By Larry Beresford
Medical cannabis continues to move into the mainstream across the United States, but in many places it’s a therapeutic option that patients with serious illnesses and their families must largely navigate on their own.
Though medical marijuana is legal in 33 states, plus the District of Columbia, conflicting federal laws and limited research on cannabis’ safety and efficacy present an ongoing challenge for hospice and palliative care programs whose patients are interested in medical cannabis or already using it to manage pain and other symptoms.
The situation is particularly challenging for hospices, which are primarily funded by Medicare. Many hospices say they cannot legally prescribe medical marijuana because it remains a Schedule 1 controlled substance under federal law.
Even if state and federal laws aligned, the evidence base is still thin for therapeutic benefits of cannabis-based products, many clinicians say. That’s in part because federal prohibitions may have inhibited research that could answer important questions about safety and efficacy.
How then can hospice and palliative care teams navigate this picture? For some, the approach borders on “don’t ask, don’t tell” – an obvious hurdle to the open communication and patient-centered approach at the center of hospice and palliative care.
‘Walking a Fine Line’
The fullest picture of hospice professionals’ attitudes toward their patients using cannabis comes from a study by Ryan Costantino, et al., first published in the Journal of Palliative Medicine in September 2019. The study is based on a survey of more than 310 hospice professionals, predominantly nurses, from 40 states.
Overwhelmingly, survey respondents agreed that hospice patients should have access to medical cannabis. They recognized the legal barriers, concerns about efficacy and safety, and the complex social factors involved. They also reported wide variation in documentation practices employed to capture cannabis use in the hospice chart.
Several hospice and palliative care professionals declined requests to share their experiences or viewpoints on medical cannabis for this article, but the ones who did said they are doing their best to support patients in what is still a somewhat murky area of serious illness care.
“In Oregon, medical marijuana is legal,” said Mia Fisher, LCSW, a hospice social worker with South Coast Hospice and Palliative Care in Coos Bay. “Many patients who come to us already have their registration card from the state. It’s out of our hands.”
“We definitely don’t prescribe (medical cannabis) and we can’t say we encourage it” she said, but the hospice team strives to support patients and maximize their comfort. That means walking a fine line, Fisher said.
“It’s not our job to judge,” she said. “People are allowed to make their own choices and hospice tries to meet them where they’re at. If asked for advice, we would refer them to their primary care physician. Sometimes we don’t even know they’re taking it.”
Clinicians Need Education
Still, some hospice and palliative care practitioners talk openly with their patients about medical cannabis.
Diana Martins-Welch, MD, a palliative care physician with the Northwell Health System in New York City, said that since medical marijuana was legalized in New York in January 2017 she has written about 2,000 certifications of eligibility for patients. The certification only attests that the patient has a “severe, debilitating condition” that qualifies them to obtain medical cannabis products.
Martins-Welch can’t prescribe medical marijuana or help the patient obtain a product from a dispensary but said she has suggested the use of cannabis for pain, anxiety, sleep disorder, nausea or loss of appetite. “Those are the most relevant symptoms to my practice as a palliative care clinician,” she said.
One of the most promising benefits of medical cannabis may be that it can allow patients to reduce their dosages of opioid analgesics, Martins-Welch said.
“I tell people my patients don’t have time to wait for research results,” she said. “I can tell you anecdotally it works for some of my patients. I don’t have concerns personally. I do things the right way. And who is more appropriate for cannabis than a hospice patient?”
Martins-Welch is known within her large health system as a cannabis expert. Few of her colleagues have accepted the responsibility of completing the law’s required education course and registering with the state Department of Health to certify patients for medical cannabis.
She said she had a hard time at first persuading the medical directors of an affiliated hospice agency to do the certifications, so those patients wouldn’t have to come to her office in person to get a doctor’s OK.
“It requires a leap of faith by the clinician, but it’s not that much of a risk, if you ask me,” said Martins-Welch, who also leads a work group of Northwell’s Opioid Management Steering Committee, providing education about cannabis.
“We want people to get on the program—but also to get educated, so they don’t just blindly certify patients. Many patients try it once, and it doesn’t work for them. I tell them that this is all trial-and-error, and a very imperfect program. We do all kinds of medications in hospice, and we’re always adjusting the doses. Why not another agent that we can bring in if it might help the patient?”
The CSU Shiley Institute for Palliative Care recently launched a new 4-week course, Cannabis in Hospice and Palliative Care, to help clinicians understand the clinical, legal, and ethical considerations surrounding medical cannabis.
For more information, contact the Institute at 760-750-4006.