End-of-Life Care: Relief for Hospice and Palliative Care Patients
A geriatric and palliative care nurse practitioner discusses how cannabis can relieve suffering and improve quality of life.
Diane Schade, NP, is a board-certified geriatric and palliative care nurse practitioner. Palliative care nurses are part of an interdisciplinary team specializing in mitigating suffering and optimizing quality of life among people with serious illness. By definition and development over the years, palliative care supports people in any life stage. Hospice care focuses on quality and comfort measures provided during the final six months of life. Schade makes home visits on the eastern end of Long Island, New York, and helps patients manage symptoms including shortness of breath, fatigue, poor appetite, depression, restlessness, agitation, constipation, diarrhea, nausea, and insomnia.
“I am always looking for alternative medicines and therapies to alleviate suffering. I felt limited by having to rely so much on opioids and benzodiazepines,” Schade says. Following a simple online search, she read about the requirements for becoming a medical cannabis provider in her home state of New York. “I found an online certification course through the New York State Department of Health that I could work on in my spare time. It was very involved, and it took me a long time to work through the information.”
After completing the course, Schade became certified, which meant that she was empowered to authorize cannabis use for qualifying patients. However, she felt that she wanted to learn more, so she attended different conferences locally. “I also inquired at our local dispensary, which is run by Columbia Care,” Schade says. “I attended an informational event. The pharmacists there were very knowledgeable.” Later, Schade hosted another event at her home in collaboration with Columbia Care. “I wanted to hear from other health professionals about their experiences using the medication, successes and failures, doses, and how it worked for different illnesses.”
Introducing a New Era of Medicine to an Older Generation
To perfect her practice, she worked through the following learning curves.
Start Low and Go Slow
Concerns About Intoxicating Effects
The introduction to the study acknowledges that, “Evidence on the effectiveness of medical cannabis for symptoms experienced at the end of life such as pain, muscle spasms, anorexia, nausea, vomiting, and cachexia dates back thousands of years.” Modern health care clinicians seem to agree with that statement. According to the study, “Regardless of legal status, hospice staff members were overwhelmingly in agreement that [medical cannabis] is appropriate for hospice patients to have access to and use.” Participants in the study reported that cannabis was effective in reducing nausea and vomiting, pain, anxiety, and dry mouth. However, one-half of the physicians who responded indicated that they don’t write orders to certify patients for cannabis use. The majority of respondents (62%) work in states where medical cannabis is legal, but 33% were in states where it wasn’t permitted, and 5% were unsure of their state’s legal status.
The study indicates that patients and their families question staff about cannabis and that some family members said nothing else was effective in giving their family members relief. In an interview discussing the study, the lead author, Ryan Constantino, PharmD, MS, told Forbes magazine that patients pay out of pocket for cannabis. He stated, “Whether or not you think your patients are using it [cannabis], they likely are, at least in hospice.”2
According to National Hospice and Palliative Care Organization’s recent report, the principal diagnoses of hospice decedents are cancer (30.1%), circulatory/heart problems (17.6%), dementia (15.6%), “other,” (13.9%), respiratory (11.%), stroke (9.4%), and chronic kidney disease (2.3%).3 The organization’s website hosts a 2016 paper written by Peter A. Radice, MD, FACP, FAAHPM, about the use of cannabis in palliative care.4 Radice chronicles various absolute and relative contraindications and points to the lack of uniform dosing guidelines. The report lists the benefits of cannabis, “in treating patients with cancer, neurodegenerative diseases, inflammatory disease, end-of-life angst, uncontrolled seizures, and HIV cachexia.” Radice cautions that older adults metabolize cannabis more slowly and are more sensitive to its effects.
Further Research Is Vital
Cannabis training may result in palliative clinicians opting to intervene with cannabis medicine sooner. Sunil Aggarwal, MD, PhD, writes in Current Oncology that the integration of cannabis into specialized palliative care for oncology patients has been shifting closer to the time of diagnosis, which, in some instances, improves not only quality of life but also survival.6
In his article, Aggarwal weighs in on the challenges of implementing cannabis. “The benefits of integrating CIM [cannabinoid integrative medicine] into palliative care have been stifled by conflicting regulations, lingering stigma, research barriers, and product scarcity—much of which stems from poor awareness and knowledge gaps for patients, clinicians, and other stakeholders.” Aggarwal poses the question: What shall we do in the face of incomplete evidence? He summarizes his findings: “Integrating CIM into oncologic palliative care promises to improve overall health-related quality of life, to provide further relief from distressing symptoms and spiritual suffering, and to bring hope to patients and families facing terminal illness.”
Schade’s role as a palliative care nurse and an end-of-life doula (also known as a death midwife, a person who provides emotional, physical, and spiritual support and offers help to other caregivers in addressing the patient’s wants and needs during the final days of life) demonstrates she’s highly trusted by patients and their families. “This is more than a career for me. It’s a calling,” Schade says. “I feel honored to serve these patients. I’m absolutely dedicated to providing the best care that I can. Medical marijuana has become an important tool for palliating pain and other distressing symptoms. I’ve seen some really positive results, as have other health care professionals. I believe providing access to this remarkable and safe medicine is our responsibility.”
— Michele Deppe is a freelance writer based in upstate South Carolina.
2. Rosner A. Cannabis in hospice: growing demand for end-of-life care. Forbes website. https://www.forbes.com/sites/abbierosner/2019/06/25/cannabis-in-hospice-growing-demand-and-acceptance-for-end-of-life-care/#43f1e74f403a. Published June 25, 2019. Accessed June 12, 2020.
3. National Hospice and Palliative Care Organization. NHPCO facts and figures: 2018 edition. https://39k5cm1a9u1968hg74aj3x51-wpengine.netdna-ssl.com/wp-content/uploads/2019/07/2018_NHPCO_Facts_Figures.pdf. Updated July 2, 2019. Accessed June 12, 2020.
4. Radice PA; National Hospice and Palliative Care Organization. Cannabis use in palliative care: history, legality and implications for practice. https://www.nhpco.org/wp-content/uploads/2019/04/PALLIATIVECARE_Cannabis.pdf. Published 2016. Accessed June 12, 2020.
5. MacDonald E, Farrah K. Medical cannabis use in palliative care: review of clinical effectiveness and guidelines — an update. NCBI Bookshelf website. https://www.ncbi.nlm.nih.gov/books/NBK551867/. Published October 29, 2019. Accessed June 12, 2020.
6. Aggarwal SK. Use of cannabinoids in cancer care: palliative care. Curr Oncol. 2016;23(2):S33-S36.