Millions of Muslims around the world observe the holy month of Ramadan. Some may have mild or chronic medical conditions that can become exacerbated, requiring emergent medical attention. Emergency Physicians ought to have a working knowledge about the religious rules of Ramadan and their medical implications. In this article, we will provide an overview of the significance of Ramadan to Muslims, its practices, and discuss the important considerations for emergency physicians when providing care to Muslim patients in the Emergency Department (ED). Lastly, we will explore ways to mitigate the ethical dilemma when a fasting patient refuses a life-saving treatment or intervention.

The significance of the holy month

Ramadan is the holiest month of the year for 1.9 billion Muslims around the world [1]. Muslims believe that the month of Ramadan is the month during which the prophet Muhammad received the initial revelations of the Quran, the holy book for Muslims [2].

Ramadan is a time of spiritual reflection, self-improvement, heightened devotion, and worship. Muslims are expected to put more effort into following the teachings of Islam. Fasting is one of the five fundamental principles of Islam; known as the Five Pillars of Islam. The pillars include shahada (a declaration of faith: “There is no deity but God, and Muhammad is the messenger of God”); prayer (Muslims pray five times a day); zakat (charitable giving); fasting and pilgrimage (Muslims are supposed to make a trip, or “hajj,” to the city of Mecca, Saudi Arabia, at least once in a lifetime if they are physically and financially able).

The fast begins at dawn and ends at sunset [3]. The act of fasting is said to redirect the heart away from worldly activities. It serves the purpose of cleansing the soul by freeing it from harmful impurities. Muslims believe that Ramadan teaches them to practice self-discipline, self-control, sacrifice, and empathy for those who are less fortunate, thus encouraging actions of generosity and communal charity.

Many mosques (Islamic places of worship) host daily community dinners where Muslims can break their fast together. Since Ramadan is a time for Muslims to be especially charitable and fasting helps Muslims feel compassion for the hungry and less fortunate, many mosques hold food drives or fundraisers for charity during Ramadan. It is also common for mosques to host open houses for their friends and neighbors of other faiths to join them for their fast-breaking feast or iftar at the end of the fasting day.

A 2017 study estimated that 3.45 million Muslims were living in the United States, about 1.1 percent of the total U.S. population [4]. Emergency physicians should be aware of the health considerations for their Muslim patients during the month of Ramadan.

How long do Muslims fast? Are there exemptions to fasting?

Ramadan is the ninth month of the 12-month Islamic calendar, a lunar calendar that’s based on the phases of the moon. The lunar calendar falls short of the solar calendar by 11 days. As a result, Ramadan doesn’t start on the same date each year and instead, over time, passes through all the seasons. In 2021, Ramadan began on April 13th and ended on May 13th. Depending on its timing of the year and the location in the world, some patients may be fasting for up to 20 hours. This extended period without food, water, and medications may pose a serious health risk to patients with certain medical conditions.

Exemptions to fasting include anyone who is traveling, women who are pregnant, breastfeeding, or menstruating, or those with acute or chronic illnesses [5].

However, many Muslims with medical conditions insist on fasting to satisfy their spiritual needs. Although Islam does not recommend it, as medical professionals, we must respect our patients’ choices. Those excused can make up the fast later or feed one poor person for each day missed. “And anyone who is ill or on a journey should make up for the lost days by fasting on other days later. God wants ease for you, not hardship.” (Quran 2:185)

I have a fasting patient in the ED. What should I do?

As previously stated, Muslims with acute or chronic conditions such as diabetes are exempt from fasting. However, they may still choose to fast. They may discontinue their medications or alter treatment regimens with or without involving their primary care physician. As a result, serious complications may develop. Patients can present to the ED with dehydration, syncope, hypo- or hyperglycemia, diabetic ketoacidosis, or congestive heart failure. ED clinicians need to approach the care of these patients with empathy and support, along with shared decision-making regarding their treatment plans and expectations.

Another important aspect of caring for these patients is the knowledge that many ED interventions can invalidate fasting. Intravenous fluid is one such example. Before you empirically order that liter of saline solution for the fasting patient who presents to the ED with dehydration, recognize that it will invalidate their fast and consider other options or have a discussion with the patient and/or their family members. The table below lists some medications and procedures that can be applied without breaking the fast [4,6].

Empathy is key in the critically ill fasting patient who is refusing care

There are unique challenges in managing patients who are critically ill and refuse to break their fast. Spirituality, religiosity, and personal beliefs are essential components of the social determinants affecting patients’ health behavior and acceptance of treatment. Depending on their cultural and religious upbringing, some patients believe their hardship, patience, and perseverance through challenges will grant them God’s mercy and forgiveness. This religious context will help guide the emergency physician when caring for the critically ill fasting patient. Fasting that endangers health or increases morbidity is not in accordance with Islamic jurisprudence. For example, if a patient presents to the ED with an acute illness that requires a blood transfusion, then they are exempt from fasting. A gentle reminder to your patients that even if they break their fast, they can make it up on another day.

Fasting beyond Ramadan

The holy month of Ramadan ends with Eid al-Fitr which is a holiday celebrated by Muslims around the world to mark the end of the sunset-to-dawn fasting of Ramadan. The festivities start with a morning prayer followed by family gatherings and sharing of food and gifts with neighbors and the local communities. It is important for physicians and ED clinicians to know that some Muslims may elect to observe six days of fasting after the day of Eid al-Fitr. In Islamic traditions, these six days of fasting along with the Ramadan fast are equivalent to fasting all year. In Islam, every good deed is rewarded 10 times, hence fasting 30 days of Ramadan and 6 days during the following month (Shawwal) is equivalent to a whole year fast. Many Muslims religiously follow this practice throughout their lifetimes. Some Muslims will follow the tradition (or Sunna) of the prophet Muhammad by fasting on Mondays and Thursdays every week. Therefore, physicians could care for a fasting patient throughout the year, beyond Ramadan, and should have an understanding of the religious and cultural context of the Muslim traditions when caring for these patients in the ED.

Summary

• Millions of Muslims around the world fast during the holy month of Ramadan from sunrise to sunset.
• Muslims with chronic conditions, those who are critically ill, or present to the ED with acute exacerbation of their chronic conditions are exempt from fasting. However, some may choose to continue to fast despite their underlying illnesses.
• Some medications and medical procedures are allowed during fasting. Providing IV fluid for hydration will invalidate fasting.
• It is important for emergency physicians to understand the cultural and religious context of fasting for Muslims in order to improve the experiences of these patients when they are cared for in the ED. Empathy and shared decision-making go a long way.
• Finally, ways to greet your patients during Ramadan and Eid al-Fitr:
  • Ramadan Mubarak: Blessed Ramadan
  • Ramadan Kareem: Generous Ramadan
  • Aid Mubarak: Blessed Aid (day of festivities after Ramadan)

References

1. Islamic world, countries with a cultural Islamic population – Nations Online Project. Accessed May 13, 2021. https://www.nationsonline.org/oneworld/muslim-countries.htm.
2.  Mubārakpūrī, Ṣafī R. (1998). When the Moon Split (A Biography of the Prophet Muhammad). Riyadh: Darussalam. p. 32.
3.  Ramadan 2015: Facts, History, Dates, Greeting, And Rules About The Muslim Fast Archived 10 July 2015 at the Wayback Machine, Huffington Post, 15 June 2015.
4. “New estimates show U.S. Muslim population continues to grow”. Pew Research Center. January 3, 2018.
5. El-Bahay El-Kholi. Al Siyam, “Fasting”. The Supreme Council for Islamic Affairs, Arab Republic of Egypt. p. 36
6. Al-Munajjid SM. He Needs to Have an Injection into a Vein – Will that Affect His Fast?  http://www.islam-qa.com/
7. Al-Munajjid SM. Types of Asthma Medication and the Ruling on Taking Them during the Day in Ramadan. http://www.islam-qa.com/