Sir: Beuks et al. [1] recently described a way to help patients choose their manner and place of death. This approach takes into account the patient's wishes, based on cultural and religious convictions. We agree that both culture and religion are major factors that influence the manner with which many patients choose to die. For this reason physicians should take into account their patients' and family's religion, culture, and wishes regarding end-of-life practices and place of death, i.e., their “deathbed” [1, 2, 3].

Muslims have a specific conception of death, and the vast majority of them desire to die at home, in their own bed, and to experience some cultural and religious rituals while surrounded by their family and friends. To achieve such a goal the health care team should help these patients go home, once physicians have determined that the patient's prognosis is hopeless.

Critically ill patients in the ICUs, however, present a special situation regarding their dying at home. Essentially, in many cases, a determination that the prognosis is hopeless, and that death is near is usually made when patients are being sustained on mechanical ventilation, the infusion of catecholamines, and other life-prolonging measures. To discharge such patients home directly from the intensive care unit would require the removal of such life-prolonging measures. We describe how the death of such critically ill patients can be managed at home, according to their and their family's wishes, once medical team agrees to this decision.

A 76-year-old man with a medical history of chronic obstructive pulmonary disease, arterial hypertension, and congestive heart failure presented to the emergency room with diffuse cerebral hemorrhage causing deep coma. His blood pressure was 160/100 mmHg and respiratory rate 36 breaths/min. The patient was intubated and ventilated (FIO2 = 70%) and was admitted to ICU. Soon after admission his blood pressure decreased to 79/40 mmHg, and electrocardiography showed an ST segment elevation in leads V1–V6. Neurological testing revealed no response to painful stimuli, fixed midposition pupils, complete ophthalmoplegia, and extensor posturing in all four limbs. Laboratory investigations showed elevated aspartate transaminase and alanine transaminase levels, increased creatine phosphokinase, and acute renal failure.

A central venous line was inserted, and dobutamine (15 μg kg–1 min–1) and noradrenaline (4 mg h–1) infusions were administered to the patient. Despite pressors the patient's blood pressure remained no more than 80/40 mmHg. We explained the severity of the illness to the family and made clear that death would occur very shortly. Subsequently the family (wife and two sons) told us that the patient wished to die at home in his own bed, and hence they asked us to discharge him home. Accordingly, after discussions with the nursing staff and after receiving a request signed by the patient's son, we called an ambulance with a medical team who took the patient home. The patient was placed in his bed with his family around him. Subsequently all resuscitation tools (mechanical ventilation, venous line, and catecholamines) were removed. The patient was given water drops in his mouth as an elderly family member whispered the Shahada (i.e., “I believe that there is no God but Allah, and that Mohammed, peace be upon him, is his slave and prophet … ”) for the patient to repeat it after him, and recited verses of the Quoran. The patient died a few minutes later, and the family was grateful to the medical team for helping them to comply with the wishes of their father.

Despite a very poor prognosis, this patient was admitted to our ICU and was initially given maximum therapeutics. Such treatments may provide some time to confirm the severity of the illness and for the medical team to discuss with and inform the family about the prognosis of the patient, to give the family some time to accept the situation, to inquire about the patient's wishes regarding the manner and place (deathbed) of his death, and to wait for the arrival of a member of the family who lives far, if necessary. The parameters on which the medical team made the determination that withdrawal of all life support was ethically appropriate included the presence of deep altered consciousness as well as severe shock and respiratory failure. The withdrawal of life support led to a quick and comfortable death. We felt comfortable with the whole process because it offered the patient the possibility to die in his own bed, as he wished, without suffering, and with all the religious and the cultural rituals. This way to die is the one that everybody wishes to experience in Muslim society.

Although our major goal is to treat and cure our patients, we strongly believe that helping them and their families to choose the circumstances of death and their “deathbed” is also a very important role of the medical team. To do this, medical transport of very severely ill patients to home and the withdrawal of all life-prolonging measures when they are on their “deathbed” surrounded by their family can be a way to satisfy the last wish of patients.