Mortality patterns among critically ill children in a pediatric intensive care unit of a developing country.

Abstract

Sir, Siddiqui et al. addressed in their interesting study that limitation of life support treatment (do not resuscitate [DNR] + withdrawal of life support treatment) was found to be the most common cause of death among critically ill children in the pediatric intensive care unit (PICU) and parents were always involved in the end-of-life (EOL) care decision-making.[1] It is obvious that different religions have considered that the preservation of life is sacrosanct. The ethical principle of preservation of life is to treat a patient's illness with the aim of prolonging life. However, this concept has been recently re-evaluated in the light of evolution of many factors affecting survival and quality of life of critically ill patients such as an often incurable or at least doubtfully curable underlying illness, treatment cost, therapy-related complications, severe pain, and immunosuppression. Important intercontinental differences do exist toward EOL issues in PICUs. Although the legal and ethical situation is rapidly evolving, a certain degree of paternalism seems to persist among European and South-American caregivers. Moreover, ethical principles depend on the cultural roots of countries or continents, emphasizing the need to foster dialogue on EOL issues around the world to learn from each other and improve EOL care in PICUs.[2] The Islamic religion viewpoint on EOL issues necessitates meticulous attention in Muslim countries, including Pakistan. At several Islamic juridical council meetings held in Mecca, Jeddah, and Amman over the past few decades, Muslim jurists of different schools ruled that once invasive treatment has been intensified to save the life of a critical patient, lifesaving equipment cannot be turned off unless the physicians are certain about the inevitability of death. The Islamic religion concepts concerning DNR decision have been clarified by the Presidency of the Administration of Islamic Research and Ifta, Riyadh, Kingdom of Saudi Arabia, in their fatwa No. 12086 issued on 30.6.1409 (Hijra) (1988 [AD]). The fatwa states that: “If three knowledgeable and trustworthy physicians agreed that the patient condition is hopeless; the life supporting machines can be withheld or withdrawn. The family members’ opinion is not included in decision making as they are unqualified to make such decisions.”[3] Actually, no obstacles do exist in the implementation of that prerequisite in intensive care units in Muslim countries. Islamic law governs EOL legal issues in Muslim countries as there is a specific legal terminology, derived from the Qura’an (holy book of Muslims) and Sunnah (verses of Prophet Muhammad [peace be upon him]), which is used to settle conflicts in EOL care. This contrasts with the nonMuslim countries, particularly in America and Europe, which has a secular system of law that informs EOL issues. Hence, it would be difficult for Muslims who constitute minorities in these countries to follow Qura’an and Sunnah laws in making EOF decisions for terminally-ill patients.