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Teaching and Learning Moments

Behind the Veil

Kheirbek, Raya Elfadel MD

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doi: 10.1097/ACM.0000000000001366
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“Do you speak Arabic?”

I was a junior attending making my rounds. Ms. Alam was a 60-year-old woman with advanced ovarian cancer; she sat with her son awaiting my answer. Yes, I was born and raised in Damascus, Syria. Arabic was my mother tongue, but I hesitated. I had no experience providing culturally competent care for a Muslim at the end of life, nor did I have experience providing care for a Hindu or a Christian. I only recalled having read, while I was preparing for the hospice and palliative medicine boards, that when a Jewish or Muslim patient dies, the body must be buried before sunset. I wanted to hide my embarrassment at my ignorance and say that I did not speak Arabic. But, if I said yes, maybe I could simply converse with Ms. Alam in Arabic, say a few comforting words, read the Qu’ran if she asked and the Imam happened to be absent. The latter option seemed the right thing to do. Still, I answered with a hesitant, “Yes, a little.”

Ms. Alam’s son raised his hands in the air and said, “Glory to Allah, a woman physician who speaks Arabic.” He quickly shifted over for me to join them at the bedside. Muslims, he asserted, believe in divine predestination. The Almighty had placed me in his journey on purpose. He described his mother’s illness: For more than a year, she had been struggling with vague symptoms—abdominal discomfort, bloating, and weight loss. Finally, the doctors discovered that she had terminal ovarian cancer. Ms. Alam underwent chemotherapy, radiation therapy, and debulking surgery twice. She had been in pain, unable to move, and was admitted for ascites and possible infection.

“That’s God’s will,” he said.

I approached Ms. Alam and extended my hand, greeting her in Arabic. Pale, thin, and frail, she looked up and smiled. Her oblong face, angular cheekbones, and pointed chin all seemed to grimace in pain; her lips were continually pursed and had been painted a dark red in an unsuccessful effort to mask their dryness. She wore a white hijab, and her body was covered with a blanket, except for one of her swollen legs, which was wrapped in bandages with a pillow under it.

Over the following weeks, I visited with Ms. Alam every day. An educated, independent woman, she insisted on making her own decisions and knowing the details of her illness. She was modest and private, and avoided shaking hands and making eye contact with male providers. I learned she was a loving wife and mother but never displayed affection in public. She insisted on being meticulously clean, following the ritual known as Wudu—the washing of one’s face, forearms, and feet as a prerequisite to praying. She constantly prayed in her bed and slept with the Qu’ran and a rosary of wooden beads at her side. The rosary beads smelled of incense when she rubbed them with her hands.

Her pain was a challenge. She refused medicine. Fearful of addiction, she stated that enduring the pain would allow her sins to be forgiven in the hereafter. We negotiated lessening her pain while keeping her in a state of alertness so she could observe her worship rites for as long as possible.

Ms. Alam forced herself to eat a little homemade food to please her distraught family. She also sipped from a bottle of Zamzam water, obtained from the well in the Holy Mosque of Mecca. Ms. Alam remained peaceful and hopeful until her last day. She told me that Muslims do not give up hope because God, not medical science, has the power to create life and cause death.

A couple days before she died, Ms. Alam asked me for the form to donate her organs. She read me a verse in the Qur’an: “Whosever gives life to a soul shall be as though He has given life to mankind.” Unfortunately, her wish could not be granted because of her cancer diagnosis.

Ms. Alam passed away peacefully and quietly at night. Her body faced Mecca, and she was buried before sunset.

Although 15 years have passed since I cared for Ms. Alam, and I have since treated many patients from all religious and cultural backgrounds, the lessons I learned from her remain vivid. Ms. Alam taught me to be present in every moment, to approach patients with humility and awe, to open my heart and mind, and to seek knowledge about their particular belief system. Islam was not only her religion but it was also her way of life.

I hope my purpose in her journey was fulfilled.

Raya Elfadel Kheirbek, MD

Copyright © 2016 by the Association of American Medical Colleges