 Today I'm going to talk a little bit about a lot of things and touch on things. It was hard to fit in how much I wanted to say in a short amount of time. So I hope it just kind of, you know, scratches the surface, maybe stirs something within you to start having these conversations, like Brother Amman said. It's interesting, you know, end of life, even just the words end of life. When I say them, although it makes sense kind of practically speaking, Islamically speaking or spiritually speaking, it doesn't fit our worldview and what we get from our own deen in terms of where we came from and where the soul is going afterwards. So to start off, I wanted to just touch very briefly on death and dying in Islam and what we can learn from some of the prophetic hadith of Rasulullah sallallahu alayhi wa sallam. I like to always start off these talks with a quote from Sheikh Hamza Yusuf Mallah preserve him and his essay death and dying in the afterlife in the holy Quran, which he says, he says, 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. I mean, think for a second what your deen would mean, what Islam would mean if there wasn't something called death waiting for us at the end of our lives. Would it make sense? So it's important to recognize that death and dying is integral to our spirituality and our faith. Just two hadith that I wanted to bring up, Rasulullah sallallahu alayhi wa sallam was asked, who are the wisest? And he responded, those who remember death most often, and who is the best in preparing for what's after it, those are the wisest. And he said, remember often the ender of pleasures. Like Amman said, people don't want to think about death. There was a French writer who wrote, death is like the sun and can't be stared at steadily, right? You can't think about death all the time. And we shy away from it. But it is a spiritual practice and one that's, you know, supported by the prophetic hadith to remember often death. Another one, and I put the picture of thorns there because we know that hadith that nothing pricks the skin of a Muslim or no harm befalls a Muslim, except that their sins are forgiven even if it's the prick of a thorn. And there was a story when a man who had died and another man who was in the company of Rasulullah sallallahu alaihi said, he was fortunate. He died and he wasn't tried by an illness. And Rasulullah sallallahu alaihi responded, he said, woe to you. How would you know that if he was tried by an illness, some of his sins would have been forgiven? And it's important. This idea of redemptive suffering is important in our deen. Now, I always like to make it a point because I see this by Muslim patients when people are suffering at the end of life to use this as a sort of okay or permission to sign up for very harmful treatments at the end of life. And I, you know, as a palliative care doctor in this field, I'd say that a person is suffering enough from their disease, from their cancer, from their heart failure, from whatever it is, and causing undue suffering from treatments, whether it's life support, CPR or chemotherapy or whatever comes up at the end of life. There's a big difference between those things, right? In fact, avoiding harm is integral to Islamic bioethics. There shall be no inflection or reciprocation of harm, and that extends into medical ethics. So now, just for the remainder of the time, I'm going to walk you through a case built off a real case of a 70-year-old Muslim man traveling from the Middle East. And right upon landing in the States, he was rushed to the emergency room and was acutely ill, and it was found to have a large clot in his lungs. And after a few days go by, he was in the ICU, and he's needing maximum support, short of life support, meaning intubation, and hooked up to a ventilator. I know this has become common speak with COVID now, so people know what I'm talking about. So palliative care, which is a specialty in medicine that deals with people with serious illness and communication and symptom management, they were consulted to help the conversation. Now, the sun comes by, flies out a few days into the course, and he's from Saudi Arabia, and a family meeting is held. And when the doctors or the staff brought up the idea of, okay, what's next to be done in terms of intubation, the sun exclaims, in my religion, we do everything. If we must intubate, then intubate. This is a scene that I've seen in my family, treating Muslim patients many times when we fall on religion and our understanding of our Dean to help dictate medical decisions. And Dr. Amit, can you explain what intubate means? Yeah, so intubate is a tube that doctors put down the windpipe to both force air in and out of the lungs. Many times it's brought up to say help you breathe, it's not helping you breathe, it is literally breathing for you. So without a ventilator, people would die, so it's life support. It's often used interchangeably. So I wanted to reflect really quickly on medical decision making at the end of life for Muslims, and some of the themes that I think in having these talks and seeing it in the hospital, what I come up with. Number one, there is a level of mistrust, much like any other racial or religious minority in the States founded on religious or racist discrimination and bigotry on the part of the health care system. That is a real thing that's there. There is a level of mistrust that Muslims and their families come to the health care system. Number two, I think I can say this since I'm a Muslim and I come from a Muslim family, we don't do well with emotions. We don't do well with grief. I think we are poor emotional processors for the most part, if I can paint everyone with one giant brush. And I think there's work to do around grief and processing emotions. Number three is duties to Allah are amplified, even if a person is not practicing for their life, the majority of their life. When they are confronted by death, because there is a fundamental belief of the afterlife, the Akhirah and meeting Allah, duties to Allah are then amplified, right? What can I do? What is halal? What is haram? And in doing that, people turn to imams. And I got to say, I feel for imams. I feel for imams, who are not only custodians of masjids, are not only overseeing weddings and nikahs and funeral processions and teaching Dean and Quran and talking about kids and marriage counselors. And now you're going to pull them in to say, hey, withdrawal of life support, is that halal or haram? That's impossible to do as an imam, let alone just one clinician who's seen it, right? So I think it puts imams at an unfair predicament. And lastly, there is an overemphasis on fiqh, I'd say, and legal aspects of actions at the end of life. What is haram, right? What is halal? Although the movie was shot in black and white, it's not black and white when a person is dying, right? There's a lot of nuances. And I'd say that an ethical approach of not necessarily one what you can and can't do but one of what you should and shouldn't do is a better lens to look at the medical decision making near the end of life. So going to the legalistic approach, I'm going to fly by this. There have been fiqh councils around the world and throughout time to help say, hey, withholding and withdrawing life support, when is it okay? And as you can see, you can read through some of these rulings. They're both vague and they're also, they rely on medical data or at least medical judgment. So these fiqh councils, I mean, who's going to dictate whether a person has no chance of survival or if treatments are futile, right? That goes to the clinician's judgment. And I want to paint for you a scene that maybe some of you have seen, maybe some of you have been part of. If you look at three parties at end of life, when if someone is on life support, the doctor, the patient and an imam who's pulled in, well, the doctor, because the way we practice here in America, autonomy is the most important. They're going to look to the patient, hey, what do you want? The patient, now my duties are to God, I got to get some religious guidance on this is going to turn to the imam. And as you saw from the different fiqh councils, they're doing it right, they go back and turn to the doctors to say, you know, what is futile? What is, you know, appropriate? What's not to make pictures were the picture worse, usually a family member. And it's not usually the family member who's been in it with the patient through all their chemotherapy sessions or all their doctor's appointments. It's usually the family member from out of state who flies in, who knows somebody who knows somebody who had the same disease and lived 10 years later because of the doctor they saw. And they bring in this idea, which really just obscures the picture and the plan. And then from the hospital standpoint, because the hospital has its own incentives, sometimes they have to bring committees like ethics committees to weigh on a case. This is chaos. This is not how people should die, right? Because all the meanwhile, while these conversations are happening and these conflicts are arising and these arguments are taking place, the patient is suffering. And, you know, that to me is the greatest, you know, failure of all this. So bringing it back to the case, and I promise I'm going to end really quickly, there was at least one fatwa from Saudi Arabia in the 80s about DNR orders. Do not attempt to resuscitate order. If someone dies, don't do compressions, just allow a natural death. And what they ruled is that a patient is unfit for resuscitation if three doctors, trustworthy doctors in the words of the fatwa, say that the disease is unresponsive and death is certain, or there's some, you know, mental inactivity and untreatable brain damage, or resuscitation would be ineffective. And in fact, in this fatwa, it goes on to say that the doctors don't have to turn to the family regarding this because they are unqualified to make these decisions. A very paternalistic, I'd say, approach, not passing judgment on one way or another. So I actually am there with the sun. And I bring up this fatwa because, hey, I'm well versed, and I read up on this and let me put that hat on to see if I can, you know, break through a barrier. But he looks to me and exclaims, look, I'm the doctor of the family. And I don't want to be seen as the one who decided our mom should die. Immediately, it threw me in for a loop because I approached it all wrong. Here is a human being. Forget that he's Muslim for a second. Forget that he's a doctor for a second. Forget that he's a son of a woman who's dying for a second. He's a human being with emotions. And in fact, he needed help processing those emotions before getting to the actual medical decision. So I just wanted to introduce advanced care planning just as a concept. This is better read backwards, planning for your care in advance. So having these conversations, putting pen to paper in advance with your family members is important to do now. There's a proverb, the best time to plant a tree was 20 years ago. The second best time is right now. So making sure that you have these discussions with your families is so important to help guide those. I'm going to skip through that to help guide through these discussions. I just want to focus on quality of life, which actually doesn't have a good translation into Arabic. My mentor and friend, Dr. Kamala Bushamsia actually says the closest is the living with dignity and how we define dignity for ourselves. So questions to ask yourself when having these questions, what brings you joy? What gives my life purpose or meaning? What would matter to me at the end of life the most? Or where would I like to be if I had the choice to be where I would die? And in hearing the answers, many Muslims would respond with communicating with loved ones is something very important for people. Being pain free as much as possible, not suffering, physical suffering. Having the mental awareness to not only communicate with loved ones, but to worship Allah, having taqlif, accountability in front of Allah and worshiping Him. And of course, one that comes up, especially from mothers all the time is not to be a burden for loved ones. They can't find that quality of life acceptable for them. And I think centering medical decisions around not the medical data, not the CAT scans, not the lab values, but in fact a person's values, how they define quality of life for themselves or dignity for themselves. I think that should be front and center. So this is an advanced directive I put on a website. If you want to take a picture of this slide, I think it's the one action item that I would say everyone should do. Everybody over the age of 18 should have an advanced directive regardless of health status, prognosis, whatever it is. So fill this out. Name a surrogate decision maker, someone who knows you well enough to make decisions on your behalf and write down your preferences. And I think that's pretty much it for my presentation. I'm happy to take questions. I'm glad. Thank you for that, Dr. Ami. That is such so many important things you talked about there, especially because this, understandably so, is an incredibly emotional moment in our lives. And nothing honestly can truly, truly prepare you for these things until they happen. And yeah, it is important to sit down and talk about those things. And alhamdulillah, before my dad passed, that is something that we did. We sat down with him and we said, okay, if you're in a situation where you're on a ventilator, what do you want us to do? And he told us exactly. He said, if there is no hope, then if it's going to be a have an adverse impact on me, then yes, I want you all to do not resuscitate. And that way there wasn't any vague interpretation. This is what dad would have wanted. Are you trying to kill dad? What are you trying to do this and that? I've had friends where they're forced to make that interpretation because they didn't have that conversation. And that five minute conversation months before my dad passed, alhamdulillah made things so much easier. So yeah, definitely recommend going to that site. And it's something that family member may have a decision now, but maybe a few months later, they decide to change their mind or maybe when they become sick, they say actually don't or do something different. And that's okay. It's important though to start those conversations and think about those things. I can't stress enough how it's awkward. It's uncomfortable. It's never a good time. But I promise you when you sit down and have that conversation, it brings your family closer together and it makes things so much more bearable. And it's again, it's hard to navigate, especially with siblings, people dispute. It's super important. And so we got a couple of questions that Dr. Amir, that did come in in a situation where, and I know, as you pointed out, these are not black and white issues. These are so nuanced from a song perspective. But oftentimes there's a situation where somebody is on a ventilator and from a medical perspective, a doctor will say there's the machine is breathing for them. And there's really no, from a doctor's perspective, there is no hope that they're going to be able to make it on their own. From your perspective and from your research, what advice would you give to a family to approach that situation? Yeah. And it comes up often. If those discussions weren't had ahead of time, I would say a couple of things. Number one is it is important to take clinical judgment from those who know situations like that very seriously, to listen to the doctors, to listen. I mean, I'm just saying here, the doctor's recommendations. Secondly, put your parents, friend, brother, sister, whoever it is, front and center. What would be acceptable to him or her? And then lastly, I always, I think the frame of mind that we approach this question is, even when you said I'm on no hope, for example, or people say the words withdrawal of care, right? Or, oh, there's nothing more we can do. No, there's always something we do. There is a million in one ways we care for patients. That includes sometimes removing harm from a patient. So if you feel that you're causing more harm than benefit, right, then I'd say it is acceptable to remove that harm. In fact, from an Islamic bioethical standpoint, there is a maximum, which translates to removal of harm actually takes precedence over provision of good. And so taking that as well from a thick perspective, seeking medical treatments, when it is uncertain whether these medical treatments would work, is not obligatory. It's not mandated from a thick standpoint. Then there is room to have those discussions and remove harm and allow people to pass naturally if that's something that fits within their goals of care. So yeah, it's a very loaded question, but I hope that some of those things help guide the conversations. Yeah. And we will, after this, we're going to be recording this event. So we'll send you all recording from it and also some additional resources, some talking points and how to start these conversations, because again, these are super, super important subjects and we all are going to deal with them in different degrees. If you all haven't dealt them already, it's important to talk about these things now. A question came up is, and I know it's a field that you're very familiar with is the last few years of a person's life. Let's say there's a situation where a parent has been diagnosed with dementia and they need to get additional care. Culturally, for many families, our parents are supposed to live with us when they get older, but we may not have the home and the resources to really give our parents the care that they need. Can you talk a little bit about, within the Bay Area community, if there's organizations or nursing centers or even other places that people can go to to get additional care? Oh, there's such a paucity of caregiver resources. And in fact, you touched on this, Amon. I mean, I think our generation, if you're in your 30s and 40s and as our parents get older, I think there is going to be a crisis nationwide in terms of caregiving. We're not equipped for it because people are living much longer with chronic illness than ever before. And the burdens of caregiving sometimes are just insurmountable because the family structures have changed compared to where they are traditionally or how they are overseas. And in fact, in our home countries where our parents came from, it's changing there too. So yes, homes, assisted livings come up. And sometimes there's a lot of emotion on that in terms of looking for placement. And then caregiving, hiring caregivers tends to be something that people have to at least discuss. And it's especially in the Bay Area, expensive. It is very, very, very expensive. So planning around that is important. Now, I'm from from, you know, from a here and now perspective. Yeah, so I don't know of any resources in specific, I would say many doctors offices have social workers who know the lay of the land, depending on what geography you're in. So getting in touch with social workers, if that's something you're thinking about, it's always good to get started now. Yeah, a lot of great questions coming in. This question I like, but it's an important one. How can Muslims in the US unite to build a Muslim hospital? We don't need more mushrooms. I'm sure it's something you've thought about as well, working in the field that, yes, it's beautiful. We have Jewish hospitals and Catholic hospitals, Presbyterian Lutheran hospitals. And I know there are, there have been, you know, a lot of Muslim nonprofit health clinics. Are you aware of any particular broader initiatives to build like nursing centers and even just hospitals along those lines? I wish there was one in Australia, a nursing home from Muslims that was built in Australia, which looked amazing. And I wish we had something similar here. And unfortunately, we're so late to the game that regulations around building clinics or hospitals have been more than they've ever been before, for a reason, if you ask me. But also it serves as a lot of barriers. So I don't know of any efforts. And I've actually been asked this question more than once because it is something that we should take seriously as a community. I just don't know. There's a question that came in and this is definitely deserves a session in and of itself is how to cope with the loss of a loved one. And this is not a black and white issue by any means. And I will share from my own experience and from my own observations and talking to people and I always tell people it's okay to not be okay. And it's important when you lose a loved one to give yourself the space to grieve. It's okay to be sad. It's okay to be depressed. The Prophet sallallahu alayhi wa sallam when he mourned the loss of one of his wives and his companions. He took the time and he was depressed. He was sad for many, many months and that's okay. It's okay to feel angry. It's okay to feel numb. It's okay to feel confused. It's just important to give yourself the space to sit with your emotions. And when you grieve, those people are going to tell you, oh, you need to do this. Everybody has their own journey. Everybody has their own process. And so it's important to give yourself that space. There's no magical thing that I can tell you that Dr. Rami can tell you that anybody can tell you that helps a wand and makes things go to where we each have our own journey. My father passed away three years ago at this point. And it is still difficult. And there's moments as little things that remind you of things and that's okay. And that is a part of life and that is a part of each and every one of our journeys. And so it's not easy. It's not difficult. And it's important to embrace that. And I'm sure Dr. Rami, you've had to deal with that as a doctor in dealing with patients that are grieving. I don't know if there's anything that you had to share on the subject here. I think everything that you said, I mean, especially looking at the seerah of how the Prophet Sallallahu Alaihi Wasallam mourned, how his companions mourned his death, like Amad Amal Khattab, Rabi Laan Hu, when he was met with the news, he was angry. He was in denial, you know, all the different emotions around grief and grieving. So it is okay to feel those emotions. If the Prophet Sallallahu Alaihi Wasallam and who he is, if Amad and his conviction and strength had those emotions, who are we not to? So I would echo the things that you said. One valuable resource that I think as people are near the end of lives or their lives are afterwards is Muslim chaplains, which I think are becoming fully, you know, more and more in number as time goes on. I think it's a field that we need more of to help with these sort of emotions to help, you know, spiritual distress for people who who are feeling it when they're met with illness or with death. So if your institution or if you know of people who are in the Muslim chaplaincy world, definitely reach out to. Yeah. And somebody brought up a question in the chat. My sister passed away last May and I feel like my grief is affecting my family. And again, each and every one of us has a journey when and I can assist her. Thank you for the question. And I can share from my experience, I have four brothers and we all dealt with the loss of our dad in different ways. And it was important for us to give each other the space to grieve how we choose it, right? If somebody feels completely withdrawn from the family and doesn't want to hang out or talk or this or that, it's important to give them that space. Obviously, it's important to, you know, be proactive and try to do things. I can't recommend enough as someone that has benefited just from therapy in general, not just because of this. I see a therapist regularly. That works for me. Other people, it's writing, it's exercising, it's poetry, it's watching something and talking about it. And everybody has their own process. And in a family, we're all going to grieve differently. We shouldn't, it's a well intended thing is like, Oh, is this am I bringing other people down by bringing up somebody dying? I don't want to be a downer. I don't want to feel like a burden when I keep bringing this up. Each and every one of us has a journey. And it's important that in our families, we give each other the space to do that. My mom, understandably so, takes it very hard. And that's okay. We all love her. We give her care. We show her support. It's just important to realize that our relationships with loved ones is very different across the family. Maybe somebody looked at sister, maybe somebody had this relationship with their sister. So they're taking it differently. And maybe you have a relationship that's different and your parents have a different relationship. And so it's important for each and every one of us to honor that. And so if somebody is grieving, our response would be, okay, how can I best support that person to give them love, to give them support and at times give them space when they need that. And so we shouldn't feel bad if we feel like our grief is coming off as a burden. A question that just came up. If an elderly person who's in a wheelchair bound is losing weight because they don't want to eat, what is the Islamic perspective on putting that person on a G tube for feeding? Yeah, another question that has multiple interpretations. And it really depends who you ask to be honest. And it really depends, I think, from a medical standpoint, what this elderly person has in terms of a disease or a diagnosis. We know, for example, from a medical standpoint, for people with advanced dementia, that not eating is the natural progression of the disease, right? People lose their ability to walk, they lose their ability to talk, and then they lose their ability to eat. And in fact, when they've done studies to see if G tube either improve mortality, meaning survival, lengthens their lives, or at least from the caregivers and what they can perceive as improving a quality of life, they've had no intended benefits. It doesn't mean starve the person, right? If you want to hand feed and have that at least attempt, you should keep their mouth moist because dry mouth is terrible. You know, you should. And at the same time, you should not feel pushed or it's not an imperative to pursue medical artificial nutrition and hydration. I actually don't even like calling it tube feeds because there's so much more around feeding than nutrition, right? Food is love, food is culture, food is being apparent, food is nurturing, food is holidays, all of this. And then we talk about it in a medical standpoint, and it just, you can't, right? You can't marry those two approaches. So I would say that it really depends on who you ask, and it really depends on the clinical status, but there is room to not pursue a G tube both from a medical and I think an ethical standpoint. And keep the questions coming. There's some questions in the chat and the folks on Facebook, we see some of your questions as well and we'll definitely get to those. A question that came up, are there Muslim chaplains for counseling? In general, I don't know if there's, not to put it in the spot, do you know any good resources that people can reach out to in the Bay Area that may not necessarily have to be Muslim, but just at least well versed in dealing with people of color issues or people of Islamic backgrounds? I think, yes, there are. In fact, we have a chaplain, Muslim chaplain on the call today. Ziata is a group that I'm a part of, made up mostly of Muslim chaplains who have some resources. I encourage you to check out the website, it's Z-I-Y-A-R-A.org, I think. So there is a group of Muslim chaplains, absolutely. Now, I would say that chaplains and counselors are different in their roles, right? Chaplains have a specific role in terms of spiritual distress, spiritual care. And I think it's an underutilized service or resource, but check that out. Great. And I can't stress enough the importance of therapy. I know I'm on my soapbox right now, but it's a part of everyday care. Like the way I go to a dentist to get my teeth checked out, why wouldn't I want to do the same for my heart? Am I going to give better care to my teeth than my heart? If my laptop is broken, I take it to the Mac store, to the Apple store, to get it looked at. Like why is my laptop getting better care than my heart and my soul? And it doesn't mean that you're crazy or dealing with this or this and that. It's just proactive mental wellness. It's just a part of how it's an extension of that. And I understand there's cultural stigma and all that, but it's nonsense. And it's important to proactively do this. It's not just reactive, I'm dealing with this. So I feel that I'm good. My life is fine. It's a proactive thing. The same way I get checkups twice a year and I go to the dentist every six months. I see a therapist every week. I have stuff that comes up, and especially during this pandemic. In this pandemic, a lot of us don't realize that in different ways, we're all dealing with grief because our lives that we lived before the pandemic are fundamentally different right now. And so we're grieving our old lives and death is around us. And there's so much happening, not only with the pandemic, but just social unrest, the world, war, the economy, this and that. That's a lot for each and every one of us to take in. And sometimes I don't think we realize just the level of trauma that each and every one of us is dealing with. And I'm sure especially as parents, it can be super difficult to raise children during this. A question that just came up and we'll take this question and then we will keep the questions going, but I do definitely do want to get to brother up there for my next. But what does Islam say on the use of morphine? Working in hospice, I see families, including Muslim families, have so much fear about using it. Can you talk a little bit about that and just other medications in general? Thank you for bringing that up. That is something that comes up a lot, not just from Muslim patients and families, but even Muslim doctors who have some kind of discomfort around providing morphine at the end of life. Morphine and opioids like it definitely help with suffering at the end of life. It does. Now, theoretically, a lot of the discomfort comes from the idea of it hastening death. There's a theoretical thing that morphine depresses our respiratory drive and therefore can hasten death. Ethically speaking, the intention of Qasid or intention is one that's very important, so that if your intention is to relieve suffering and if an unintended, seemingly bad consequence were to happen from that, then it is still permissible and good, in my opinion, to relieve that suffering. Again, no harm should be inflicted or reciprocated in Islam. I'd say that it's not a blanket statement. I actually ask my patients and I prescribe opioids a lot in the field that I'm in for people near the end of their lives. And I say, listen, some people would rather be because some of the side effects of opioids are sleepiness and drowsiness and sometimes confusion. Some people are okay with that as long as their pain is controlled and other people would rather deal with pain if it gives them more moments of lucidity and being awake. Where are you in that spectrum? And therefore, a person can say their personal preference of I would rather deal with pain and be awake or no, this pain is unbearable, treated with everything you have, regardless of the side effects. So there is definitely room to treat symptoms near the end of life for people who are dying. On a related note, I'm sure you deal with this a lot as well. There's a lot of like well-intended cultural practices when it comes to medicine saying, oh no, just eat, drink some Zum Zum and take this black seed. You don't need all this treatment and medications. And again, there is benefits to holistic, all natural remedies and treatment, not only from a scientific perspective, but a medical perspective. But I'm sure very often times in the hospital, you may deal with families that are really insistent on certain things. What is a healthy way to navigate that? Because it comes from a loving place. It comes from a very well-intended place. But what is the best way to diffuse some of those situations? Explore it. Explore, like take the time, be curious. And I say this to doctors usually who, you know, if you hear something about holistic medicine and you're just like, you know, they roll their eyes. No, sit down, explore, be curious. Learn about the experiences that made a person want to, you know, look for holistic or non-western pharmacologic treatments. I think there's room for that, to be honest with you. See what the patient is trying to accomplish or trying to avoid in either not signing up for more traditional medicines or going with the unconventional medicines. Explore and be curious. Great. And keep the questions coming. We're going to go ahead and keep things moving, but we will actually real quick, somebody asked, can you repeat the Saudi Fatwa on end of life? Oh, I think I responded to it, but I responded to the panelists. I'll just repeat it verbally. A patient is unfit for resuscitation if three competent and trustworthy doctors say that the person's disease is unresponsive to treatment and death is certain. There's a state of mental inactivity or untreatable brain damage or resuscitation would be ineffective. So those are the three points. You don't have to check all of them, just one or the other, according to the Fatwa. Great.