Fasting during Ramadan—a time of profound spiritual journey for Muslims globally and a month dedicated to fasting, prayer, and deep introspection—involves abstaining from food, drink, medications, and other physical indulgences from dawn to sunset.¹ The Islamic lunar calendar shifts Ramadan 11 days earlier each year, causing fasting durations to vary by location and season, ranging from a few hours to more than 20 hours daily. In 2025, Ramadan was expected to begin on February 28 or March 1.²

Islamic teachings prioritize health and grant exemptions to those for whom fasting poses a risk, including travelers, pregnant or breastfeeding women, menstruating women, and individuals with acute or chronic illnesses.³ Despite these allowances, many individuals with chronic conditions, such as diabetes or cardiovascular disease, choose to fast, often modifying medication regimens or delaying treatment, which can exacerbate health risks.

Islamic jurisprudence permits alternatives for those unable to fast, such as fasting later or feeding the needy:⁴ “And anyone who is ill or on a journey should make up for the lost days by fasting on other days later. God wants ease for you, not hardship” (Quran 2:185). Recognizing these provisions helps emergency physicians respect patients’ spiritual beliefs while ensuring appropriate care.

Common Emergency Presentations During Ramadan

Fasting can exacerbate chronic conditions or trigger acute medical emergencies. Common emergency department (ED) presentations include:

• Dehydration and electrolyte imbalances.
• Glycemic emergencies: Altered medication regimens or dietary patterns may lead to hypoglycemia, hyperglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic states.
• Syncope and orthostatic hypotension: Reduced caloric and fluid intake can cause syncopal episodes, particularly in elderly or patients with cardiovascular compromise.
• Exacerbation of chronic conditions: Patients with heart failure, chronic kidney disease, or other illnesses may experience worsening symptoms due to dietary and fluid restrictions.

Ethical Dilemmas

Critically ill patients may refuse interventions, such as intravenous fluids or emergency medications, to maintain their fast. Although Islamic teachings prioritize the preservation of life and permit breaking the fast in life-threatening situations, some patients view hardship as spiritually rewarding.

Emergency physicians can navigate these challenges by:

• Engaging in compassionate dialogue: Use culturally sensitive language to explain the necessity of interventions and the religious permissibility of breaking the fast to protect health.
• Involving family and religious leaders: Seek support from family members or spiritual advisors to reassure patients.
• Providing alternatives: Emergency physicians can reassure fasting patients that certain medications and procedures do not invalidate fasting, including:^5,6
  • Medications:
    • sublingual medications or lozenges (excluding nicotine gum)
    • topical medications, creams, and ointments
    • oxygen supplementation
    • vaccinations (excluding oral vaccines)
    • metered-dose inhalers (excluding nebulizers)
    • contrast dye for imaging (excluding oral contrast)
    • injected medications (intramuscular, intravenous or subcutaneous; excluding fluids, glucose, or electrolytes)
    • insulin therapy
  • Procedures:
    • nasal packing
    • pelvic exams
    • foley catheter insertion
    • endoscopy

Beyond Ramadan

Although Ramadan is the primary fasting period, many Muslims fast at other times, such as the six days of Shawwal (immediately after Ramadan), weekly fasts on Mondays and Thursdays, and specific religious occasions.⁴ These practices mean fasting patients may present to the ED year-round. Maintaining cultural humility and applying empathetic care ensures consistent, high-quality care for Muslim patients at any time.⁷

Conclusion

Ramadan presents unique challenges and opportunities for emergency physicians to deliver culturally sensitive care. Key considerations include:

• Recognizing common health risks, such as dehydration, glycemic emergencies, and exacerbation of chronic conditions.
• Respecting patients’ spiritual beliefs while prioritizing health and safety.
• Addressing ethical dilemmas with empathy, shared decision-making, and culturally appropriate communication.
• Preparing for year-round fasting practices among Muslim patients.

By integrating cultural humility into clinical practice, emergency physicians can enhance the quality of care for patients, fostering trust and promoting health equity.

Dr. Hagahmed is clinical assistant professor of Emergency Medicine at the University of Pittsburgh Medical Center in Pittsburgh, Penn. He is also the department’s director for diversity, recruitment, and relations, and EMS medical director, and the associate medical director for the Center for Emergency Medicine.

Dr. Abubshait is a clinical assistant professor of emergency Medicine at Thomas Jefferson University in Philadelphia, Penn. She is also the Associate Program Director of the Emergency Medicine residency program at Jefferson Einstein Montgomery Hospital.

References

1. Islamic World. Nations Online Project. Published January 7, 2025. Accessed January 10, 2025.
2. Ramadan 2015: Facts, History, Dates, Greeting, And Rules About The Muslim Fast Archived 10 July 2015 at the Wayback Machine. Huffington Post. June 15, 2015. Accessed January 10, 2025.
3. El-Kholi EB, Al Siyam. Fasting. Cairo: The Supreme Council for Islamic Affairs, Arab Republic of Egypt:36.
4. Mubārakpūrī, SR. When the Moon Split: A Biography of the Prophet Muhammad. Riyadh: Darussalam. 1998:32.
5. Al-Munajjid SM. He Needs to Have an Injection into a Vein – Will that Affect His Fast? Islam QA. Accessed January 10, 2025.
6. Al-Munajjid SM. Types of Asthma Medication and the Ruling on Taking Them during the Day in Ramadan. Islam QA. Accessed January 10, 2025.
7. Mohamed B. New estimates show U.S. Muslim population continues to grow. Pew Research Center. January 3, 2018. Accessed January 7, 2025.