When caring for a patient, having a basic understanding of their culture and values can go a long way to building trust and improving their experience and outcomes. This rings true especially during Ramadan, considered the holiest month of the year in the Muslim calendar. A basic understanding of Ramadan will help promote shared decision-making with improved provider-patient partnerships, leading to better care for sick Muslim patients during the holiday, which this year runs from April 2 to May 2. .
Providing care during Ramadan
Not everyone knows the intricacies of Ramadan and what observance entails, so a brief breakdown may benefit healthcare workers during the holy month. Ramadan is a month-long religious observance, during which many Muslims fast from dawn to dusk, worship, pray, give generous charity, reflect on themselves, and focus on building character and self-control. It culminates with the celebrations of the Eid-al Fitr holiday. When treating patients, it is important to remember never to make assumptions about the patient’s practices – instead ask the patient about their observances.
Ramadan fasting takes place from dawn to sunset, with abstinence from food, drink, tobacco and sexual intercourse during the fasting hours. Islam adheres to a 12-month lunar calendar; Ramadan is the ninth month and is one of the five pillars of Islam. The Islamic year is about 11 days shorter than the Western Gregorian calendar, so Ramadan occurs at different times of the calendar year. Ramadan in winter brings shorter fasts due to shorter days. Summer Ramadan fasts are much longer, with thirst being a bigger challenge for many. Fasting Muslims typically eat a suhoor meal to begin the fast at dawn and an iftar meal to break the fast at sunset. Exceptions to fasting include anyone who travels, is pregnant, breastfeeding or menstruating; prepubescent children or those with acute or chronic illnesses that may worsen with fasting are also exempt.
Despite these exemptions, some patients can still fast. Providers should be aware that patients can make up a day of fasting if they were unable to participate in the fast. They can also feed someone less fortunate to compensate for not fasting. There are also procedures that can invalidate the patient’s fast. Physicians should be aware of these cases because invalidating the fast can create significant distress for the patient. Disabling procedures include the use of oral medications, asthma inhalers, most endoscopic procedures, general anesthesia, IV fluids, parenteral nutrition, and intentional vomiting. It is important to work in partnership with the patient and family to review these and other procedures that may invalidate the fast. In some cases, you may need to alter the timing of medications or procedures to accommodate fasting times. Most Muslim scholars consider the following to be permissible: ear, nose and eye drops, rectal suppositories, enemas and blood transfusions.
When providers are equipped with theological understanding and appreciation of different schools of jurisprudence, they are better positioned to present their patients with more options, make shared and partnered clinical decisions, and plan certain procedures and medications during the hours without fasting or after Ramadan.
Beyond the physical, Ramadan is also a spiritual mission. Patients may have disrupted sleep cycles by waking up early for the pre-dawn meal and attending to life obligations such as work or school on an empty stomach. The holy month provides an opportunity for providers to team up with individual patients to achieve specific health goals. It is important for health care providers to educate fasting patients on how to stay hydrated and drink enough fluids, eat well-balanced nutritious meals, maintain good sleep hygiene, fast safely and maintain good adherence to medications and treatment of comorbid conditions. Taking advantage of the discipline and self-control that Ramadan demands, doctors can help fasting patients achieve lifestyle health goals, such as quitting smoking or drinking alcohol, and maintaining meaningful and supportive relationships with family and friends. Patients should be encouraged to maintain the healthy habits established during Ramadan during the post-Ramadan period and beyond.
Managing chronic illnesses during Ramadan
With comorbid chronic diseases, Muslim patients risk serious complications such as dehydration, hypoglycemia, hyperglycemia, and diabetic ketoacidosis. Fasting Muslims may not adhere to prescribed medications and may refuse treatment or diagnostic tests during Ramadan that could invalidate the fast. Muslims with advanced diabetes are exempt from fasting, but some may still choose to fast. The International Diabetes Federation and Diabetes and Ramadan have created risk-stratified guidelines for fasting in people with type I or type II diabetes mellitus who take religious considerations into account when making medical recommendations. High-risk categories are strongly discouraged from fasting. Recommendations include a pre-Ramadan medical evaluation to check the latest HbA1C and a consultation that educates the patient on diabetes management during Ramadan, which consists of proper diet, nutrition, exercise while fasting, and recognition of symptoms. hypoglycemia and hyperglycemia. Patients are advised to eat several small meals between iftar and sahoor instead of one large meal at iftar, change medication dosage, check blood sugar several times during the day, and break immediately their fast if their blood sugar falls below or above certain thresholds or if they become symptomatic of hypoglycemia or hyperglycemia.
Patients with unstable angina, decompensated heart failure, recent heart surgery, or myocardial infarction are advised against fasting. Heartburn, bloating, and indigestion are common gastrointestinal symptoms that occur during fasting and may be due to overeating late at night. This can be avoided by eating small meals and avoiding trigger foods. Patients with active peptic ulcers and uncontrolled asthma should be discouraged from fasting. Patients with kidney problems or on dialysis are advised to increase their fluid intake and schedule dialysis sessions on non-fasting days.
Understanding the interplay between fasting and these medical conditions will help the medical team ensure timely and appropriate patient care. It is also helpful for healthcare workers to understand the depth and breadth of the Muslim experience in the United States. The terrorist attacks of September 11, the wars that followed, and the growth of Islamophobia in certain segments of society have, in part, shaped the Muslim experience. and serves as an important social determinant of health. Some healthcare workers may have developed implicit biases and be unaware of the suboptimal care they provide to their Muslim patients, especially during the vulnerable fasting period of Ramadan.
The recommendations we offer are not exhaustive – you might consider consulting local religious leaders, either in your hospital or in the community. The vast cultural diversity of the American Muslim community must also be appreciated in this regard, as the layering of regional cultural practices overlaid on religious theology may add additional richness to the Ramadan norms practiced by American Muslims, which may require examination. further investigation by health care providers.
Adil Afridi, MS, is a fourth-year medical student at New York Medical College, with an interest in multiculturalism in medicine and Islamic history, civilization, and theology. After graduating, he will begin a residency in diagnostic radiology. Moulin Etienne, MD, MPH, is an associate professor of neurology and medicine at New York Medical College, where he teaches multiculturalism in medicine, and is also vice chancellor for diversity and inclusion and associate dean of student affairs.