their families to make that decision and if they don't then the default is to be full code I could speak to the responsibility on clinicians and doctors around providing what can be deemed as futile care am I saying that right I think studies have shown that number one patients expect their doctors to bring it up even though they're thinking about it they don't so I do think that it is on the shoulders of clinicians to bring this up I mean obviously I'm doing a talk here in the community to bring it to your radar but it's just impossible to reach everyone most people don't know that these things exist even though it's very important I do think that it's the responsibility of a clinician now to the topic of futile care that's opening up a whole bag of worms in terms of what's determined as futile and not many times when patients and doctors are at odds and sometimes doctors feel that distress of providing that futile care but again that cloud of emotion prevents or misunderstanding prevents patients families from really grasping that that ethics committees sometimes have to get involved and some hospitals have structures placed in to carry out if a treatment is futile it's hard to say how things change I think the hardest part about all of this is the unknown we just don't know and doctors can rattle off statistics but then you'll have your cousin from New York who flies in at the last moment and says I had a friend who lived with a coma for three weeks and doctors were ready to pull the plug and then now he's working and he's okay so it's always hard to balance between that in these decisions did that answer your question any other questions before we move on so talking about Sharia Imam al-Jawaini then Imam al-Ghazali and then finally Imam al-Shaltabi put together the the objectives of Sharia and we know that heften nefs the preservation of life is something very important in our Dean we know the verse whoever kills someone is as if they've killed all of mankind whoever saved one is as if they saved all of mankind and we know that the sacred law in most schools can be broken down in terms of our deeds and our actions into these five categories forbidden, discouraged, permissible recommended and finally obligatory at risk of oversimplifying this I'm going to take what is now contemporary Islamic bioethicists have taken in terms of boiling it down to seeking medical care going to your doctor when you're sick where does it fall in this continuum and we'll look at traditionally there was a small difference of thought this is just looking at the when you look at the effectiveness of a particular treatment when there's any doubt around it or uncertainty around it what did these medical jurists say Halafi, Malikis and Hanbalis say that if there's any doubt around the treatment that it's Mubah and Wajib when it's certain certain there are very few things that are certain in medicine I will tell you that wholeheartedly but Hanbali's favor some Hanbali's classically favor that it's never Wajib and in fact in many instances it's preferable that you more contemporary scholars came together in the Fiqh Academy in Jeddah in 1992 and they broke it down too and all four schools were represented don't know how many clinicians were involved in these discussions but they said it's Wajib if it leads to disability death loss of organ or if it's contagious it's Mandub if it just leads to weakness otherwise and in fact it's Makruh or discouraged if the complications may outweigh the benefits now that first line I do have my bones to pick about it because it's never that black and white right and I want to highlight this with some recent medical data in one study this study Pali of Care Doctors loves and what it did I'll spell it out for you 151 patients with metastatic lung cancer if anybody knows about stage 4 lung cancer most often you're not living past a year your prognosis or how long you have left to live is on the order of months and what they did is they divided these 151 patients into getting Pali of Care two weeks after diagnosis or not just regular standard care and what did they find well not surprisingly quality of life was better in people with Pali of Care of course you have a team you had a nurse and a doctor that focuses on that that's not surprising they had better mood scores so that better depression scores with Pali of Care now here's the kicker though these patients with Pali of Care were less likely to receive chemotherapy in the last two weeks of life less likely to be in the ICU and more likely to sign on to hospice sooner actually lived longer 11.6 months compared to 8.9 months and 2.7 months may not sound like a lot to you with metastatic lung cancer that's a lifetime if there was a chemotherapy drug that showed 2.7 month survival in this population you'd be seeing commercials on it you know for it on TV so again this doesn't just sway you one way or another in terms of getting chemotherapy or not this is to highlight the level of uncertainty we have when we are practicing medicine specifically with terminal illness specifically with terminal illness this is a a chart that looked at varying councils around the country and across time around withholding and withdrawing life support these are the answers they gave pretty vague brain depth if useless persistent vegetative state a little more specific if no chance of survival it's okay or it's not okay and what is happening here who is to say that someone is brain dead or is terminally ill well usually doctors or clinicians are best suited to answer that question so what we have here is a paradigm where some of our imams and scholars rely on the interpretation from doctors and doctors practicing medicine here in America will always defer to patients because autonomy is so important and of course patients want to know what's okay in my Dean this is important stuff let's go back to the imams on top of that family is very heavily involved in that emotion is raging and it's hard to see past that and of course like I said earlier ethics committees can get involved when it really gets hairy and doctors feel that distress about the care or lack of care that they're providing this is a messy situation this is what we want to avoid this is what advanced care planning hopefully avoids this is what hopefully this talk and ongoing discussions around this will help avoid one last ruling that I'll highlight is Saudis now in 1989 idea passed a festival three competent and trustworthy doctors deem a life sustaining treatment right ineffective or inappropriate and that's it that's the process they have and specifically in the fatwa it asks well what if there's a disagreement between families and doctors well you do not need to turn to the opinions of the family because it's not from their expertise it's not their specialty this will never fly here this is paternalistic medicine I think that there's something good about this though too so in the 70s and before that doctors used to be more paternalistic in this country it swung all the way to the other side and now it's so much to a point where doctors and clinicians are even afraid to present their recommendation okay we have to pray so I do think that it helps lift the burden a bit but at the same time not something that will fly we can come back for Q&A there's just a couple more slides that we can go through but I do want us to make aisha inshallah Alhamdulillah I just wanted to there are only a few more slides and I do want to highlight something that's important to bring it really to important for us at the end of life and that's how the prophet sallallahu alayhi wa sallam died does anybody know what arzmoryendi means arzmoryendi translates from latin into the art of dying and in the the dark ages a third of europe a third of europe was decimated by the bubonic plague or the black plague and people were dying left and right and priests from the catholic church who usually served as the religious figures to help those who were dying spiritually could not keep up so they made this manual called arzmoryendi the art of dying in terms of what's important for a catholic or a christian when they were dying and I challenge us as a community hopefully to really focus on the prophet sallallahu alayhi wa sallam and how he died and what's important and I didn't formalize this or anything this is just me reading through it and kind of the important things that came up number one is the acknowledgement that he was dying sallallahu alayhi when he sent he said I love you and then he said you won't see me in the next year the next time you come back you'll be visiting my grave and you'll be dying the farewell sermon was him saying that was important number two is the preferred place where he wanted to die sallallahu alayhi wa sallam he was at maimuna radilawanha's house when he first got the fever when he gathered his wives at the end said where shall I stay and they all knew he wanted to stay with aisha radilawanha and that's where he stayed so a preferred place where he was dying is in the sunnah legacy and charity whether it was pointing abu beker radilawanha to lead prayer when he was too ill to get up or the day before he died sallallahu alayhi wa sallam he asked sallallahu alayhi wa sallam what do we have in this house in terms of his money seven dirham which is equatable to twenty dollars today and what they say he'd wake up he'd say go and give it to the poor go and donate it to the poor while back in out of consciousness wake back up sallallahu alayhi wa sallam he knew that this was something so important that he wouldn't let go until it happened so she did so charity being important communication with loved ones on his last day sallallahu alayhi wa sallam when his daughter Faltimah radilawanha came in and he whispered in her ear and she started crying and he whispered in her ear again and started laughing what did he say to her said that father will no longer be here the first time so she started crying and then he gave her the news that she will be the first among his family to join him so she started laughing this communication with loved ones was important she was ritual on the last day sallallahu alayhi wa sallam and from Abu Bakr's family came in and he had a miswak on his person and Aisha radilawanha being the wife that she was she saw that the prophet sallallahu alayhi wa sallam was focusing on this miswak she knew she wanted it she took it she moistened it in her own mouth and gave it to the prophet and she recounted the story and it was him brushing with the miswak with more energy and vigor than he had ever done before and lastly autonomy and decision making that's how we translate it into present day terms but when he was in and out of consciousness by some narrations it was the abbas by other narrations it was wives forced medicine in his mouth or something called pleurisy and he woke up upset sallallahu alayhi wa sallam what would you like it if I forced this in your mouth on top of that we know when he was on the minbar the last time and he said abdun khayyarahu allah and yuqtiahoo zahratat dunya baina an yuqtiahoo zahratat dunya wa baina ma'inda it was a servant among the servants of Allah who Allah had given the choice the luxuries of this dunya or that which is with Allah and Abu Bakr started weeping and all the sahaba were concerned I mean why are you weeping and Abu Bakr he knew that the prophet sallallahu alayhi wa sallam was talking about himself and his last words were what the highest companionship and that's because we know that the angel of death asked the prophets for permission before taking their souls and the prophet sallallahu alayhi wa sallam was uttering his choice that autonomy and decision making as part of the sunnah and if there were any more blessed place to die than in the arms of your wife at home the prophet sallallahu alayhi wa sallam would have died that way and I hope through this talk that we start to reclaim the dying process as Muslims we are up against a lot what our community what our society values in terms of medicine and medical care but there is something to be said there is room for us as Muslims to reclaim that narrative and make it so that the people in our community that are inevitably faced by their mortality have something to turn to well again I hope you've gained something from this talk if you want to hang around and ask me questions or more importantly feedback I give this talk it's only been a few times so far things you liked, things you didn't like things you wish you saw more of would be very helpful for me