CBD in the Hospice Setting More and more terminal patients and their families are calling upon cannabis to provide some symptom relief, and understandably so. Cannabis has been used for centuries Dr. Genevieve Newton explores how cannabis therapeutics may be a beneficial addition to hospice and palliative care. Discover the science and hear from experts in the field. End-of-life care is one of the less frequently discussed uses of medical cannabis. Palliative care, however, is perhaps the area of medicine that would most benefit from its clinical use.
CBD in the Hospice Setting
More and more terminal patients and their families are calling upon cannabis to provide some symptom relief, and understandably so. Cannabis has been used for centuries to treat a broad assortment of symptoms and diseases. Over 100 known cannabinoids have been identified, each appearing to exert different effects. Most Americans are fairly familiar with the two main cannabinoids, tetrahydrocannabinol (THC) and cannabidiol (CBD). The psychoactive THC is the cannabinoid responsible for the “high” associated with marijuana and the majority of its negative effects. On the other hand, CBD, found in both marijuana and hemp, has non-rewarding effects and does not cause dependence.
Properties of CBD are believed to include anticonvulsant, muscle relaxant, anxiolytic, antioxidant, and anti-inflammatory effects. Thus, it may provide benefit in treatment of pain, anxiety, depression, insomnia, neurological disorders, epilepsy, inflammation, and cancer and is believed to produce an overall calming effect on the central nervous system.
With the wide variety of CBD products available in the United States, it is helpful for hospice nurses to have a general understanding of the variations between products, their expected adverse effects, and whether patients are using products appropriately. Understanding the following can provide hospice staff with a more comprehensive understanding of the important differences among the plethora of CBD products on the market and how best to advise patients to ensure appropriate use:
Using Cannabis in End-of-Life Care
As a hospice volunteer, I have seen firsthand the range of symptoms that patients experience at the end of life. Symptoms vary widely. They include issues like fatigue, pain, anorexia, cachexia, dyspnea, anxiety, sleeplessness, and depression. 1 It can be an incredibly difficult time for patients and caregivers alike. There is a great need for effective treatments to reduce suffering.
The period near the end of life can involve different types of care. By definition, 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. 2 In contrast to hospice care, palliative care is not limited to a specific time or prognosis and can be used alongside curative care. 3 Regardless of the definitions used, the goal of end-of-life care (EoLC) is to optimize quality of life. It also addresses not only physical symptoms, but also social, psychological, and spiritual issues. 4 In this way, the scope of appropriate therapies is expanded beyond traditional pharmaceutical drugs.
The importance of cannabinoid therapeutics in EoLC has been acknowledged through some medical cannabis programs in the United States. 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. 5 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. 6,7,8,9 Cannabinoid pharmaceuticals such as Nabilone and Dronabinol 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 products are also available in the United States and some countries with cannabis laws on the books.
Despite its potential benefits, there are many obstacles to integrate cannabis-based medicine (CBM) into EoLC. For example, there is a lack of clinical research regarding the effectiveness of cannabis in treating symptoms when approaching death. There is also limited clinical knowledge regarding how CBM can be initiated and monitored. 10 Moreover, physicians such as medical oncologists who treat patients during the end-of-life period often do not feel sufficiently informed to make recommendations about CBM to patients. However, most of them are having conversations with patients and view CBM as a useful therapy. 11
An additional issue is the nearly exclusive focus of clinical research on CBM with pharmaceutical cannabinoids. In a 2018 systematic review of cannabinoids in palliative medicine, 10 clinical trials were included. Only one used herbal cannabis. Several benefits to CBM were noted, such as for weight gain and appetite stimulation in HIV patients. But overall, the benefits of CBM were not striking. 4
This focus on pharmaceutical cannabinoids is an issue. The exclusion of whole plant cannabis is problematic. The use of isolated THC (Dronabinol and Nabilone) or THC and CBD in a 1:1 ratio (Nabiximols) will reduce the potential for synergies between molecules that occur naturally in the cannabis plant. Major and minor cannabinoids, terpenes, and other phytoconstituents enable the entourage effect which may more effectively reduce symptoms. 12 It should be noted that as a herbal cannabis extract, Nabiximols will contain an unspecified quantity of other cannabis-derived molecules such as minor cannabinoids, terpenes and flavonoids, although the amount of CBD and THC is standardized. Also the use of pharmaceutical CBM does not reflect the lived experience of many patients with severe or life-threatening conditions. Many of these patients report using herbal cannabis formulations with a range of THC:CBD ratios, including tinctures, vaporizers, and capsules. 13
Based largely on these clinical trials, evidence-based guidelines for cannabis in palliative care have been developed in some jurisdictions. In Canada, one guideline recommends against the use of medical cannabis as a first or second-line option for palliative cancer pain. The recommendation is that CBM should only be considered in the case of refractory symptoms and with careful risk consideration. A second guideline recommends that medical cannabis should only be used when other treatments have failed, and only after weighing potential adverse events and drug interactions. 14 Unfortunately, there is a wide breadth of research that is not captured by these guidelines. This includes studies that show cannabis and opioid synergy that allows for opioid doses to be reduced. 15,16 They also do not support clinicians in helping patients access CBM.
Clinical Training Course on Cannabis in Hospice & Palliative Care
For those who are interested in learning more about the scope of this work, the Society of Cannabis Clinicians offers a course by Valerie Leveroni Corral on the topic of Cannabis Use in Palliative Care & End of Life. Valerie is a longtime palliative patient caregiver, the founder of the Wo/Men’s Alliance for Medical Marijuana (WAMM), and the Executive Director of Raha Kudo: Design for Dying Project. She has extensive experience working with dying patients and has advocated to increase access to medical cannabis for over forty years.
Valerie provides valuable clinical pearls gleaned from her personal experience. First and foremost, she emphasizes that it is important to recognize that each patient is unique in terms of their condition and needs, as well as in their response to cannabis products. She notes that observation and monitoring of the patient is extremely important both before and during treatment. She suggests that whole plant cannabis offers greater benefits than individual cannabinoids. Valerie mentions that THC and CBD (along with terpenes) can work together to provide the best benefits. However, she has found that many patients may wish to avoid THC and prefer to use CBD or other cannabinoids.
In the course, Valerie speaks candidly about her use of cannabis in supporting the needs of dying patients over the last many decades. Her presentation of four patient case studies illustrate the unique approaches to using cannabis in EoLC. Each of her patient’s needs were met using a different cannabinoid concentration and ratio that was tailored to each individual based on careful observation and monitoring. The care and compassion shown by Valerie in her caregiving is both humbling and inspiring. This course would be of value to anyone wanting to acquire tools to appropriately gauge cannabis application in end-of-life care.
Palliative Care Physician Dr. B.J Miller
In order to learn more about how clinicians are using cannabis in end-of-life care, I interviewed Dr. B.J. Miller. Dr. Miller 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.
Dr. Genevieve Newton: 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.
GN: 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.
GN: 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.
GN: 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.
GN: 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.
GN: 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.
GN: 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.
GN: 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.
GN: 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.
The SCC recently profiled a valuable review article on the use of cannabis in hospice and palliative care. This paper by Cyr et al. from 2018 discusses current challenges in using cannabis in palliative care and provides many practical recommendations, such as:
- Inform patients that individual responses to CMB can vary, and that the evidence for treatment of many symptoms is still inconclusive.
- Consider the use of longer lasting cannabis preparations (such as oils) as a harm reduction strategy for patients. This can be used to activate pleasure reward pathways when their survival is estimated to be several months or more.
- Use cannabis with caution in patients with severe cardiac or pulmonary disease.
- Recommend CBD-rich formulations for those with a personal or family history of psychotic disorders.
- Encourage patients to try different chemovars with similar THC:CBD ratios and track their personal responses. 10
This paper is a must-read for anyone with an interest in CBM and palliative care. As stated by the authors:
“…the clinical usefulness of CBM, still considered by many to be limited to pain control, appears to encompass a much broader range of symptoms encountered in palliative care settings.”
In conclusion, patients, clinicians, and caregivers support the value of using cannabis in EoLC even if clinical research and supportive practice guidelines are lacking. More clinical research is needed. This should better reflect the real-life use of cannabis, which includes primarily herbal (rather than pharmaceutical) preparations. Cannabis can be incorporated into end-of-life care in a variety of ways, both as an adjunct and a complement to traditional care. It can provide support to patients for a wide range of not only physical, but also emotional and spiritual needs. It is a valuable addition to the end-of-life toolbox.
Dr. Genevieve Newton has spent the past 19 years as a researcher and educator in the field of nutritional sciences. A series of personal health crises led her to discover the benefits of medicinal cannabis, and she soon found herself engrossed in studying the endocannabinoid system and therapeutic applications of cannabis/cannabinoids in mental health, pain, sleep, and neurological disorders. Genevieve is the Scientific Director of a new medical education and CBD company and an Adjunct Professor at the University of Guelph.
Cannabis in Palliative Care
End-of-life care is one of the less frequently discussed uses of medical cannabis. After all, most of us who turn to cannabis, want to continue living, right? And yet, thanks to the ability of cannabis to ameliorate the heavy symptom burden experienced by patients with minimal side effects, palliative care is perhaps the area of medicine that would most benefit from its clinical use.
Dying is a journey all of us will inevitably take, however how to ‘die well’ is something we tend not to consider. Dignity with dying is only possible, I believe, when there is a certain amount of consciousness and acceptance of the process. Something that a skinful of morphine doesn’t allow. But cannabis does, and I experienced this for the first time with a friend’s mother.
As Jose neared the end of her life after battling pancreatic cancer, morphine failed to control her pain, leaving her confused and unable to connect with loved ones. Thanks to an open-minded doctor who recommended cannabis oil, the last few weeks of her life became the gift her family longed for. The pain no longer troubled her, the anxiety lessened, sleep returned, as did her appetite. Not only that, Jose remained fully lucid until moments before she died.
This changed me forever and it’s why I’m sitting here today writing about cannabis.
Sadly, when my mother became terminally ill with advanced cancer, this option was not available in the UK . Sure, I had a few offers from my cannabis contacts. But for an 82-year-old Irish ex-nurse, trusting a funky tasting oil (that I couldn’t say for sure how much to take) over the pharmaceutical meds prescribed in precise dosages was never going to happen.
Instead, I found myself administering a list of medications that just kept growing and growing as the disease progressed. This included morphine for the pain (which incidentally my mum couldn’t tolerate), antiemetics for nausea, laxatives for the constipation caused by both the cancer and the pain medication, as well as Lorazepam for the middle-of-the-night agitation.
The frustration was overwhelming. I knew that instead of the sledgehammer approach to her symptom control, a far more holistic, person-centred alternative existed that could not only ease her pain, take the edge off her anxiety and agitation, stimulate her appetite and help with the nausea, but also allow her to be present for the time that remained.
What is Palliative Care?
According to the World Health Organization, palliative care is “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Palliative care encompasses end-of-life care, but a patient receiving palliative care is not necessarily approaching death.
In other words, palliative care encompasses end-of-life care, but a patient receiving palliative care is not necessarily approaching death.
However, when a patient enters the end-of-life stage in a hospice setting, the emphasis on quality of life means rules often get bent in a bid to fulfil a dying patient’s wishes and beliefs. Dogs and family pets are welcome guests in a patient’s room, and a glass of wine is not unheard of, if that’s what the patient wants. So why not allow access to medical cannabis if that will help ease the suffering of a dying patient?
In some countries and states in the US , palliative and end-of-life care is considered a qualifying condition for the prescription of medical cannabis.
Using Cannabis in Palliative Care
Since 2007, the Israeli Ministry of Health has approved medical cannabis for palliative care in patients with cancer. This led to a prospective study analysing the safety and efficacy of cannabis in 2970 patients and the responses were overwhelmingly positive. 1
Ninety-six percent of patients who responded in the 6 month follow-up reported an improvement in their condition, 3.7% reported no change and 0.3% reported deterioration in their medical condition. Furthermore, while only 18.7% of patients described themselves as having good quality of life prior to cannabis treatment, 69.5% did six months later. Tellingly, just over a third of patients stopped using opioid pain medication.
Cannabis can improve symptoms commonly found in advanced cancer, as well as improving quality of life.
While observational studies such as these suggest cannabis can improve symptoms commonly found in advanced cancer, as well as improving quality of life, in practice physicians often feel insufficiently informed to prescribe cannabis to their patients.
A 2018 survey found that of the 237 US oncologists interviewed, 80% conducted discussions with their patients about cannabis, while only 30% actually felt they had enough information. 2 However, an encouraging 67% viewed cannabis as a helpful additional way to manage pain, and 65% said that it was equally or more effective than the standard treatments for the rapid weight loss often found in advanced cancer. And yet, only 45% of them actually prescribed cannabis to their patients.
These discrepancies mean that even in countries where cannabis can legally be prescribed for palliative care, many physicians prefer to stick to the usual methods of symptom control.
A Physician’s View
Claude Cyr, MD , a Canadian family physician and author of “Cannabis in palliative care: current challenges and practical recommendations,” believes palliative care is uniquely suited to cannabis. 3
“If we’re going to integrate cannabis products in medicine,” he told Project CBD , “palliative care is the best port of entry because of the fact that doctors have more time, and patients also have the time to deal with possible issues of the medication.”
However, in order for cannabis to fulfil its potential in palliative care, Dr. Cyr believes a shift in how physicians view symptom control is needed.
Cannabis is mildly effective for a wide range of symptoms common to people in palliative care.
“What seems to be coming through with the research for symptom control,” says Cyr, “is that cannabis is mildly effective for pain, mildly effective for nausea, mildly effective for insomnia and anxiety. It doesn’t treat any one of these conditions dramatically better than the other medications that we have. So, many physicians are like ‘why would we take a medication that is mildly effective when I can take a much more incisive approach with specific symptoms.’ Instead of saying ‘Do you have a bit of pain, a bit of anxiety, a bit of insomnia, a lack of appetite and a bit of nausea? So why don’t we start with something that’s mildly effective for all that and then we’ll be able to work on more specific symptoms in the long run’.”
Cyr is also critical of fellow physicians’ tendencies to rely on clinical evidence while dismissing the validity of their patients’ positive experiences.
“Palliative care is a specific situation where we can actually put into question the core philosophy of medicine which is the evidence based paradigm. I think physicians need to stop obsessing over the evidence when their patients are dying and clearly telling them, ‘I’m really enjoying this, I’m getting huge benefits from this, I’m sleeping better, I’m eating better.’ But the physicians are nodding their heads and saying, ‘I hear you, but I can’t accept this because I’m still lacking evidence.’
“But I think there is enough data out there to convince physicians that it’s safe for palliative care patients, and it’s predictable.”
Psychoactivity in Palliative Care
Cyr urges doctors to find peace with the idea that cannabis is psychoactive, which he believes could actually help patients process the existential anxiety often experienced at the end of their lives.
“When you look at the studies of psychedelics in depression and existential anxiety in cancer patients, some of these results have been dramatic,” says Cyr. “Although cannabis isn’t a true psychedelic, there are some similar experiences that patients tell us about. 4 At smaller doses patients experience a psycholytic effect, a lowering of the defenses allowing people to explore other aspects of their psyche, and that’s when they start making connections between different aspects of their reality.”
THC ’s ability to reduce activation of the default mode network, the area of the brain involved in cognitive processing and where our ego or sense of self is thought to reside, could also potentially bring a sense of peace to dying patients. 5 6
Cyr explains: “Existential anxiety is rooted in the loss of the self, but when you can dissolve the ego temporarily and you realize it’s not all about me, that can be liberating.”
For the last fifty years, activists have been campaigning for the right to use cannabis to treat their health conditions in order to be well. This must also be extended to using cannabis to maintain quality of life in life-threatening illnesses, and when this no longer becomes possible, to die well and with dignity.
In memory of Jose and Agnes.
Mary Biles, a Project CBD contributing writer, is a journalist, blogger and educator with a background in holistic health. Based between the UK and Spain, she is committed to accurately reporting advances in medical cannabis research.
Copyright, Project CBD . May not be reprinted without permission.