As seen on Table 2, 10 were women and 13 were men; 78.2.% were Caucasian, 13.0% African American and 4.3% Latino; the mean age was 63 (range 42–72). They were from throughout the U.S., with diverse religions; 21.7% had doctorates and 43.5% had Masters degrees; and their mean length of practice was 18.8 years (range 3–30).
Table 2
Characteristics of Sample (N = 23)
|
Variable:
|
Number:
|
Percentages:
|
|
Gender:
|
|
|
|
Male
|
13
|
56.5%
|
|
Female
|
10
|
43.5%
|
|
Race & Ethnicity:
|
|
|
|
Caucasian
|
18
|
78.2.%
|
|
African American
|
3
|
13.0%
|
|
Latino
|
1
|
4.3%
|
|
Other
|
1
|
4.3%
|
|
Age:
|
|
|
|
Range
|
42–75 years
|
|
|
Mean
|
63 years
|
|
|
Geographic Region:
|
|
|
|
Northeast
|
12
|
52.2%
|
|
Midwest
|
4
|
17.4%
|
|
Southeast
|
3
|
13.0%
|
|
Southwest
|
3
|
13.0%
|
|
West
|
1
|
4.3%
|
|
Religion:
|
|
|
|
Protestant
|
6
|
26.1%
|
|
Catholic
|
4
|
17.4%
|
|
Christian, not otherwise specified
|
6
|
26.1%
|
|
Jewish
|
3
|
13.0%
|
|
Muslim
|
3
|
13.0%
|
|
Buddhist
|
1
|
4.3%
|
|
Highest Degree Held:
|
|
|
|
Master’s
|
10
|
43.5%
|
|
Doctorate
|
5
|
21.7%
|
|
Bachelor
|
1
|
4.3%
|
|
Associate
|
1
|
4.3%
|
|
Unknown
|
6
|
26.1%
|
|
Years Practiced as Chaplain:
|
|
|
|
Range
|
3–30 years
|
|
|
Mean
|
18.8 years
|
|
In brief, as outlined in Fig. 1 and described more fully below, both Muslim and non-Muslim chaplains raised several issues concerning Islam that emerge among chaplains, doctors and patients, e.g., challenges and mutual misunderstandings between non-Muslim staff and Muslim patients, often due to limited knowledge and differences in perspectives. Several types and causes of, and approaches to, these challenges emerged. Muslim chaplains can bring particular background and understandings that can enhance trust and thus offer added benefits with certain Muslim patients’ needs.7
[INSERT FIGURE 1 AROUND HERE]
Misunderstandings and discrimination
Stresses arise because Islam is widely misunderstood, and can be the subject of prejudice. As a Muslim chaplain said,
Islam is the most misunderstood religion in the world, especially in America. There is a lot of resistance from other faith traditions, which still have to understand where the Islamic community, persons, or faith come from in dealing with death and dying. Even chaplains from other faiths may be prejudiced against Islam. [Chaplain #3]
Certain particular aspects of Islam may fuel misunderstandings and feelings of lack of familiarity among non-Muslims. For instance, many non-Muslim Westerners may mistakenly feel that Muslim and Judeo-Christian notions of God are dramatically different, rather than related. As another Muslim chaplain said,
When we say 'Allah,' we're not talking about a Muslim God. We're talking about the Creator. Muslims believe in God. It's that same God. It's just a different name. But people often think that we believe in some other kind of God. That's not true. We believe in the same One, as created Adam and Eve. So, when we're able to get them to understand that, it's a breakthrough. Non-Muslims may be put off in using the word Allah instead of God. When they hear Allah it's strange to them. [Chaplain #21]
Yet non-Muslim staff frequently have little understanding of Islam, and are affected by social media, which can be biased. "They get their information from the news." [Chaplain #21]
Such limited knowledge, however, coupled with Islamophobia, can yield not only misunderstandings, but hesitancy and hostility. As a Muslim chaplain reported,
Sometimes we have a lot of resistance. One Christian student didn't know anything about Islam, and was saying all these negative things. I said ‘I don't want to hear Muslims are this, Muslims are that.’ Even some very Orthodox rabbis I’ve met would just get up and walk out of the room if I talk about Islam and my theology. [Chaplain #3]
Relatedly, Muslim patients may also fear or face discrimination fueled by political events and certain politicians’ statements, and thus not disclose their religion to the hospital.
Since 9/11 and Trump, many Muslims also fear being misunderstood or facing discrimination. When asked their religion on hospital forms, some Muslims write ‘none.’ [Chaplain #21]
Muslim chaplains may therefore not rely wholly on hospital lists of self-identified Muslim patients, but proactively look for patients with Arabic names.
Islamophobia is not going down, especially in the last four or five years. [My city] is relatively better than most other places. But there is still fear. I see a lot of Muslim patients whose religion is listed as ‘unknown’ or ‘other’ because they don’t want to say they are Muslim. When patients are admitted, I look at their name and see if it’s Arabic. When I meet them, I find out. [Chaplain #22]
Muslim patients may thus be wary of discussing their religion unless chaplains are themselves Muslim or perhaps able to establish significant trust and sense of safety.
Specific areas of misunderstandings
Misunderstandings can emerge regarding several specific issues, particularly regarding the role of God, pain, suffering, end-of-life care and family decision-making and interactions.
The role of God in disease
Views can clash concerning the cause of individual disease and treatment outcomes, leading to problems in both what and how providers communicate. As a Muslin chaplain, reported,
Most non-Muslim doctors do not understand that Muslims believe that all events are due to the will of Allah. So, doctors saying to a patient's wife, 'Your husband has two months to live' rubs the family the wrong way, because they fervently believe that God, not the doctor, makes decisions about life. The physician should say instead: 'Among patients with your husband's condition, 80% live for around two months.' [Chaplain #21]
This view of God can have several implications, including affecting patients' acceptance of pain and comfort expressing anger, frustration and negative feelings about their disease. Muslim patients may hence be relatively less open about their feelings – and just they're ok, and chaplains may therefore need to visit several times. Such patients may feel that they cannot question their fate, which they see as derived from God.
They may think it’s not ok to complain because I have to be faithful to God. ‘I have to be thankful no matter what situation we are in.’ So, if that’s the issue, I share with them some incidents that people in the scripture: Abraham, Moses, Jesus and Muhammad all had life situations like this – very vulnerable moments – and expressed their vulnerabilities, shared their moments of sorrow and grief. So, it’s normal. Being angry with illness is ok. Moses was angry with his brother, Aaron, the Prophet Muhammad was sad, too, with the way he was being treated, but God was counseling him. [Chaplain #22]
Chaplains may therefore draw on the Qur'an to show how historical religious leaders, too, were angry and sad, normalizing and validating these emotions for patients and families.
It is very difficult for Muslim patients to open up so quickly. It takes a while. They don’t want to share things. People from [certain Muslim countries] don’t like to share. To them, it’s private, special, they don’t want to make it public. So, it takes a while to make them open up. But South Asian and East Asian people are more likely very quiet and don’t want to share their emotions. So, as a chaplain I struggle with this. I also share with my colleagues that if you visit a Muslim patient, bear that in mind – even if they are dying they will say, ‘I’m ok, I’m fine.’ It takes a while, you may need several visits. [Chaplain #22]
Pain management and end-of-life care
Problems surface because of differing views of suffering and its role. As a Muslim chaplain described,
The Prophet Mohammed teaches that it is virtuous to suffer. Hence, this life is a trial-and-error for the next one. The Prophet also says that for every illness there is a cure, and that saving life is the most important thing. So, Do Not Resuscitate [DNR] orders and withholding of care pose problems. Many patients think that withholding some care means withholding all care. Doctors should frame it in other ways. For instance, Arab legal scholars say that no one can inflict harm or suffering on a patient. Risky treatments and procedures that have side effects and little if any chance of success can in fact make patients suffer. Patients and their families may accept that reason as a way to avoid additional futile interventions. [Chaplain #3]
Muslim patients themselves may this misunderstand DNR, and benefit from education about the religion's stances on this issue.
Islam can also shape patients' and families' views and decisions about pain management.
Part of being a patient is being patient. So, when a doctor asks, 'How are you doing?' Muslim patients may say, 'Ok,' even if they’re in pain, because it is virtuous to suffer – they will be rewarded because of dying, death, or suffering. At the end of life, it's important many Muslims might not want a lot of morphine, if they can help it, because they want to be able to declare at death: 'there's no God, but the one God, and Mohammed is His Prophet.' Just as we would do certain rituals for Catholics, we want the patient to say that. [Chaplain #3]
Muslim patients with serious pain may, therefore, want to avoid opiates. As one Muslim patient told a chaplain,
I'm dying, and know I'm dying. I can't stand the pain, but don't like morphine because it makes me groggy, and when I die I want to be able to make a [Declaration of Faith]. [Chaplain #3]
Muslim chaplains can, however, aid such patients by reinterpreting the term, "declaration" more broadly and flexibly, pointing out that the Qur'an also supports patients not unduly suffering.
If patients are intubated and can't talk, we want them to raise their right index finger, or we will raise their right index finger, and then the family will say these words. If the imam is not there, it's the family's obligation to make that happen. It's important for the staff to know that. Chaplains and staff can tell the family, 'Look, the physician said you can go ahead and make this end-of-life ritual for this patient while he or she is dying. If the patient comes back to life, then we can do it again, and again.' [Chaplain #3]
Providers can thus learn to communicate about these topics and ways of interpreting and adopting practices in helpful manners. Staff can help by re-framing DNR, hospice and palliative care as acceptable in Islam, by citing not only Arab legal scholars, but verses from the Qur’an itself.
Most Muslims do not understand DNR, so we try to explain what it means – to allow 'natural death.' Muslim patients misunderstand the language, and may think that DNR is against the religion, so I give verses from the Qur'an that say allowing natural death is ok. We don't look at illness and death as a bad thing, that you're being punished in most cases. We try to give Qur'anic verses, and sayings of the Prophet to patients that feel that, so they can make their own decisions. Muslim patients may require and benefit from particular approaches, based on recognizing their religiousness. [Chaplain #22]
Muslim families may want more aggressive treatment for dying patients because they feel strong duties to do whatever they can to assist their family members. Yet a Muslim chaplain can thus instead suggest that God also would not want the patient to undergo more suffering, which additional treatment would cause. Providing education on details about Islam, may, however, be stronger coming from a Muslim rather than a non-Muslim chaplain. Muslim chaplains may be seen as having more legitimacy or authority and thus readily obtain added trust from frightened and/or wary families and patients.
Yet physicians may not grasp the implications of these beliefs. Another Muslim chaplain described an Islamic woman who, for instance, wanted more aggressive treatment for her dying husband, though the doctors considered such efforts futile. In the husband's chart, the staff wrote that she was ‘in denial,’ had poor coping skills, and wouldn't accept his situation. After several weeks of mutual frustration and antagonism, a social worker finally arranged for a Muslim chaplain to visit. The wife, it turned out, believed that without the treatment, her husband wouldn't go to heaven. The staff had failed to appreciate her perspective. This chaplain told her that God wouldn't want her dying husband to undergo more suffering, which additional treatment would cause, and she agreed.
Family decision-making and interactions
Chaplains saw how they and other providers needed to be sensitive to not only religious, but cultural differences.
I tell doctors that culturally, decision-making might also be different. It's sometimes a group, family decision, and is about hierarchy. The grandmother or grandfather may be in Saudi Arabia, but helping to decide for the patient here. Physicians want to know who is making the decision, and rely on the patient to make it, but the patient has to get back to them. Doctors don't understand that the elders back in Pakistan are involved as well. I try to buffer this, and give doctors a handout to educate themselves. [Chaplain #3]
Doctors may also find family decision-making differs from Western medical ethics' focus on individual autonomy challenging.
Here [in the West], we work differently. Western medical ethics emphasizes patient autonomy, so family decision-making is challenging for the medical team. They don't know how it works in another part of the world. [Chaplain #22]
Diversity within Islam
Muslims hail from different countries, but providers may also not fully grasp how these patients relevant cultural practices may in fact range widely.
I’ve seen Muslim patients from all over the world, including the African-American community, and others who have gotten away from their cultural identity and want to be more Americanized. I try to focus on the individual, what their cultural needs are, whether they are Sunni, Shite or African-American. All of us are equal in prayers, religious services, washing before prayer and liking halal food, if available. But I try to navigate and work with them and see what their cultural needs are. [Chaplain #3]
Islamic sects have similarities as well as differences. They all follow the Qur'an and the Prophet, but differences may arise due to culture or politics.
The Roles Of Muslim As Non-muslim Chaplains
Questions arose regarding the potential use of, and needs for, Muslim vs. non-Muslim chaplains with Muslim patients. Non-Muslim chaplains generally felt they were able to aid Muslim patients. As a Christian chaplain observed,
Some Christians say, 'Islam is based on the Ishmael and Isaac problem, so Muslims are bitter and always will be.' But every religion has fundamentalists. I have a hard time dealing with Fundamentalists Baptists. But overall, Muslims are very easy to work with. They're very peaceful, very intelligent and really good. When you embrace and reach out to them, they embrace you back. [Chaplain #8]
Chaplains commonly see varying religions as simply different roads to the same place. As a Protestant chaplain explained,
As Muslims, Jews and Christians, we are all praying to the same God. If I drive to my state capital, I can take the interstate, but other people may want to take the backroads. We're all going to get there, but in different ways. [Chaplain #2]
Non-Muslim chaplains may try to make even small comments or gestures to counteract Muslim patients' and families' fears, and express openness, and support. As a Christian chaplain said.
With Muslims, I say 'as-salamu alaykum (peace be with you), and they respond, 'wa-alaikum-salaam (peace be upon you also).' All of a sudden, they're relaxed. They fear that we think they're all terrorists. They're not! [Chaplain #2]
Yet many Muslim immigrants don't know what "chaplaincy" is, and chaplains must thus first explain.
We meet a lot of immigrants and people who are not familiar with the term chaplains. So, we have to give a little bit of introduction about what we do: that we include spiritual and emotional care. Then they understand. [Chaplain #22]
Muslim patients may thus have little familiarity with chaplaincy or see it as potentially aiding them. As a non-Christian chaplain said,
Muslims assume that the chaplaincy service isn't for them. They wouldn't necessarily know – America has a lot of anti-Muslim stuff going on right now. They'd be surprised to learn we have a Muslim chaplain, and Jum'ah prayer services and a box of prayer rugs and supplies. [Chaplain #9]
Mutual wariness and misunderstanding can consequently emerge between Muslim patients and non-Muslim providers.
Muslim patients may, however, strongly prefer having a chaplain of their own faith.
A Muslim patient was dying at a major hospital, which sent him a Catholic priest. The Chaplaincy Department marketed themselves as a 'multi-faith' organization, but was not, because it left out Islam, Buddhism, Hinduism and others. The patient said, 'I do not want a Catholic chaplain. I want a Muslim one.' [Chaplain #3]
Muslim patients appear very grateful to have a chaplain of their own faith, whom they may trust more, feeling more understood. As a Muslim chaplain said,
A few days ago, a Middle Eastern patient shook my hand, and said, 'Speaking to you has been the most comforting thing that has happened to me here in the hospital, because I can connect with you! You are an Imam. You would understand me.' [Chaplain #22]
With Muslim patients, addressing religious issues early on in care can also be especially helpful.
A big challenge for all of us – physicians, and the religious community – is to be able to help religious patients and family members who have never before been in the hospital, and come to the end, and we bombard them with medical terms and issues, without giving them an opportunity to understand it from a layman's terms. They are confused. Then, you've got friction between the medical community, the family, and the religious community. That's why it needs to be brought in in the front end – as opposed to the middle or the back end: what are their religious preferences, how important it is to them, would they or a family member like to talk to a religious person? [Chaplain #3]
More than non-Muslim patients, many Muslim patients may have particular religious rituals such as those involving prayer and handwashing, which may be difficult to follow and/or adapt within the context of hospitals and new disease-related physical limitations. Such patients may benefit from chaplains who can specifically help them adapt these practices, but who therefore need to have a knowledge of Islam.
I get a print-out of every Muslim that comes to the hospital, and my responsibility is to go and touch base with them, introduce myself, and let them know the services available for them, because we truly want them to practice in their tradition. Those who pray five times a day, and now hear the words’ cancer’ and ‘death,’ think they’re coming to die. We want them to practice their faith, but many of them can’t get up to wash and do the rituals they need to do to pray. I can be with them, and try to help them understand that this is ok, we can do that. Educating the staff about those situations is also very helpful. [Chaplain #3]
Muslim chaplains suggested that they might be able to provide certain added benefits to Muslim patients and families, who may more readily trust and relate to chaplains of their own faith, bring deeper understanding of specific religious and cultural issues (which may be more intertwined than for many Judeo-Christian patients living in far more secular societies), as well as address broader familial religious needs.
A family from the Middle East had traveled all over the world for a 14-year-old son with a tumor on his neck that was bigger than a softball. The doctor called, telling me to talk to this family, because there's nothing further he could do for the child. The child would die on the operating table, attempting to remove the tumor. He was the parents' only child, and in their culture, it was important to carry the name on. The child was very educated and articulate. He did everything a wonderful young man likes to do. The father said, 'I've been all over the world and paid all this money. Now I've come to America. I'm going home now, broke. I have no money.' And he left the mother and the child in America all alone with no support system. It was terrible. He just walked away. So, I visited the child every day, just to talk with him. He liked soccer. We watched the games, and talked about girls – the good things in life. I wanted to keep it normal. And after these sessions, we would pray together. He was very religious. One day he said to me, 'Imam, help me do one thing: Help my mother regain her faith in God so I can meet her in Paradise.'
Every time I went into the room, she would walk out the room, and just stand by the door, with her hands crossed, mad and angry. Angry with God. But she would not go far. I talked louder with him, so she could hear. The next day, she stayed in the room, but didn't pray at the end of our session together. She raised her hands just a little bit, but still didn't pray. The third time, she raised her hands and began to pray. I looked at him and he looked at me. He was so happy that his mother was praying again. Three or four days later, he died.
About a month later, his mother called me from the Middle East and said, 'Thank you.' I said, 'For what?' She said, 'You stood by me and my child when nobody else would. My husband left me. The doctors and the nurses left us. But you came and stayed. Now I go to the mosque and pray and do all the things I used to. Thank you so much for that.'
That's more important to me than anything you can pay me. I see I made a difference. To this day, I'm still honored to remember that child and his mother, what they gave. I tell all our staff and patients: 'You give me something.' I just want to be present, and support you the best that I can.' One day, we're going to find ourselves needing that same type of support. Hopefully, we can give everybody that – to be present for people at their bedside, no matter who they are, what their circumstances or their background are. Because at the end, we're all one human spirit, we are connected no matter what. Everybody is going to experience illness, and death. It's not the illness we are fighting, it's more how we deal with it, treat and help each other. [Chaplain #3]
Facing end-of-life issues may thus be, confronting, too, patients’ and families’ broader ongoing spiritual and religious needs. Full knowledge of the specific religion and culture can thus clearly aid both the mother and child. The trust this chaplain developed appeared to have been helpful. It is unclear whether a non-Muslim chaplain could have assisted a family member regain her faith in her religion in this way. The fact that the chaplain was Muslim may have instilled vital trust.
Given Islamophobia, chaplains may this emphasize commonalties across faiths.
Yet trained Muslim chaplains, though possessing important specific expertise, remain relatively rare. Hospitals often lack trained chaplains from outside Judeo-Christian traditions. Yet, within the chaplaincy, Muslim chaplains face challenges, since the field was largely built and structured around the needs and views of Judeo-Christian patients.
Board certification itself can be hard since it was established with Christianity and Judaism as models. It wasn't anything I was expecting, due to resistance from other faith traditions. It caused me a lot of stress in the beginning: how are we going to get board certified, because the processes were mainly for Jewish and Christian theological educations. I had to bring the Islamic theological education into that process, while receiving the clinical education from Jewish and Christian educators and physicians. [Chaplain #3]
Though having an in-house Muslim chaplain appears to have certain advantages, the presence of such chaplains appears to vary the hospitals' size, patient population and geographic location. Several hospitals have a Muslim chaplain because they treat a relatively larger number of Muslim patients, but not all such hospitals have one. "We had a Muslim imam who was one of our candidates," one Catholic chaplain recalled. “He is now gone. But it was nice because we have a lot of patients from the Middle East. They connect themselves with the community resources here." [Chaplain #21]
As a Christian pediatric chaplain in a relatively large city admitted,
I wish I could recruit non-Judeo-Christian chaplains. Unfortunately, in this region of the country, I can't. But we do have a couple of community members – imams, rabbis and several Buddhist temples. [Chaplain #17]
Many hospitals don't have Muslim chaplains, but even Muslim chaplains recognize that their departments have limited resources.
A lot of hospitals don't have Muslim chaplains. Chaplaincy is a very small department compared to any other department in the hospital. When I was interviewed for this job, the program director said, 'Ok. Be mindful that this is a secular hospital. So…' I told him, 'Yes.' Secular hospitals don't have too much money for this. [Chaplain #22]
Needs for education of non-Muslim chaplains and staff
Broader needs for education thus remain still. As a Christian chaplain observed,
There's more of a need, especially in cities, for training to include religions other than Christianity and Judaism, which aren't included anywhere in the formal curriculum. We have a Diversity Week in the fall and the spring, celebrating different cultures. But that's all. [Chaplain #1]
Muslim chaplains can also play vital roles educating non-Muslim colleagues, providing in-depth insider understanding of this faith.
There's nothing like having someone who's actually a practitioner of the faith and can give insight into what it is that we do and believe, and recognize that we want the same things that other people want: I want my children to be safe. We don't want to have to worry about our houses being robbed. [Chaplain #21]
Muslim chaplains thus often try to correct misconceptions among colleagues, by highlighting how this faith grows out of Judaism and Christianity, and is thus connected to these other traditions. As a Muslim chaplain said,
I try to work through that process without getting angry or upset, because most people don't understand that Islam is just an extension of the teachings of religions from Judaism to Christianity. But that took me aback. Because of my tenacity, I was able to be able to stay and stick with the hardship that goes on with that. [Chaplain #3]
At hospitals without a Muslim chaplain, non-Islam chaplains or providers can incorporate a local community imam. Judeo-Christian chaplains may feel more comfortable working with Protestant, Catholic or Jewish patients than with Muslims. As a Muslim chaplain advised,
Make sure the patient's family members and their local imams are involved or contact a Muslim chaplain. Interfaith chaplains should reach out or have a list of local mosque leaders. Family members have a particular mosque, and its imam or his representative can come and be with the patient, and help them guide through end-of-life issues. [Chaplain #3]