Ramadan and the Emergency Department: Compassionate Care for Fasting Patients

The holy month of Ramadan is a sacred time during which millions of Muslims worldwide embark on a profound spiritual journey marked by fasting, prayer, and reflection. In the emergency department, this period presents unique challenges and opportunities for health care providers.

Fasting can impact the health of patients with chronic or acute conditions, making it essential for emergency clinicians to navigate both the medical and cultural dimensions of care. By understanding the practices and significance of Ramadan, clinicians can ensure compassionate, respectful, and effective treatment for Muslim patients, even in critical moments.

Islam and the Holy Month of Ramadan

Ramadan, the ninth month of the Islamic lunar calendar, is a sacred time of spiritual devotion, worship, discipline, and self-restraint from worldly activities.¹ It marks the period when the Prophet Muhammad is believed to have received the first revelations of the Quran, Islam's holy scripture.¹ Fasting during the month of Ramadan is one of the Five Pillars of Islam, which are the foundation of a Muslim’s faith and practice. The other pillars include the declaration of faith (Shahada), performing five daily prayers (Salah), giving to the poor (Zakat), and undertaking the pilgrimage to Mecca (Hajj) once in a lifetime, provided one is physically and financially able.² 

The observance of Ramadan begins and ends with the sighting of the crescent moon, symbolizing the start and conclusion of the month.³ This year, Ramadan is projected to start on Feb. 28, 2025. Because the Islamic lunar calendar is shorter than the solar calendar by approximately 10–12 days, Ramadan shifts earlier each year, cycling through all seasons over a 33-year period.^2,3 This progression introduces unique challenges, as fasting during the summer months can be particularly difficult due to longer daylight hours, whereas fasting in winter is often more manageable.⁴

During Ramadan, Muslims refrain from eating, drinking, smoking, and sexual activity from sunrise to sunset; this often includes refraining from taking medications.² A typical day in Ramadan is centered around fasting, prayer, reflection, and community. It begins with Suhoor, a pre-dawn meal, followed by the morning prayer, Fajr. Muslims then fast from dawn to sunset, abstaining from food, drink, and other physical needs, while focusing on spiritual growth, patience, and charity. During the day, prayer, Quran recitation, and acts of kindness are emphasized.

The fast is broken at sunset with Iftar, often starting with dates and water, followed by a communal meal with family and friends. The evening concludes with the Tarawih prayers, special nightly prayers performed in local congregation, often at the local mosque.

Ramadan concludes with the holiday of Eid al-Fitr, during which Muslims gather for a morning prayer, food, and gifts. However, emergency clinicians should be aware that some Muslims may continue fasting for six additional days after Ramadan.⁵ This is because, according to Islamic tradition, these six days, combined with the Ramadan fast, are considered equivalent to fasting the entire year.⁵ Additionally, many Muslims adhere to the tradition (Sunna) of the Prophet Muhammad by fasting on Mondays and Thursdays throughout the year.¹ Consequently, emergency clinicians may encounter fasting patients even if it is not Ramadan.¹

Exemptions to fasting 

In the event of a health emergency, Muslims are permitted to break their fast, as fasting is intended to be a spiritual challenge rather than a risk to one’s health; fasting that poses a danger to health is not in accordance with Islamic teachings.^1,6 However, it is important to recognize that although Islam is a flexible religion, some Muslims may still choose to fast despite being ill.^2,7 Those who are pre-pubescent, elderly, pregnant, breastfeeding, ill, traveling, menstruating, or have medical conditions that make fasting harmful are exempt.^2,8,9 Under these conditions, one can either make up the fast later or feed the needy as a charitable expiation.⁶

Considerations for the Emergency Clinician 

When providing care to a fasting patient, emergency physicians should carefully consider several key factors including dehydration, diabetes, pregnancy or breastfeeding, and medication management. 

Dehydration

Fasting patients visiting the ED during Ramadan may present with dehydration, especially when fasting during longer, hotter summer days. Dehydration can manifest as headaches, fatigue, or hypotension. In such cases, emergency physicians should recognize that interventions like intravenous fluid hydration and enteric medications (eg, oral acetaminophen) will invalidate the fast, which may be a concern for the patient (medications are covered in “Medications in the Emergency Department”).

Diabetes

Recent studies indicate that individuals with chronic conditions, such as diabetes, asthma, hypertension, and renal failure, often adjust or discontinue their treatment regimens during Ramadan without consulting their healthcare providers.^10,11 A recent study found that Muslim patients with diabetes are hesitant to report self-directed changes in medication due to feelings of vulnerability and being misunderstood by their providers.¹² As a result, patients may present to the ED with serious conditions, such as hypoglycemia, hyperglycemia, or electrolyte derangements. In these cases, it is essential for ED clinicians to engage in empathetic discussions with patients and their families about the risks and benefits of interventions that may provide relief but invalidate the fast. 

Pregnancy and Breastfeeding

Research shows that most pregnant Muslim women do not consult with their physicians before deciding to fast during pregnancy.¹³ Approximately 88% of pregnant Muslim women choose to fast during Ramadan, with a higher incidence among immigrant women when compared to U.S.-born.¹⁴ Although pregnant and breastfeeding women are exempt, many still chose to fast to meet their spiritual needs. However, many remain flexible and may discontinue fasting if health issues arise, aligning with Islamic principles of avoiding harm.¹⁴ Breastfeeding is another exemption to fasting, as it may affect milk supply and micronutrients, which can also lead to unwanted stress and in some cases decrease milk supply.^8,9 

Medications in the Emergency Department

Several medications could invalidate a fast, including any enteric medication, IV fluids, nebulized medications, and blood transfusion. Generally, medications administered intravenously (IV), intramuscularly (IM), or subcutaneously (SubQ) are permissible and do not invalidate the fast (see Table 1 for exemptions), thus medication routes should be adjusted when possible.¹ 

Although challenging in the emergency department, patients on chronic medications could benefit from adjusting their schedules to coincide with non-fasting hours.¹⁶ Consideration of long-acting formulations (eg, sustained-release) or altering dosing regimens to once or twice daily may help optimize medication management during fasting periods.¹⁶ It is important to advise patients to consult their primary care doctors, as they may need guidance not only on modifying their medications but also on making lifestyle adjustments to mitigate potential health risks during fasting.

Table 1. Acceptable medications during Ramadan fasting

Table 2. Acceptable procedures relative to Ramadan observance

Adapted from ALiEM's Emergency Medications and Procedures that are Permitted while Fasting.

Practical Advice to the Emergency Clinician

Many Muslims, even when faced with medical conditions that may endanger their health, may still choose to fast.^2,7 Barriers to discussing fasting include negative past experiences, fear of disrespect, or blanket prohibitions without culturally sensitive explanations.¹⁵ In these situations, it is essential for emergency clinicians to approach patients with humility, empathy, and compassion, fostering trust and enhancing the patient-physician relationship.¹⁷ 

Interventions such as enteric medications, IV fluids, or blood transfusions invalidate fasting, but may be medically necessary and should be approached through shared decision-making and empathy.¹ A gentle reminder that breaking the fast for health reasons is permissible and can be compensated later can help build trust and support the delivery of optimal care.¹ Furthermore, encouraging adequate nutrient intake and hydration during the pre-dawn and evening meals (Suhoor and Iftar, respectively) may help prevent myriad conditions including dehydration, lightheadedness, syncope, electrolyte derangement, and hypoglycemia.

By understanding Islamic beliefs and recognizing how religious practices shape the lives and health behaviors of Muslim patients, clinicians can foster trust, improve communication, and provide culturally sensitive and medically effective care.¹⁷ This approach enhances the patient-physician relationship and ensures that patients feel respected and supported in their health care decisions, ultimately contributing to better health outcomes and a more inclusive environment.

TAKE-HOME POINTS 

• During the month of Ramadan, many Muslims fast from sunrise to sunset, which may include altering or discontinuing medication plans.
• Muslim patients experienced higher rates of ED visits during Ramadan.
• Fasting that poses a danger to health is not in accordance with Islamic jurisprudence, and those with chronic illness are exempt from fasting. However, many may still choose to fast. 
• Patients are more likely to follow the advice from providers who are understanding and knowledgeable about their religious practices.
• Compassion, respect, and understanding of Ramadan can foster trust and contribute to better health outcomes.

References

1. AliEM. Caring for the Fasting Patient. Available from: https://www.aliem.com/caring-for-the-fasting-pt/. Accessed 18 Jan 2025.
2. Ezenkwele UA, Roodsari GS. Cultural competencies in emergency medicine: caring for Muslim-American patients from the Middle East. J Emerg Med. 2013;45(2):168-74. 
3. Encyclopaedia Britannica. Ramadan. Available from: https://www.britannica.com/topic/Ramadan. Accessed 18 Jan 2025.
4. Suha Al-Oballi K. Health beliefs and practices of Muslim women during Ramadan. Am J Matern Child Nurs. 2011;36:216–21.
5. Global Sadaqah. Fasting in Shawwal: Why It’s Important. Available from: https://blog.globalsadaqah.com/fasting-shawwal/. Accessed 18 Jan 2025.
6. Brandeis University. Guide to Observances: Ramadan. Available from: https://www.brandeis.edu/spiritual-life/resources/guide-to-observances/ramadan.html. Accessed 18 Jan 2025.
7. Hammoud MM, White CB, Fetters MD. Opening cultural doors: providing culturally sensitive healthcare to Arab American and American Muslim patients. Am J Obstet Gynecol. 2005;193(4):1307-11. 
8. Human Milk Foundation. Ramadan fasting and breastfeeding [Internet]. [cited 2025 Jan 22]. Available from: https://humanmilkfoundation.org/ramadan-fasting-and-breastfeeding
9. Rakicioğlu N, Samur G, Topçu A, Topçu AA. The effect of Ramadan on maternal nutrition and composition of breast milk. Pediatr Int. 2006;48(3):278-283. 
10. Alshehri AM, Barner JC, Wong SL, Ibrahim KR, Qureshi S. Perceptions among Muslims regarding fasting, medication use, and provider engagement during Ramadan in the United States. Int J Health Plan Manag. 2021;36(3):945-57. 
11. Bouchareb S, Chrifou R, Bourik Z, et al. “I am my own doctor”: a qualitative study of the perspectives and decision-making process of Muslims with diabetes on Ramadan fasting. PLoS One. 2022;17:e0263088. 
12. Myers PR, Shoqirat N, Allen DH, Dardas LA. Patients with diabetes observing Ramadan: the experience of Muslims in the United States. Diabetes Res Clin Pract. 2019;150:282-7. 
13. Lou A, Hammoud M. Muslim patients’ expectations and attitudes about Ramadan fasting during pregnancy. Int J Gynecol Obstet. 2016;132(3):321-4. 
14. Shahawy S, Al Kassab L, Rattani A. Ramadan fasting and pregnancy: an evidence-based guide for the obstetrician. Am J Obstet Gynecol. 2023;228(6):689-695. 
15. Robinson T, Raisler J. “Each one is a doctor for herself”: Ramadan fasting among pregnant Muslim women in the United States. Ethn Dis. 2005;15(Suppl 1):S1-99.
16. University of Washington School of Pharmacy. Ramadan and medications [Internet]. [cited 2025 Jan 22]. Available from: https://sop.washington.edu/wp-content/uploads/Ramadan-and-Medications.pdf
17. Zagloul M, Mohammed B, Abufares N, et al. Review of Muslim patient needs and its implications on healthcare delivery. J Prim Care Community Health. 2024;15:21501319241228740.