Death Then, at the fourth places being placed by

Death is a very well-known fact.
It has always been indisputable and no one has ever doubted death. Although
human beings rarely agree on anything, they have never disagreed on their mortality.
Such as in the Quran also had been stated that “Every soul shall taste
death” (al-Imran 3:185). So it is important for every person to be
prepared before facing the death including the persons surrounding them where
it can be the doctors itself.

For doctors, it is always not an easy
duty to make a decision when it comes to the care of someone who is critically
ill and the struggle on how to talk to patients about death and dying. In some
cases, a bleak prognosis may require them to advise a patient against
continuing their treatment. Other times, they may see cause for optimism,
however remote it may seem. Knowing how or when to make their determination is
the tricky part.

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In Malaysia, it must be noted
that that most of major causes of killer diseases in Malaysia are widely due to
diet and food intake of the victims. Apart from that, bad lifestyle practices
are also known as the major causes as well. Malaysia faces similar health risks
with its neighbours in the same region and also with many other parts of the
world.

The top killer in Malaysia in the
year 2016 by the Institute for Health Metrics and Evaluation was the ischemic
heart disease where it never changes since the years before. It is the top
killer in Malaysia followed by lower respiratory infect and also
cerebrovascular disease. Then, at the fourth places being placed by the
Alzheimer disease and also road injuries continue with COPD and also lung
cancer, with diabetes, chronic kidney disease and also colorectal cancer as the
last ranking of the top diseases that cause death in Malaysia.

 

 

                It must be a real
challenge for emergency physicians to utilize a multifaceted and dynamic skill
set towards end-of –life care. Such skills include medical therapies to relieve
pain and other symptoms near the end of life. Physicians must also demonstrate
aptitude in comfort care, communication, cultural competency and also ethical
principles. It is imperative that the emergency physicians demonstrate a
fundamental understanding of end of life issues in order to apply the multidisciplinary
and also versatile approach that was required in order to provide the highest
quality end of life care for patients and family.Medical care at the end of
life should focus on patient comfort, communication, psychosocial , cultural
and spiritual support. This allows such patients to shift focus from their
upcoming condition to optimizing the remainder of life.

                The
primary role of emergency physicians toward the near the end of life is to
coordinate and administer an appropriate medical and also psychosocial care for
the patient. Where first the physicians must respect the dying patient’s needs
for care, comfort and also compassion. Ideally, the dying process should never
entail sustained severe pain or any other physical suffering. The physician also
should assure the patient and family that comfort is a high priority and that
troubling symptoms will be expertly treated.

                When
possible, we are encourages to involve an interdisciplinary team that offers
comprehensive, coordinated care for both the patients and the family by
promoting good communication among the members of clinical team. Nurse
interventions such as oral care, skin and wound care, application of heat and
cold packs can be critical in addressing the full range of the patient’s and
family members’ needs, as can the attention from mental health providers,
social workers, music therapists, volunteers and others. In Islam,it is also
from the Sunnah of the Prophet peace be upon him, to moisten the lips and
throat of a dying person so that he can pronounce well the Shahada. The mouth
becomes more dries during the last moments of death. Ayesha may Allah be
pleased with her used to say:

“The Prophet peace be upon him had a can of water with him.
So he would enter his hand in the water and then he would wipe his face and say
“There is no God but Allah. Death has its intoxications” (Bukhari, 6145) ”

                The
physicians also must inquire about the patient’s spiritual and religious needs
and offer chaplaincy services when appropriate. While the unconscious patients
are still able to hear, nurses may suggest that family members invite the
religious persons to come and perform certain prayers such as in Islam where it
will help the patient with their spiritual needs. The physicians also can
encourage families to share their memories of good times with the patient since
it is never too late to say how they feel. In Islam it is really important for
the Muslims to be able to recite the Syahadah at the end of their breath, and
this can be accomplished through the help of the nearest family members or
relatives to help the patients with the recitation. That is why it is important
for the family members to always be near the patients towards the end of their
life as the Prophet peace be upon him said: “Dictate to your dying people La
ilaha illa Allah” (Aljami,8550)

                The
physicians also are encourage to discontinue the diagnostic or treatment
efforts that are likely to have negligible benefit or that may cause harm by
diminishing the patient’s quality of life and the patient ability to interact
with loved ones .Monitoring of vital signs is rarely useful in the final days
of life, especially when obtaining this information that involves the use of
noisy, distracting monitors in the patient’s room. Unnecessary treatment with
medications not intended for comfort such as statins for hyperlipidemia should
be discontinued. Mouth, skin care and also changing the patient’s position in
bed may enhance comfort in some situation, but in other situations these
measures may bother the patient and also can contribute to suffering and this
should be discontinued.

                Prophylactic
analgesia or sedation should be administered before distressing procedures are
performed removal of a chest tube, withdrawal of mechanical ventilation in a
conscious patient or changing the dressing on a pressure sore. Treating the
symptoms associated with such procedures only after they occur is likely to
lead to unnecessary discomfort until the appropriate medication takes effect.
Encourage oral assisted eating for pleasure but respectfully inform the
patients and families that the administration of intravenous fluids and
nutrition through a feeding tube has no benefit in terms of comfort or survival
at this phase of illness. The physicians also must inform the patients and
family about any proposed major changes in the management of the patient’s
condition.

                The
physicians also must consider the home care, rather than care in the hospital,
for the patients if appropriate. Most dying patients are more physically
comfortable at home, and family members have generally been found to be most
satisfied with the experience of relatives who die at home with hospice care.
This is because some patients just want to have their end of life to be at the
place that there were once had spent their whole life on. So we as the physician
need to provide the best caregiver that we can provide to the patients.

                Then
the physicians also need to communicate promptly and appropriately with
patients and their families about end of life care choices, this communication
must be done by avoiding medical jargon to make sure that they fully understand
about the things that we want to convey about. At these vulnerable times of the
patients and families, proper communication is essential throughout the entire
disease course as a patient’s goals and preferences may change over time, due
to a multitude of factors. The use of open ended questions towards patients and
their families allows us to assess the baseline knowledge about the particular
situation. As in Islam we are encourage to have a proper language with the sick
or dead person. The prophet peace be upon him said: “If you approach the sick
or dead person, then only say good, as the angels are saying Ameen to whatever
you say” (Muslim, 2079)

 Besides that we also need to elicit the
patient’s goals for care before initiating the treatment, because end of life
care will includes a broad range of therapeutic and also palliative options. As
we know that every one of us has their own personal sense of whose they are,
what they like to do, what brings the greatest meaning and value to their
lives, and also the things that they hope for. Where they also can choose the
treatment and care that we want to give them, based on our diagnosis and
prognosis, the potential benefits and also the risks associated with various
therapies, and also their personal priorities. So we as the physicians, must
clarify properly the patient and also the family hopes and goals for care and
also the current treatment priorities before we developing or negotiating any
plan of care.

                We also
need to respect the wishes of patients that are dying including those who
expressed it in advance directives. For the people to have the death that is
right in front of them it is essential that they are involved in decisions
about their care and they are empowered to make choices, know what questions to
ask their doctor and feel able to make informed decisions. This shows that we
have applied the respect for autonomy and also the patient-centred care.

                In a case where patient lack of
three elements required for informed consent which are the decisional capacity,
delivery of information and also voluntariness, then we need the assist
surrogates to make end of life care choices for this patient. But this must
done based on the patient’s own preferences, values and also goals. Informed
consent is a fundamental patient right that serves to protect the patient
autonomy regarding the treatment options. If the patients are not capable of
doing so, then the informed consent should be obtained from the family or
surrogate.

We also need to encourage the
presence of their family and also friends at the patient’s bedside near the end
of life so that they will get the spiritual and also the emotional support
towards their end of life, especially when it is desired by the patients
itself. In such conditions, the simple act of physical contact such as holding
hands, a touch, or a gentle massage can make a person feel connected to those
he or she loves where it can be very soothing. In Islam, we encourage the
Muslims near the patients to recite the Quran as it can comfort the patients by
improving the patient’s mood and relaxation and also reducing their pain. Or
else, just being present with the patient is often enough. Sometimes, the quiet
presence can be a very meaningful gift for the end of life patients.

                Besides
that, we also need to protect the privacy of patients and families near the end
of life. Because it is our responsibility to keep the patients issues
confidential. Every physician understands and respects the need for patient
confidentiality. As professionals, our connection to our patients and also our
colleagues depends on it. But the truth is, the advanced in the technology, the
new demands in the health care, and also the developments in the
world-at-large, make it more difficult to keep this promise. But keep it is a
must!

In order to help patients and
families honour end of life culture and religious traditions, we can also
promote the liaisons with the individuals and also the organizations. Cultural
and spiritual care may become more important to people when they are in a
palliative state, and their spiritual needs may include finalising things that
they have set out to do and “making peace” with others or they may be religious
or spiritual beliefs. Such as in Islam, we are asked to pay all the debt before
we die such as in: Sahih Bukhari Chapter No: 38, Transferance of a Debt from
One Person to Another (Al-Hawaala)Hadith no: 497,narrated by Salama bin Al-Akwa
said that :

“A dead person was brought to the
Prophet (SAW) so that he might lead the funeral prayer for him. He asked,
“Is he in debt?” When the people replied in the negative, he led the
funeral prayer. Another dead person was brought and he asked, “Is he in
debt?” They said, “Yes.” He (refused to lead the prayer and) said,
“Lead the prayer of your friend.” Abu Qatada said, “O Allah’s
Apostle (SAW)! I undertake to pay his debt.” Allah’s Apostle (SAW) then
led his funeral prayer. ”
Relevance: 10.9547

 We also need to develop skill at communicating
sensitive information, including about the poor prognoses and the death of a
loved one, where we need to show the empathy towards the patient issues. We had
been recommends to do frequent pauses in conversation especially when breaking
the bad news. This allows the patients to integrate the information as well as
physician interpretation of patient understanding. Other important
communication techniques that we can use are may include eye contact,
reflective listening and also the position of speaking where we can do it from
the seated position.

                As the
physicians also, we need to comply with institutional policies regarding
recovery of organs for transplantation besides we also need to obtain informed
consent from surrogates for the post-mortems procedures. The requirement to
obtain a valid, informed consent before surgery is becoming increasingly more
important with patients demanding more information and the courts also applying
tougher standards on what information should be provided by doctors.

                Euthanasia
and Physician-Assisted Suicide are illegal in every state including Islam.
Euthanasia can be defined as intentional ending of the life of a person
suffering from an incurable or terminal illness and Physician-Assisted Suicide
can be defined as a practice in which the physician provides the patient with a
lethal dose of medication, upon the patient’s request, which the patient
intends to use to end their own life. This is because it is defined as
attempted for suicide and suicide is strictly prohibited in Islam such as in
the hadith had said that:

“Narrated Anas bin Malik: The Prophet (peace be upon him)
said, “None of you should wish for death because of a calamity befalling him;
but if he has to wish for death, he should say: “O Allah! Keep me alive as long
as life is better for me, and let me die if death is better for me.’ ” Sahih
Al-Bukhari – Book 70 Hadith 575

                In this
situation, the physicians must explain properly their legal obligations even
the patients express wishes regarding one of these forms of death. When
treating patients who make such requested, physicians should have the attempt
to understand and know the root of these feelings. Many patients may
contemplate this attempted of suicide out of fear, but these problems could
potentially be resolved by giving them the education and knowledge about their
disease and also the effective palliative symptom management towards their
diseases.

                Emergency
physicians play a multifaceted role in the end of life care of acute and also
the critically ill patient. The responsibilities extend far beyond the
capability of the clinical skills and the essential intellectual and knowledge but
also must possess the competency in such the communication, empathy, cultural
and also the ethical issues. Such abilities are not innate, but rather, they
can and should be continually refined and improved. It can be concluded that
the complete cares involves the integration of all of these factors that result
in a multidimensional, patient-specific approach.

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