Understanding faith considerations when caring for bereaved Muslims

Ethnic and religious pluralism are now key features of most Western societies, with Muslims representing the largest religious minority group. Although Muslims are ethnically, culturally and linguistically heterogeneous, they share common core beliefs these centring on the unity of Allah (God) and the message sent to mankind in The Holy Qur'an. A key theme running through The Qur'an is the contrast between the transitory nature of this world and the permanent abode of the Akhirah (Hereafter).

Bereavement represents a significant life event, often resulting in major social, psychological and spiritual transitions.¹ In this paper, we consider core Muslim beliefs in relation to death and bereavement, and draw on these beliefs and teachings, the limited available empirical data on the subject and our personal experiences to reflect on possible implications for care, particularly in relation to patients being managed in Western secular care contexts (see Box 1 for further details).

Box 1. Methodology.

Sources of information

• We searched Medline in September 2012 for relevant articles regardless of language and date of publication using a combination of the following search terms: bereavement, death, dying, grief, Muslim and Islam. Bibliographies of identified articles and personal libraries were screened.

• We drew on our research data-sets, particularly the study ‘Developing services to meet the end-of-life care needs of South Asian Sikh and Muslim patients and their families in Scotland’ and an ongoing Danish study on ethnicity, migration and cancer care.²

• Our own experiences of witnessing and caring for bereaved individuals were an additional source of information. These experiences are based on research among, as well as personal relations to, bereaved Muslims and the healthcare professionals caring for them.

Challenges in caring for bereaved Muslims

Religious beliefs provide a way of making sense of the human condition, the means to join together those with a shared understanding into a coherent unit or community, and the basis for communicating existential reflections to others. As such, religious beliefs have considerable potential to influence how grief is experienced and expressed in interactions between the bereaved and healthcare professionals.

Discussing death and dying can be difficult and even more so in encounters with religious minorities. Acknowledging the meanings of death among different religious groups and being willing to engage in conversations on these meanings facilitates the provision of competent care.

Despite the best of intentions, healthcare professionals often struggle when faced with bereaved Muslims. Some express uncertainty about how to differentiate between variations in bereavement processes reflecting religious differences across population groups on the one hand and, on the other, symptoms indicative of aberrant grief processes, which have the potential to benefit from professional help and support. Lack of cross-cultural competencies due to inadequate diversity training, insecurity and worries about causing offence if topics are raised inappropriately, and language barriers in encounters with relatives of dying Muslim patients are therefore likely to cause Muslims, and other religious minority groups, to be at higher risk of being misinterpreted or inadequately supported in the bereavement process. In order to provide sensitive, patient-centred care, healthcare professionals need to have the insights and expertise to provide humane care to all patients, irrespective of background, particularly at times of immense personal loss and associated vulnerability.^3,4

The view from within

Death is inevitable marking a transient separation

Life and death are believed by Muslims to be in accord with the will of Allah – the timing of death is therefore predetermined with a fixed term for each human being. Death marks the passing to the Hereafter – the ultimate destination. Our earthly life is considered a testing ground and our relations are trusts from Allah, which we are asked to treasure, but in doing so to remember that these are ultimately to be returned to Him.

Death is not a taboo subject for Muslims. On the contrary, Islam encourages Muslims to be ever-mindful of the temporary nature of this life and to focus on spiritual (rather than material) growth, which equips one with the wherewithal to deal with periods of difficulty that are integral to the human condition.⁵ For example, the Prophet Muhammad reminded Muslims to ‘be in the world as if you are a stranger or a traveller’.⁶ Death is in this sense, a new beginning, not the end.

For the deceased, death marks the transition to the Hereafter; the suffering experienced by the dying may represent a source of Divine recompense experienced in this world, but many take solace in the words of the Prophet that any form of suffering – whether experienced by the dying or the bereaved – can serve as a source of reward in the Hereafter.⁷ The Prophet said:

No fatigue, no disease, nor sorrow, nor sadness, nor hurt, nor distress befalls a Muslim, even if it were the prick he receives from a thorn, but that Allah expiates some of his sins for that.⁸

Moreover, Allah is repeatedly described in The Qur'an as ‘The Most Merciful, The Most Kind’ and He is thus inherently aware of the intense pain associated with losing a loved one and so in response sheds the sins of those who, despite the period of adversity, show patience, resolve and remain steadfast in their beliefs:

Be sure we shall test you with something of fear and hunger, some loss in goods or lives or the fruits (of your toil), but give glad tidings to those who patiently persevere.

Who say, when afflicted with calamity: ‘To Allah We belong, and to Him is our return’.

They are those on whom (descend) blessings from Allah, and Mercy, and they are the ones that receive guidance. The Holy Qur'an.⁹

Finding meaning in bereavement

The overall purpose of the human existence and the promise of comfort, strength and reward revealed in The Qur'an help shape the responses of Muslims to bereavement. Although reactions to loss are unique for each individual, the sense of bewilderment, anger and denial predicted by bereavement models are in our experience far less likely to be evident among Muslims than those with a more secular outlook.¹⁰ Believers take comfort in knowing that Allah is aware of any suffering they go through and that trials are signs of love. Furthermore, although a sense of loss is inevitable, the belief in the Hereafter carries with it the promise that separation is temporary. For the bereaved, comfort is found in this enduring relationship which is maintained through prayers (Dua) and a motivation to ‘get on with life’ at a deeper spiritual level of faith in order to re-unite in Paradise. This perspective may prevent the destructive self-neglect that has been associated with increased risk behaviour, morbidity and mortality among bereaved individuals.¹¹

Bereavement represents an occasion to reflect on social and spiritual relationships, to revisit the core values guiding one's life, and readjust life accordingly.^12,13 In this manner, the loss of a beloved person may be a blessing since it brings the opportunity to return to our primordial state (Fitrah), in which we are attached, above all else, to Allah. The ordeals of life, the death of those we love, are all intended to bring us back to this natural state, to the humility, fragility and the most essential longing that brings us closer to Allah.¹⁴ Closeness to Allah during a period of intense loss opens the doors of Allah's mercy, which provide solace and help to enlighten the lives of those left behind.

Muslims are encouraged to have resolve and retain their trust in Allah's Providence. This does not mean that sadness and grief are signs of disbelief. Rather, although pre-Islamic practices of excessive wailing are strongly discouraged, sorrow and tears are reflections of a gentle, spiritually alert heart. Asked why his eyes were filled with tears when witnessing the death of a child, the Prophet replied:

It is mercy which Allah has lodged in the heart of His slaves, and Allah is Merciful only to those of His slaves who are merciful (to others).¹⁵

However, at times expressions of despair and anger among bereaved Muslims may be perceived by fellow Muslims to be signs of spiritual deficits, thereby making it difficult for some to acknowledge such emotional problems openly.²

Coping with bereavement is influenced by, among other things, the nature of the relationship and the closeness to the deceased. The loss of a young child is acknowledged to be one of the most distressing human experiences since it implies the breakage of the most intimate bonds between human beings. Immense comfort for parents is however found in the promise that their child has died in a state of innocence (and hence has no judgement) and will refuse to enter Paradise without his/her parents.^16,17

It can however prove difficult to find meaning in some contexts and these may increase the risk of aberrant grief reactions. For example, if death was caused by behaviours considered to be un-Islamic, such as suicide or drug abuse, and among unmarried partners, guilt, which is often compounded by exclusion from religious communities, may complicate the grief reactions.

Implications for care

Caring for the dying, dead and bereaved

The importance of social support for patients and their relatives is well-known. Visiting the sick is a particularly meritorious practice in Islam. Healthcare professionals involved with dying Muslims often describe how both distant and more intimate friends and relatives of the family visit prior to death offering important social support for the patient and his or her relatives. Visitors will often recite key verses of The Qur'an and help the dying reiterate his/her Islamic beliefs (repeating the Shahada). Although these visitors may be valuable sources of support, healthcare professionals may struggle with balancing the number of visitors with the needs of the dying patient, the immediate family and other patients at the ward.^18,19

Healthcare professionals at times express a need for more knowledge regarding the practices among different religious groups at the end of life and the implications for service provision. Caring for the deceased include washing and shrouding the body; reciting the funeral prayer in the mosque and attending the funeral. Engaging in such rituals help the bereaved to uphold important roles at the bedside of the dying and in the following days.¹⁸ Healthcare professionals are rarely required to engage directly in such practices. However, in encounters with bereaved Muslims who are isolated from religious communities (e.g. newly arrived migrants, Muslims from small ethnic groups) healthcare professionals may help the bereaved by facilitating contact to existing Muslim organizations and/or communities.

Bereavement transcends beyond the individual or the family inflicted with the loss of a beloved person. It involves the religious community that is expected to support those left behind in various ways, each aiding the bereaved and helping them cope with their loss. Offering condolences and aiding with, e.g. preparing foods or taking care of children are forms of emotional and tangible support given by fellow Muslims in this period. Such support releases relatives from their duties, thus enabling them to focus on coping with bereavement. However, it is important that healthcare professionals do not assume that the apparently large social networks that are involved prior to death are available sources of support for the bereaved following death. Rather than assuming that ‘they handle it within their extended families’, healthcare professionals should conduct a systematic assessment of available sources of social support as part of care for bereaved individuals irrespective of religious beliefs.

Conclusions

Coping with the loss of a significant person is undeniably difficult. For some Muslims, religious beliefs in relation to death and bereavement serve as resources helping them understand and react to their loss. Rather than ‘dying from a broken heart’, Muslims may find blessings in hardship, and if so they may be less likely to suffer the adverse effects on physical health and psychological wellbeing associated with pathological reactions to bereavement.

Healthcare professionals should be aware of the role of Islam for how Muslims cope with their loss. Enhanced understanding of the role of religious beliefs among Muslims as well as other religious minority groups are likely to improve not only the care of the dying patient and his or her relatives, but also the healthcare professionals’ sense of satisfaction and meaning in caring for the dying.²⁰

A number of other individual and contextual resources and vulnerabilities, besides religious beliefs, shape bereavement processes and should be attended to in care for bereaved Muslims. Individual psychological resilience, prior traumatic experiences and the way these have been coped with, stressors occurring alongside the loss (e.g. diseases, unmet psychosocial needs) and availability of social support all frames bereavement processes. For those who show signs of pathological grief, referral to appropriate counselling services is warranted. Such services should embrace the religious identity of Muslims acknowledging the potential resources that such beliefs and practices constitute (Box 2).

Box 2. Key messages.

Key elements in care for bereaved Muslims

• Muslims now represent Western Europe and North America's largest minority group; many migrated in the 1960s to 1980s and there is therefore a large elderly Muslim population emerging in Europe and North America for the first time.

• Muslim beliefs about the transitory nature of this world, the meanings behind, pain, loss and suffering and the permanent nature of the Hereafter can all have a profound effect on shaping bereavement reactions in Muslims, which may be very different from those with more secular outlooks.

• A working appreciation of these beliefs can help healthcare professionals to engage more effectively with their bereaved Muslim patients and draw on these deep-rooted beliefs and practices to help bring healing in the aftermath of the death of a loved one.

• It is important not to simply assume that religious and social structures are in place; these may in particular be absent in the context of lone and recent migrants, and those who die from a frowned upon illness (e.g. substance abuse or suicide).

DECLARATIONS

Competing interests

None

Funding

There was no direct funding for this work; AS was however supported by a grant from the Chief Scientist's Office of the Scottish Government, data from which have been drawn upon in the writing of this essay

Ethical approval

There was no specific ethical approval needed for this essay; the Scottish end-of-life study received ethical approval from Lothian research ethics committee and research governance approval from NHS research and development

Guarantor

MK

Contributorship

Both authors contributed equally

Acknowledgements

None