Hospice & Palliative Care |
The period near the end of life can involve different types of care. Palliative care is specialized support for people living with a serious illness. Hospice care is provided to a person with a terminal illness with six months or less to live. In contrast to hospice care, palliative care is not limited to a specific time or prognosis and can be used alongside curative care. Regardless of the definitions used, the goal of end-of-life care is to optimize quality of life. It also addresses not only physical symptoms, but also social, psychological, and spiritual issues. In this way, the scope of appropriate therapies is expanded beyond traditional pharmaceutical drugs. The importance of cannabinoid therapeutics in EoLC (End of Life Care) has been acknowledged through some medical cannabis programs. For example, there is a Terminal Illness Program in Illinois. The program allows patients approaching death certified by their physicians a no-cost expedited pathway to purchase and consume cannabis products from licensed dispensaries. Support for such programs is provided by evidence that the use of cannabis is associated with an improvement of many symptoms for terminally ill patients including pain, gastrointestinal, and emotional issues. Cannabinoids are available to treat nausea and vomiting associated with cancer chemotherapy and AIDS, which may be experienced at the end of life. A wide range of plant-based medical cannabis oils are also available in some countries with cannabis laws on the books.
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Palliative Care Physician Dr. B.J Miller |
To learn more about how clinicians are using cannabis in end-of-life care, this is an excerpt of an interview with Dr. Miller who is a palliative care physician and the author of A Beginner’s Guide to the End: Practical Advice for Living Life and Facing Death. He is also the former Executive Director of the Zen Hospice Project, and the current President and Counsellor at Mettle Health, a company that provides support and guidance for patients and caregivers facing serious illness.
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Question: In your experience, are patients using cannabis as part of their medical toolbox in end-of-life care? If so, how?
Dr. B.J. Miller: This depends in part on how close to the end-of-life folks are getting. In the final days and weeks, people tend to have more symptoms. They are more dependent on stronger pharmaceuticals. But over the course of a chronic illness where symptoms are less severe, I’ve pointed people to cannabis for the management of a variety of things, such as chemotherapy-related nausea, neuropathic pain, and to improve sleep. As a general statement, I have seen cannabis used more as a form of symptom control than for the treatment of severe symptoms in the period close to death. Also, how people use cannabis at the end of life depends in part on their relationship with it. For those who have used cannabis previously, they are more likely to use it during the end-of-life period. Question: Do you see cannabis being used to support mental health during the end-of-life period? BJM: Certainly. People do report cannabis can reduce symptoms of anxiety and depression. Many patients have reported a historical use of cannabis for this purpose, as well as for less clinical outcomes such as relaxation. If someone has a history of using cannabis and is reporting stress, I might encourage them to go back to cannabis and try it in this new context. The plant may also help with existential issues. It may help them to pull themselves out of a rut, approach their situation differently, and enjoy the playfulness of life. However, if a patient is presenting with clinical depression or anxiety that implies severe pathology, I would rarely introduce it in those settings. And if they were using cannabis and their anxiety were getting worse, it might be something that we pull away from for a while. Question: Compared to traditional medical end of life care, do you think cannabis is a complement, an alternative, or both? BJM: There’s fluidity to the way we use cannabis. Towards the end of life, I would say that it’s more of a complement. Stronger drugs are often needed to control symptoms, especially pain. Earlier in the end-of-life period, it may be used more as an alternative. If someone is in a mild or moderate pain crisis, cannabis may be an important piece of the puzzle. But in a severe crisis, drugs like morphine are usually required as well. Question: Do you recommend the use of whole plant cannabis or cannabinoid pharmaceuticals like Dronabinol with your patients? BJM: I’ve never had much luck with the pharmaceutical versions of cannabinoids. I generally point people to the plant, or a tincture. My recommendation is to use something from the whole plant. Question: What are some of the barriers that patients face in accessing cannabis in end-of-life care? BJM: Patients at the end-of-life may face mobility issues, which can reduce access to cannabis. However, fortunately delivery services are now widely available in many states. More specifically, patients may have difficulty accessing certain varieties of cannabis that they find most beneficial. A more important issue around accessibility relates to information. It can be difficult to access trustworthy resources on cannabis products and how to use them effectively. Question: Are there barriers that patients might face specifically in a hospice setting? BJM: Much of the hospice care in many states is now done at home. In that setting, there are no restrictions. At a hospice facility, there are regulations that must be followed. People are not allowed to smoke inside. So that form of cannabis consumption will be limited only to patients who are ambulatory or can otherwise go outside. In a hospice facility, alternatives to cannabis combustion such as tinctures, lozenges, and gummies could be considered. Question: What is the typical stance of palliative/hospice physicians on cannabis access for patients? BJM: I think that most palliative care physicians are on the cannabis-friendly side of the spectrum. We deal primarily with symptom control as the bailiwick of palliative care, and cannabis can be helpful with that. Another important issue in palliative care is treating a person’s sense of agency and giving them as much freedom and control as possible. As pointed out by my colleague David Casarett, cannabis puts some control back into the hands of the patient. Oftentimes, we’re just blessing what patients are already doing with the plant. One issue is that end-of-life patients with lung problems are usually advised against inhaling cannabis smoke. But there are alternative modes of consumption in this situation. Question: What are some of the barriers that doctors face in recommending cannabis to patients in end-of-life care? BJM: I think a lot of people presume that they have liability issues. There are also cultural barriers coming from the healthcare field, which may be because cannabis doesn’t come from Big Pharma. I don’t think any of my colleagues in medicine have a love affair with Pharma, but it is tricky to recommend plants. It’s also difficult to have access to good information, including knowledge about different cannabis varieties and their cannabinoid profiles. I hope that body of knowledge is being developed. But right now it’s all over the place. I’ve also heard from people over the years that cannabis has gotten so much stronger than they’re used to. So, for a physician, it makes it a little mysterious to recommend cannabis with great confidence. Question: Do you have any advice for doctors who are interested in using cannabis to support their patients at the end of life? BJM: Yes – get informed. There are articles written in the palliative care literature from time to time. Cannabis is also usually discussed at palliative care conferences. If you were to go to our annual three- or four-day conference, you would probably find one or two talks that involve cannabis. And if this is something that you’re interested in, dig deeper. Education on cannabis is not part of the basic training that we presently get |