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A Man with Colorectal Cancer Having an Intestinal Stoma: Religious Perspectives
Khairunnisa Che Ghazali*, Karthigesu Aimanan, Aisah Munirah Wahi and Ahmad Junaidi Ahmad Hamidi
Department of General Surgery, Hospital Miri, Sarawak, Malaysia
Received Date: 07/05/2024; Published Date: 27/09/2024
*Corresponding author: Dr. Khairunnisa Che Ghazali, Department of General Surgery, Hospital Miri, Jalan Cahaya, 98000 Miri, Sarawak, Malaysia
https://orcid.org/0000-0003-0990-5060
Abstract
Living with an intestinal stoma is not easy. Whether it is for temporary or permanent purpose, performing religious practice while having an intestinal stoma can be the utmost challenges to the patient from the physical, mental and spiritual aspects. A proper, comprehensive preoperative counselling regarding stoma creation and its care is vital to ensure patient’s acceptance and accordance to the treatment. While postoperative guidance on stoma care is paramount to ensure cleanliness and prevent further complications. Hence, the religious practice can be performed without any doubt or significant adverse effect after stoma surgery.
Keywords: Colostomy; Ileostomy; Religion; Spirituality
Introduction
Colorectal Cancer (CRC) is the most common cancer in Malaysia, based on our Malaysian National Cancer Registry Report 2012-2016. For CRC survivors, some of them living with intestinal stoma either temporarily or permanently. Being a Muslim country, where Islam is the constitutionally the country’s official religion, 60% are Muslims out of 31 million populations. Unfortunately, these are the group of people who had been tested with malignancy. As a Muslim, we are obligated to perform religious practice particularly five daily obligatory prayer. This act of worship requires us to be in a clean state prior performing Solah. Having an intestinal stoma, where you can literally see normal physiological process of defecation and feces coming out, makes Muslim people wonders whether this is considered as najasat (ritual impurity) or not. Hence, this issue casts a doubt about the acceptance of their acts of worship by God. Therefore, we are looking at evidence from religious perspective, based on concessions from few Fatwa Conferences, the highest religious authority bodies across globally.
Case Summary
Mr MD is a 52 years old gentleman, who works as an Imam in a mosque in his village. He presented with a complaint of altered bowel habit for 6 months duration, associated with occasional per rectal bleed and constitutional symptoms. There were no symptoms of intestinal obstruction. Clinically he was a thin built gentleman with a BMI of 18.5kg/m2. Per abdomen was soft and no mass palpable. Other systematic examinations were unremarkable.
He underwent colonoscopy investigation and showed a fungating mass at the upper rectum, 15cm from the anal verge. The colonoscope can be passed beyond it and there was no synchronous tumour up to caecum. Biopsy was taken and reported as well differentiated adenocarcinoma. Computed Tomography (CT) of the thorax, abdomen and pelvis showed no distant metastases. Magnetic Resonance Imaging (MRI) of the pelvis showed T2N1 tumour.
He refused for surgery and later defaulted treatment. After a year, he presented again with similar complaints. Now he had passed small, pellet-like stool with mucus and blood. There was no vomiting, abdominal pain or distension. A repeat CT scan showed presence of liver metastasis and MRI pelvis showed T4N2 tumour.
He was planned for trephine colostomy before neoadjuvant concurrent chemoradiotherapy. Initially he refused for surgery with a reason of it will disturb his works and claimed that it will be difficult to perform the religious practice (particularly concern about ablution and performing prayers). After details explanation and counselling regarding intestinal stoma, he agreed for the procedure. Postoperative recovery was uneventful. He was able to manage the stoma after teaching and guidance from the stoma care nurses.
(Patient consented the illustration of his case as an example for the purpose of education and academic discussion).
Discussion
Colorectal Cancer (CRC) is one of the commonest malignancies affecting whole world society. In Malaysia, it become the first common cancer in males and in females as third most common cancer [1]. Treatment plan in the management of CRC might include creation of intestinal stoma, either colostomy or ileostomy. Its indications and timing of stoma creation varies, depending on patient’s condition, stage of the disease and treatment plan. This therapeutic method can either be momentary or permanent. Hence, it has makes patients encounter challenges in terms of functioning and quality of life [2].
Intestinal stoma may affect individuals, family, and social life. It also somehow affects routine of religious obligations [3]. In a matter of fact, religion plays a role in patient’s acceptance of the treatment but also his/her post treatment lifestyle [3]. In a systemic review study by Iqbal et al, after surgically created ostomy, quality of life in Muslim patients significantly affected, and it also causing diminished religious practice. In extreme end, some patient refused surgery despite diagnosis of colorectal cancer [4]. As per highlighted in our case summary, this is the example of how a Muslim patient perceived creation of ostomy might cause disturbance in performing daily prayer and affect quality of life generally.
Islam teaches us great importance of cleanliness. Muslims are obliged to cleanse their bodies and perform ablution before each prayer [3]. Ileostomy output is clean and considered like a stomach content, thus it does not nullify the ablution [5]. However, colostomy output is considered dirty and must be dispensed carefully. The uncontrolled passing of faeces or flatus from the colostomy negates the ablution which leads patient to stop the rituals while praying at the mosque or even alone [5]. Cavdar et al found that routine of fasting and praying reduced among Muslim Turkish patient after stoma creation. It showed that ostomates have doubt to perform religious duties or worship [3,4].
It is understandable that our patient is in dilemma before agreeing to underwent stoma surgery as he anticipates experiencing problems in maintaining purity while performing prayers, resulting in disturbance his daily works as an imam (muslim priest/leader) at the mosque and eventually leads to spiritual discomfort. Although few studies have demonstrated that stoma is not having a significant impact on religious practice, a survey from Cavdar et al showed 71.4% of the participants stated did not performed their prayers due to unclean sentiment [3].
According to the 79th Muzakarah (Conference) of Fatwa Committee of the National Council for Islamic Religious Affairs Malaysia held on 6th to 8th September 2007, the ruling on performing acts of worship for patients using colostomy bag have decided that [6]:
- Patient using colostomy bag are categorized as those in the state of extreme necessity/emergency (darurah) and as such are not considered to carry impurities. They are not required to empty or clean their colostomy bag during ablution or prayers.
- Ablution performed by the patients can be used to perform all acts of worships including obligatory prayers until it is invalidated.
Another study has concluded that Muslim having a stoma should not cause any religious or social issues as the stoma was raised for a serious disease or suffering. According to Board of Mission Council in Indonesia, it stated that there are few options for stoma patient (ostomate) to perform ablution and prayer [5]:
- Ostomate should perform ritual ablutions every prayer time if feces came out continuously
- The ritual cleanliness status is preserved if the stoma bag is secured and its purity maintained, and feces are discharged without any intention.
- For those who are having physical troubles at the time of prayer and not capable to wash prior to a prayer session, they may wash later, perhaps after the prayer session. They are advised to perform two prayers at a time except for the dawn prayer.
- If prostration (sujud) is challenging due to stoma, the ostomate can sit, lie, gesture or adopt other positions whereby they can carry out their prayer obligations to the best of their ability.
- Pilgrimage for stoma patients should be done in the normal way as afar as possible.
Conclusion
Religious acts of worship can be performed for patients who are on intestinal stoma. A detail and comprehensive pre-operative counselling are important for the patients to ensure they fully understand and adhere to the treatment plan. Postoperative stoma care and cleanliness is important in which patients can perform religious practice without worry or doubt, after stoma surgery, as stoma content will not nullify the purity of ablution and solah (prayer).
Conflict of interest: None
Funding: None
References
- Veettil SK, Lim KG, Chaiyakunapruk N, Ching SM, Abu Hassan MR. Colorectal cancer in Malaysia: Its burden and implications for a multiethnic country. Asian Journal of Surgery, 2017; 40(6): 481-489. doi: 10.1016/j.asjsur.2016.07.005.
- Dabirian A, Yaghmaei F, Rassouli M, Tafreshi MZ. Quality of life in ostomy patients: A qualitative study. Patient Preference and Adherence, 2010; 5: 1-5. doi:10.2147/PPA.S14508
- Ikbal Cavdar, Ayfer Ozbas, Nuray Akyuz, Ummu Yildiz Findik YK. Religious Worship in Patients with Abdominal Stoma: Praying and. International Journal of Caring Sciences, 2013; 6(3): 516-521.
- Iqbal F, Kujan O, Bowley DM, Keighley MRB, Vaizey CJ. Quality of life after Ostomy surgery in Muslim patients. Journal of Wound, Ostomy and Continence Nursing, 2016; 43(4): 385-391. doi:10.1097/WON.0000000000000235.
- Black P. Understanding religious beliefs of patients needing a stoma. Gastrointestinal Nursing. 2011;9(10):17-22. doi: 10.12968/gasn.2011.9.10.17.
- Jabatan Kemajuan Islam Malaysia. The Ruling on Performing Acts of Worship for Patient Using Colostomy Bag. 79th Muzakarah of Fatwa Committee of the National Council for Islamic Religious Affairs Malaysia, 2007.
