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Ethical considerations on advance directives: an overview of the ethical and legal aspects in the context of Islamic teachings
Jannat Mashayekhi, Mansure Madani, Saeedeh Saeedi Tehrani,
Volume 8, Issue 3 (9-2015)
Abstract

According to the principle of respect for autonomy, which is one of the essential precepts of medical ethics, patients are entitled to the right of self-determination for a hypothetical future when they may lose the decision-making capacity. Thus, when still adequately competent to make decisions, a person can prepare a document and predict their therapeutic options and state their wishes for the possible time of lack of decision making capacity, or assign a surrogate who will make the best decision considering the attitudes and interests of the patient. This document, called advance directive, has advantages and disadvantages, and has been investigated from different perspectives. The present study addresses this new issue through non-systematic internet and library review of resources, and aims to investigate some aspects of this subject and examine the possibility of its naturalization from certain viewpoints, particularly from the Islamic perspective. In Islam, life is highly respected and physicians are obliged to do their best to protect human life. In cases where patients refuse the suggested treatments, even when it harms them fundamentally, the physician is obliged to respect their wishes for several reasons. Nevertheless, physicians should avoid any direct measure that may end up in the patient’s death. As regards advance directives, the patient no longer has the capacity to make decisions and has done so formerly, which may be in conflict with the physician’s responsibility to save the patient’s life under present circumstances. In such cases, despite a preliminary injunction, there is no reason to extend the patient's right to the time of their consciousness. Therefore, based on the religious principles observed in Iran, acting on the patient's previous decisions can only be valid as long as they do not conflict with the physician’s responsibilities. Furthermore, advance directives currently do not have a place in our legal system and the recognition of such documents is contingent upon further studies, including legal and cultural reviews.


Exploring Advance Directives and End-of-Life Preferences in Heart Failure Patients: A Systematic Review and Meta-Analysis
Aydin Feyzi, Amirali Soheili, Samira Chaibakhsh, Fidan Shabani, Shiva Khaleghparast,
Volume 17, Issue 0 (12-2024)
Abstract
Advance directives (ADs) are legal instruments that enable individuals to express their healthcare preferences in anticipation of a future loss of decision-making capacity. These directives are particularly important in the context of chronic conditions such as heart failure (HF), a disease marked by progressive functional decline and unpredictable medical crises. ADs help safeguard patient autonomy by ensuring that care aligns with personal values and preferences, especially at the end of life. This systematic review and meta-analysis was conducted in accordance with PRISMA guidelines to examine the preferences of patients with heart failure regarding life-sustaining treatments and end-of-life decision-making. A comprehensive literature search was performed across PubMed, Scopus, and Web of Science databases, covering publications up to March 2024. Search terms included "advance directive," "advance care planning," "heart failure," and "end-of-life decision-making." Studies were included if they were original, peer-reviewed, full-text articles focusing on HF patients aged 18 and older. Non-peer-reviewed works and inaccessible full texts were excluded. A total of 25 eligible studies were identified and appraised using the NIH quality assessment tool. Extracted data included demographic characteristics, preferences for treatment, surrogate decision-making, and educational interventions. Findings from the reviewed literature reveal consistently low levels of awareness and completion of ADs among HF patients. Completion rates varied significantly across studies, reflecting potential cultural and systemic influences. Preferences for surrogate decision-makers overwhelmingly favored family members over healthcare professionals. A notable finding from Jawahri et al. (2016) indicated that patients who received video-based education were significantly less inclined to choose cardiopulmonary resuscitation (CPR) or mechanical ventilation compared to those receiving only verbal information. Additional qualitative insights, such as those from Formiga et al. (2004), showed that patients prioritized maintaining dignity, independence, and meaningful relationships over merely extending life. These patterns highlight the necessity of aligning care with patients’ broader goals and values. Across the 25 studies included, a total of 4,091 heart failure patients were analyzed, with a mean age of 68.22 years. Meta-analytic findings demonstrated diverse preferences regarding life-sustaining interventions: approximately 53.73% of patients favored such treatments, while 45.37% declined CPR. These statistics underscore a substantial variability in end-of-life preferences, further reinforcing the need for individualized care planning. In conclusion, patients with heart failure display heterogeneous preferences concerning end-of-life care, shaped by cultural context, personal values, and the type of information provided. Despite the established importance of ADs, significant deficits in awareness, understanding, and documentation persist. These findings point to a critical need for tailored educational interventions, improved provider-patient communication, and culturally sensitive approaches to advance care planning. Future research should focus on designing and integrating standardized AD facilitation tools into routine clinical practice to support truly patient-centered care.

Is it Possible to apply an Advance Directive in Iran’s Health System?
Amin Arman, Mina Mobasher, Mohammad Aminizadeh,
Volume 17, Issue 1 (3-2024)
Abstract

Deciding on whether to continue life-prolonging treatments for terminal patients is a major challenge in healthcare. Advance directive emerges as a proposed solution to this issue in the world. The patients record their preferences regarding the continuation of life-prolonging treatments while they still are able to make decisions. Although advance directive is morally justifiable from the perspective of principlism, respecting the patient’s right to autonomy and assessing the benefits and drawbacks of providing such services, the religious beliefs of patients, their families, and healthcare providers always exert a significant influence on this matter. In Islam, preserving human life heavily affects these decisions. Several juridical and legal rules can culminate in different decisions on the continuation or termination of life-prolonging treatments including the absolute legal power of the owner to exercise dominion[1] or control over property and permission of intervention in their body[2], the rules of prohibition on causing the death[3], the sanctity of human killing[4], the rule of prohibition of detriment[5], the concept of unstable life[6] in Article 372 of the Islamic Penal Code and the rules of preventing losses[7], and the rule of sanctity of idle[8]. Nevertheless, given various types of will in Islamic Jurisprudence and according to the contract of agreement[9], it is possible to record the patient’s request regarding how to continue the treatment. This study indicated that implementing advance directives in Iran’s health system requires a more accurate analysis of moral, legal, and jurisprudential foundations.

 
[1] (tasli¯t)
[2] (ezn dar tasarof)
[3](nafy al-d.arar )
[4] (Hormat Ghatl)
[5] (la¯ d.arar wa la¯ d.ira¯r fi¯ al-isla¯m)
[6] (Ghayr-Mustaqarr)
[7] (‘usr wa al-h. araj, al-)
[8] (hormat laghw)
[9] (agde solh)
[1]. (tasli¯t)
[2]. (ezn dar tasarof)
[3]. (nafy al-d.arar )
[4]. (Hormat Ghatl)
[5]. (la¯ d.arar wa la¯ d.ira¯r fi¯ al-isla¯m)
[6]. (Ghayr-Mustaqarr)
[7]. (‘usr wa al-h. araj, al-)
[8]. (hormat laghw)
[9]. (agde solh)

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