When caring for any patient, having a basic understanding of their culture and values can go a long way towards building trust and improving their experience and outcome. This rings true especially during Ramadan, considered the most sacred 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 takes place this year from April 2 until May 2.
Providing Care During Ramadan
Not everyone knows the intricacies of Ramadan and what the observance entails, so a brief breakdown can benefit healthcare workers during the sacred month. Ramadan is a month-long religious observation, wherein many Muslims fast from dawn to sunset, worship, pray, give generous charity, self-reflect, and focus on strengthening character and self-control. It culminates with celebrations of Eid-al Fitr holiday. When treating patients, it's important to remember to never make assumptions about the patient's practices -- ask the patient about their observances instead.
Ramadan fasting takes place from dawn to sunset, with abstinence from food, drink, smoking, and sexual intercourse during 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 approximately 11 days shorter than the Western Gregorian calendar, so Ramadan occurs at different times of the calendar year. Ramadan in the winter leads to shorter fasts because of the shorter days. Summer Ramadan fasts are much longer, with thirst being a greater challenge for many. Fasting Muslims usually eat a suhoor meal to begin the fast at dawn, and an iftar meal to break the fast at sunset. Exemptions to fasting include anyone who is traveling, pregnant, breastfeeding, or menstruating; prepubertal children or those with acute or chronic illnesses that may worsen with fasting are also exempt.
Despite these exemptions, some patients may still fast. Providers should be aware that patients can make up a day of fasting if they weren't able to participate in the fast. They can also feed someone who is less fortunate to make up for not fasting. There are also procedures that may invalidate the patient's fast. Physicians should be aware of these instances since invalidating the fast may create significant distress for the patient. Invalidating procedures include consuming oral medications, asthma inhalers, most endoscopic procedures, general anesthesia, IV fluids, parenteral nutrition, and intentional vomiting. It is important to partner with the patient and their family to go over these and other procedures that may invalidate fasting. In some cases, you may need to alter the timing of medication administration or procedures to accommodate for fasting hours. Most Muslim scholars consider the following permissible: ear, nose, and eye drops, rectal suppositories, enemas, and blood transfusions.
When providers are equipped with the theological understanding and appreciation of different jurisprudence schools, they are better positioned to present their patients with more options, make shared and partnered clinical decisions, and schedule certain procedures and medication during non-fasting hours or after Ramadan.
Beyond just the physical, Ramadan is also a spiritual mission. Patients may have disturbed sleep cycles from waking up early for the pre-dawn meal and tending to life's obligation such as work or school on a fasting stomach. The holy month provides an opportunity for providers to team up with individual patients to achieve specific health goals. It is important for healthcare providers to educate fasting patients on how to hydrate and drink enough fluids, eat well-balanced nutritious meals, maintain good sleep-hygiene, fast in a safe manner, and maintain proper adherence to medications and treatment of comorbid conditions. Taking advantage of the discipline and self-control that Ramadan demands, physicians can help fasting patients achieve their lifestyle health goals like quitting smoking or alcohol and maintaining meaningful, supportive relationships with family and friends. Patients should be encouraged to maintain the healthy habits established during Ramadan into the post-Ramadan period and beyond.
Managing Chronic Conditions During Ramadan
With comorbid chronic conditions, Muslim patients risk serious complications such as dehydration, hypoglycemia, hyperglycemia, and diabetic ketoacidosis. Fasting Muslims may not adhere to prescribed medication 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 created for fasting among people with type I or II diabetes mellitus that take into account religious considerations in making medical recommendations. High-risk categories are strongly discouraged from fasting. Recommendations include a pre-Ramadan medical assessment to check the latest HbA1C and a consultation that educates the patient on diabetes management during Ramadan, which consists of proper diet, nutrition, exercising while fasting, and recognition of hypoglycemia and hyperglycemia symptoms. Patients are advised to eat multiple small meals between iftar and suhoor instead of one big meal at iftar, modify medication dosage, check blood glucose multiple times throughout the day, and to immediately break their fast if blood sugar falls under/above certain thresholds or if they become symptomatic of hypoglycemia or hyperglycemia.
Patients with unstable angina, decompensated heart failure, recent cardiac surgery, or myocardial infarction are discouraged from fasting. Heartburn, bloating, and indigestion are common gastrointestinal symptoms that occur during fasting and can be due to excessive eating 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 renal conditions or on dialysis are advised to increase fluid intake and schedule dialysis sessions on non-fasting days.
Other Considerations
Understanding the interplay between fasting and these medical conditions will help the medical team ensure a safe fast and proper care of patients. It's also of value for healthcare workers to understand the depth and breadth of the Muslim experience in the U.S. The terrorist attacks of 9/11, the subsequent wars, and growth of Islamophobia in some segments of society has, in part, shaped the Muslim experience and serves as an important social determinant of health. Some healthcare workers may have developed implicit biases and may be unaware of the suboptimal care they provide their Muslim patients, particularly during the vulnerable period of fasting throughout Ramadan.
The recommendations we offer are not all inclusive -- you might consider consulting with local religious leaders either in your hospital or in the community. The vast cultural diversity of the American Muslim community should also be appreciated in this regard, as the overlay of regional cultural practices superimposed on religious theology may add further richness to Ramadan norms practiced by American Muslims, which may require further consideration by healthcare 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. Upon graduation, he will begin residency training in diagnostic radiology. is associate professor of neurology and of medicine at New York Medical College, where he teaches multiculturalism in medicine, and is also the vice chancellor for diversity and inclusion and associate dean of student affairs.