Muslim Woman Discusses End-of-life Care and Religious Traditions — Free SCA Practice Case
A Muslim woman discusses end-of-life care and religious traditions
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Ahmed Rahman
Age
72 years
Consultation Type
VideoAge
72
Caller
Fatima Rahman (Wife)
Situation
Telephone or Video Consultation.
Reason for Encounter
"Telephone call requested by the wife of a palliative patient. She wishes to discuss his ongoing care and what will happen in his final days at home."
Medical Records (Ahmed)
- ●PMH: Advanced Pancreatic Cancer with hepatic metastases. Deemed to be entering the final weeks of life. Discharged to home for Best Supportive Care.
- ●Medications: Syringe driver currently NOT in situ. Taking Oramorph 5mg PRN for pain, Haloperidol 0.5mg PRN for nausea.
- ●Allergies: NKDA.
Recent Notes
- ●3 days ago: District Nurse review. Pain well controlled. Patient is becoming increasingly sleepy and bedbound. Wife coping well with physical care but expressed anxiety about "the system."
Patient Script
For the friend playing the patient role
Character Overview: You are Fatima, Ahmed's wife of 45 years. Your husband is dying, and while you have accepted this medically, you are deeply anxious about the logistical and spiritual aspects of his death. In Islam, the moments before and immediately after death are sacred. You have specific religious duties that must be fulfilled to ensure his soul is at peace. However, you have heard horror stories from friends about doctors refusing to issue death certificates over the weekend, bodies being taken to the morgue unnecessarily, or nurses handling the deceased inappropriately. You want reassurance that your religious needs will be respected, but you are mindful that not all doctors understand Islamic traditions. You will not list your specific religious needs immediately. You will state that you have "traditional requirements" or "religious needs," and wait to see if the doctor has the cultural humility to explicitly invite you to explain them.
Consultation Flow & Responses:
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The Opening:
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If the doctor asks an open question: "Good morning, Doctor. Thank you for the call/video call. Ahmed is sleeping a lot more now. I know we are nearing the end. I wanted to talk to you because I am very anxious about what happens... when the time comes. We are practicing Muslims, and we have very strict religious traditions that need to be followed."
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Data Gathering (The Layers):
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Layer 1: The Invitation (Cultural Humility):
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If the doctor gives generic reassurance ("Don't worry, we always respect religion"): "Well, I appreciate that, but I need to know exactly how things will work. The rules are very specific."
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If the doctor actively asks you to describe your traditions/needs: "Thank you for asking. Before he passes, we need to ensure his bed faces Mecca (the Qibla). It would be beneficial if he could be facing Mecca (the Qibla) so the patient can continue to pray permitted that he is in the condition where he can do so. We will want family around to recite the Quran. We don't want him overly sedated if it can be avoided,"
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Layer 2: Post-Death Handling:
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If asked about what happens after he passes: "Once he passes, his body is sacred. We need to close his eyes and jaw immediately. He should only be handled by me, or his sons, or male nurses if absolutely necessary. We have to perform a ritual washing (Ghusl) before he is wrapped in a plain white shroud."
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Layer 3: The Bureaucratic Fear (The Urgency):
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If asked what your biggest worry is: "My biggest terror is the paperwork. In Islam, a person must be buried as quickly as possible, ideally within 24 hours. If he dies on a Friday night, I've been told we might have to wait until Monday for a doctor to sign the certificate, meaning he would have to go to a morgue. We cannot let that happen. Can you guarantee me a quick certificate?"
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Layer 4: Current Symptom Check:
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If asked how Ahmed is right now: "He is peaceful. The Oramorph is keeping the tummy pain away, and he isn't vomiting. It's just my mind that is racing."
ICE — Ideas, Concerns, Expectations
(Fatima does not volunteer these unprompted. These surface only if the candidate directly explores her perspective, e.g. "What do you think is happening?" or "What are you most worried about?")
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Ideas: Fatima understands that Ahmed is dying — she has accepted the medical reality. She does not have misconceptions about the prognosis. Her focus is entirely on ensuring the process of dying and death is handled correctly: "I know there is nothing more to be done medically. I just need to know that when the time comes, everything will go the way it should — the way our faith requires."
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Concerns: Her deepest fear is that the system will fail her at the most sacred moment — that bureaucratic delays will prevent timely burial, that unfamiliar staff will handle Ahmed's body inappropriately, or that he will be over-sedated and unable to hear the final prayers. She is also quietly worried about being alone when it happens: "What if it's the middle of the night and I'm on my own? Who do I call? Will someone actually come?"
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Expectations: She wants a concrete, step-by-step plan — not vague reassurance. She wants to know exactly who to call, what paperwork is needed, that her religious handling wishes are formally documented in Ahmed's notes, and that the Out of Hours service will be informed. She also wants to feel that the doctor genuinely understands and respects the religious dimension, not just tolerates it: "I just want someone to sit down — even on the phone — and go through it all with me properly, so I know what to do and I know it will be right."
If Asked — Medical History and Medications
(Fatima can relay information about Ahmed's medical history and medications if the candidate asks. She is well-informed as his primary carer.)
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If asked about the Oramorph (oral morphine): "He takes the Oramorph when the pain in his tummy gets bad — maybe two or three times a day now. It does seem to help. He pulls a face at the taste but he manages it. The nurse said we can give it every four hours if he needs it."
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If asked about the Haloperidol: "He has that for the sickness. He was vomiting quite a bit last week but it's settled down. He hasn't needed it for a couple of days now, but I keep it ready just in case."
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If asked about a syringe driver: "The nurse mentioned something about a pump — a syringe driver? She said if he gets to the point where he can't swallow the medicine, they would set one up. But he's still managing to take things by mouth at the moment."
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If asked about his cancer diagnosis and prognosis: "It started in his pancreas and then they found it had spread to his liver. The hospital said there was nothing more they could do — no more treatment. They sent him home about three weeks ago. They said it would be weeks, not months."
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If asked about allergies: "No, he doesn't have any allergies to medicines. They always ask that at the hospital and there's never been anything."
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If asked about the district nurse visit: "She came three days ago. She was lovely — checked him over, said the pain was well controlled. She could see he's sleeping a lot more. She told me I was doing a good job, but I think she could tell I was anxious about everything else."
Social History and Lifestyle Impact
(Fatima will share this naturally in conversation if the candidate asks about her situation, how she is coping, or what her day-to-day looks like.)
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Family and home context: Fatima and Ahmed live together in their family home. They have three adult sons — two live locally and visit most days, and one lives further away but calls regularly. Their eldest son has been staying overnight to help. The local mosque community has been supportive, bringing food and offering to sit with Ahmed so Fatima can rest. "Our boys have been wonderful. Tariq is staying with us now, sleeping in the front room. The mosque has been sending meals — I couldn't eat otherwise, I don't think."
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Impact of caring on Fatima: Fatima is Ahmed's primary carer and has been managing his medications, personal care, and meals. She is physically tired but emotionally resolute. The hardest part is not the physical care — it is the uncertainty and the weight of responsibility for getting the religious aspects right: "The washing, the feeding, the medicines — I can do all of that. I've looked after him for 45 years. It's the other thing that keeps me awake — making sure everything is in place for when it happens. I lie there at night going over it in my head."
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If asked whether she is looking after herself: "I'm not sleeping well, but I don't think anyone would in my position. The boys make sure I eat. I'm alright — I just need to get this sorted so I can stop worrying."
If Asked — Associated Symptoms
(These reflect symptoms the candidate should enquire about regarding Ahmed's current condition in the final weeks of life. Fatima can report on what she has observed as his carer. All responses are in Fatima's voice.)
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If asked about his breathing: "His breathing has changed a bit — it's a bit noisier sometimes, especially when he's deeply asleep. Not like he's struggling, more like a rattling sound. The nurse said that can happen."
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If asked about confusion or agitation: "He's not confused exactly, but he does say odd things sometimes — he called me by his mother's name yesterday. He's not agitated though, he's calm."
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If asked about his appetite or eating: "He's barely eating now. He'll take a few sips of water or tea, and maybe a spoonful of yoghurt, but that's about it. I've stopped trying to push food — the nurse said not to force it."
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If asked about his urine output or continence: "He's passing very little urine now. I've got pads on the bed. He hasn't had a proper wet pad in about a day and a half. He hasn't opened his bowels for four or five days either."
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If asked about his skin or pressure areas: "I turn him every few hours like the nurse showed me. His skin looks alright to me — no sores that I can see. He's very thin though."
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If asked about swallowing: "He can still swallow if I give him small sips, but he does cough a little sometimes. I'm careful with the Oramorph — I give it slowly with the syringe."
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If asked about pain (beyond what is in Layer 4): "The pain has actually been better these last few days. He winces sometimes when I turn him but he doesn't cry out. He was in a lot more pain a couple of weeks ago."
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If asked about fever or temperature: "He doesn't feel hot to me. I haven't been taking his temperature, but he doesn't seem feverish."
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If asked about any bleeding: "No, nothing like that. No blood anywhere."
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If asked about oedema or swelling: "His ankles are a bit puffy and his tummy has got bigger — I think the nurse said that was fluid. But it doesn't seem to be bothering him."
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If asked about mood or emotional state: "When he's awake, he's peaceful. He held my hand yesterday and said he was ready. That was hard to hear, but I'm grateful he's not frightened."
Negotiation & Collaborative Management Plan:
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If the Doctor promises a "guaranteed" certificate on a weekend without explaining the Out of Hours system:
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Reaction: "But you won't be working on Sunday, Doctor. How can you guarantee it? Who actually signs it?" (Testing the doctor's knowledge of the OOH palliative handover).
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If the Doctor explains the Special Patient Note / Out of Hours Handover and the Medical Examiner system:
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Reaction: "So you will put a note on his digital file today that the Out of Hours doctors can see? And you will state that he needs an expedited certificate for urgent religious burial? That makes me feel so much better."
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If the Doctor asks to document the handling wishes in an Advance Care Plan / ReSPECT form:
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Reaction: "Yes, please write down that only male staff or myself should handle him after he passes, and that the family must be called immediately. If that is in his official notes, I can finally sleep at night."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Recognising the Actively Dying Phase
Identifying that a patient has entered the final hours to days of life is a core clinical skill in palliative care. The following signs, taken together, indicate the actively dying phase:
- ●Markedly reduced oral intake — the patient is taking only sips; anorexia at end of life is physiological, not a sign of treatable cause
- ●Reduced urine output — oliguria or near-anuria reflects shutting down of renal perfusion, not dehydration requiring IV fluids
- ●Increased somnolence and difficulty rousing — progressive drowsiness is normal; distinguish from opioid toxicity by checking for myoclonus or pin-point pupils
- ●Noisy, irregular breathing — Cheyne-Stokes or gurgling respirations indicate loss of pharyngeal tone and pooling of secretions; not a sign of distress to the patient
- ●Mild terminal confusion — disorientation, misidentifying family members, and restlessness are common; assess for reversible causes (urinary retention, pain, constipation) but avoid over-investigation
- ●Peripheral mottling and cooling — a late sign, often appearing hours before death
When these signs are present together, communicate the likely prognosis to the family sensitively and honestly — 'hours to days' is more useful than vague language such as 'things are getting worse.'
Anticipatory Prescribing and Syringe Driver Planning
When a patient in the final days of life can no longer reliably swallow oral medications, there must be a clear plan in place before that point is reached.
- ●Anticipatory medicines should be prescribed and kept in the home in advance, so that the district nurse can administer them promptly without waiting for a new prescription. The standard set covers four symptom domains:
- ●Pain: subcutaneous morphine (or diamorphine) — dose calculated from existing oral morphine requirement
- ●Breathlessness/agitation: subcutaneous midazolam
- ●Respiratory secretions (death rattle): subcutaneous hyoscine butylbromide (Buscopan)
- ●Nausea: subcutaneous haloperidol or levomepromazine
- ●Syringe driver (CSCI): when breakthrough doses are required frequently (typically three or more times in 24 hours), or when the oral route is lost, a continuous subcutaneous infusion should be commenced. The district nurse can initiate this without a further GP visit if anticipatory prescriptions are already written
- ●Ensure the family understands what the syringe driver is and is not — it is a comfort measure, not a form of euthanasia. This misconception is common and causes significant distress if not pre-emptively addressed
Managing the Death Rattle (Terminal Respiratory Secretions)
Noisy, gurgling breathing — the 'death rattle' — is caused by pooling of oropharyngeal secretions in a patient who has lost the ability to swallow or cough effectively.
- ●It is not a sign of distress or suffocation to the patient — reassure the family clearly and explicitly
- ●Repositioning (turning onto the side) may reduce the sound by allowing passive drainage; this is the first-line intervention
- ●Hyoscine butylbromide (Buscopan) 20 mg subcutaneously reduces secretion production; it will not clear existing secretions but prevents further pooling. It has no sedative effect
- ●Suctioning is not appropriate in this setting — it is distressing, ineffective for deep secretions, and not in keeping with comfort-focused care
- ●The primary management is family support and reassurance, not pharmacological intervention
Balancing Symptom Control with the Family's Spiritual Request
Families from many faith traditions — including Islam — may request that sedation be minimised in the final hours so that the patient can hear or participate in prayers and declarations of faith (the Shahada in Islam).
- ●This is a clinically and ethically legitimate request. Symptom control at end of life should always be titrated to the minimum dose required for comfort — not used to sedate beyond necessity
- ●In practice, if pain is well controlled and the patient is not agitated, there is often no clinical indication for midazolam at all; it should be prescribed anticipatorily but used only when needed
- ●Document this wish explicitly in the shared care record so that all professionals — including OOH GPs and district nurses — are aware. A verbal agreement with the usual GP is not sufficient
- ●If agitation does develop and medication is required, explain to the family that the goal remains comfort, and that a dose titrated to symptom control is not the same as terminal sedation
Understanding Islamic End-of-Life Traditions
- ●For many practicing Muslims, spiritual preparation for death carries equal weight to physical symptom control. Practices vary by family, culture, and individual preference — invite the family to describe their specific needs rather than assuming. Common requests include:
- ●Qibla orientation: the family may ask to reposition the bed so the patient faces Mecca. A smartphone compass is sufficient to find the direction
- ●Family presence and Quran recitation: family members will want to be present; do not restrict this
- ●The Shahada: families may request that sedating medications be minimised so the patient remains conscious enough to hear or say the Declaration of Faith as death approaches. Take this seriously as a clinical negotiation (see Section 4)
- ●Post-death handling: treat the body with complete dignity. Close the eyes and jaw gently. Only same-sex individuals should handle the body; use gloves if contact by non-family staff is necessary. The family will perform Ghusl (ritual washing) and wrap the body in a white shroud (Kafan) before burial — typically at a mosque or Islamic funeral facility
- ●Post-mortem: strongly discouraged in Islam. For an expected death from a known terminal illness, Coroner involvement and post-mortem are not indicated — this should be explicitly documented in advance to protect the family from unnecessary distress
The 24-Hour Burial Requirement and the Death Certification Pathway
Islamic tradition requires burial as soon as possible after death, ideally within 24 hours. This creates specific systemic pressures that the GP must actively anticipate and mitigate — the steps below are the same regardless of timing, but how quickly they can be completed depends entirely on when death occurs.
The certification pathway (England, from April 2024)
- ●The regular GP issues the Medical Certificate of Cause of Death (MCCD). This requires clinical familiarity with the terminal diagnosis, not physical presence at death
- ●The MCCD is reviewed by an independent Medical Examiner (ME) — now a statutory requirement in England
- ●The family registers the death at the local Register Office, which issues the green disposal certificate
- ●Burial can proceed
Key point: the Coroner is not routinely involved in an expected death from a known terminal illness. Stating otherwise to a family causes unnecessary distress.
If death occurs in hours
The most straightforward pathway. The GP can verify and certify in the same visit, and the process can often be completed within a single working day.
Death occurs → GP attends and verifies → GP issues MCCD → GP contacts ME office directly to flag urgent faith burial → ME scrutiny completed same day → Family registers death → Green certificate issued → Burial
If death occurs out of hours or over the weekend
A common misconception is that the OOH GP who attends can complete the death certificate. They cannot — their role is verification only. The MCCD can only be issued by the regular GP on the next working day. This is why advance documentation matters: it allows the certifying GP to issue the MCCD promptly on Monday morning, and allows the ME to scrutinise and release it the same day if pre-flagged.
Importantly, the body is not held pending certification — Ghusl and body preparation can proceed immediately after verification.
Death occurs (weekend) → District nurse or paramedic verifies → Body released, Ghusl can proceed → [certification runs separately] → Monday AM: regular GP issues MCCD → ME contacted directly, scrutiny expedited if pre-flagged as urgent faith death → Family registers death, emergency out-of-hours registration available → Green certificate issued → Burial
The realistic minimum for a weekend death is Monday afternoon at the earliest, more likely Tuesday. Families should be told this before the weekend — not discovered in grief on a Sunday morning.
The OOH Handover — The Single Most Important Clinical Action
The GP's responsibility does not end at the end of the working day. Creating a documented OOH safety net is the most practically important step in this consultation.
- ●Update the shared electronic palliative care record (EPaCCS, CMC, or local Special Patient Note system) on the same day. This record must be visible to OOH GPs, district nurses, and ambulance services
- ●The note should explicitly state:
- ●Diagnosis: advanced pancreatic cancer with hepatic metastases — actively dying, expected death within hours to days
- ●The patient's GP is willing to issue the MCCD; anticipated cause of death is known
- ●The patient is of Islamic faith; expedited processing of the MCCD is required for urgent 24-hour religious burial
- ●Specific handling wishes: same-sex handling only; family to perform Ghusl; body not to be moved to a public mortuary unnecessarily
- ●Anticipatory medicines prescribed and location in the home
- ●Flag to the Medical Examiner office in advance that this is an 'urgent faith death' requiring expedited scrutiny when the MCCD is submitted — many Medical Examiner offices have a pathway for this
- ●A vague verbal handover is not sufficient. The OOH GP attending a weekend death will have no recollection of a phone conversation that happened days earlier
Practical Safety-Netting: What the Family Should Do When Death Occurs
Families caring for a dying patient at home need a clear, rehearsed plan — not general reassurance. Cover the following explicitly:
- ●Do not call 999 unless there is genuine uncertainty about whether the patient has died, or unless the patient has a medical emergency inconsistent with comfort care. Calling 999 for an expected death may trigger an ambulance, police attendance, and potential Coroner involvement — the opposite of what the family needs
- ●Call the district nursing team first — they are trained to verify death and to notify the certifying GP
- ●If out of hours, call NHS 111 and state that this is a palliative patient with a Special Patient Note on the system. The 111 palliative pathway will connect them to the OOH GP who can attend to verify death. The MCCD will be completed by the regular GP on the next working day
- ●Provide or confirm the OOH contact number directly; do not leave the family to search for it at the most distressing moment
Documenting Religious and Cultural Wishes Formally
A verbal conversation — however thorough — is not sufficient. Every professional who enters the home after this call must have access to the family's wishes.
- ●Record all cultural and religious wishes in the ReSPECT form or local Advance Care Plan documentation: Qibla orientation, family presence, same-sex handling, Ghusl, expedited burial requirement
- ●Ensure this documentation is accessible on the shared record, not only in the GP system
- ●Confirm with the family that you have done this — this is often the single most reassuring thing the GP can do, because it transforms a verbal promise into a formal, system-wide commitment
Carer Support and Practical Resources
Fatima is Ahmed's primary carer and is not sleeping. Acknowledging this — and acting on it — is part of the clinical management of this case.
- ●Marie Curie Night Nursing Service — provides overnight support from trained nurses for patients in the final days of life at home; refer via district nursing team or Marie Curie directly
- ●Hospice at Home services — many areas have community palliative care teams who can provide crisis support and skilled nursing at short notice; the district nurse will know the local provision
- ●Macmillan Cancer Support — practical, financial, and emotional support for carers
- ●Fatima's fear of being alone when Ahmed dies is one of the most commonly expressed and most neglected concerns in this setting. Address it directly with both practical information and emotional acknowledgement
Mapped to the RCGP curriculum topic: People at the End of Life.
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