Dying with dignity is a human right, and cannabis could help.
End-of-life care is one of the least discussed uses of medical cannabis. After all, most of us who turn to cannabis want to continue living, right? And yet, thanks to cannabis's ability to ameliorate the heavy symptom burden experienced by patients with minimal side effects, palliative care is perhaps the area of medicine that would benefit most from its clinical use.
Dying is a journey we all inevitably undertake, yet how to "die well" is something we tend to overlook. I believe dignity in death is only possible when there is a certain awareness and acceptance of the process. Something a morphine caplet doesn't allow. But cannabis does, and I first experienced this with a friend's mother.
As José neared the end of her life after battling pancreatic cancer, morphine failed to control her pain, leaving her confused and unable to connect with her loved ones. Thanks to an open-minded doctor who recommended cannabis oil, the final weeks of her life became the gift her family had longed for. The pain no longer troubled her, her anxiety subsided, sleep returned, as did her appetite. Not only that, José remained completely lucid until moments before he died.
This changed me forever and that's why I'm sitting here today writing about cannabis.
HOLISTIC MEDICINE
Sadly, when my mother was terminally ill with advanced cancer, this option wasn't available in the UK. Sure, I had a few offers from my cannabis contacts. But for an 82-year-old former Irish nurse, relying on a funky-tasting oil (who couldn't accurately predict how much to take) over prescription pharmaceutical drugs in precise doses was never going to happen.
Instead, I found myself managing a list of medications that kept growing as the disease progressed. This included morphine for pain (which, by the way, my mother couldn't tolerate), antiemetics for nausea, laxatives for constipation caused by both the cancer and the pain medication, and lorazepam for middle-of-the-night agitation.
The frustration was overwhelming. He knew that instead of the sledgehammer approach to managing his symptoms, there was a much more holistic and person-centered alternative that could not only relieve his pain, ease his anxiety and agitation, stimulate his appetite, and help with nausea, but also allow him to be present for the remainder of his life.
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 problems associated with life-threatening illnesses, through the prevention and relief of suffering by means of early identification and the sound assessment and treatment of pain and other physical, psychosocial and spiritual problems."
Palliative care encompasses end-of-life care, but a patient receiving palliative care is not necessarily approaching death.
In other words, palliative care encompasses care at the end of life, 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 that rules are often bent in an attempt to fulfill a dying patient's wishes and beliefs. Dogs and family pets are welcome guests in the 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 it will help ease a dying patient's suffering?
In some countries and states in the U.S., 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 cancer patients. This led to a prospective study analyzing the safety and efficacy of cannabis in 2,970 patients, and the responses were overwhelmingly positive.(1)
Ninety-six percent of responding patients at the 6-month follow-up reported improvement in their condition, 3.71% reported no change, and 0.31% reported deterioration in their medical condition. Furthermore, while only 18.71% of patients described themselves as having a good quality of life before cannabis treatment, 69.51% did so six months later. Tellingly, just over a third of patients stopped using opioid painkillers.
Cannabis can improve symptoms commonly found in advanced cancer, as well as improve quality of life.
While observational studies like these suggest that cannabis may improve symptoms commonly found in advanced cancer, as well as enhance quality of life, in practice, physicians often feel inadequately informed when prescribing cannabis to their patients.
A 2018 survey found that of the 237 US oncologists interviewed, 80% discussed cannabis with their patients, while only 30% actually felt they had enough information.(2) However, an encouraging 67% saw cannabis as a useful additional way to manage pain, and 65% said it was as effective as or more effective than 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 be legally prescribed for palliative care, many physicians prefer to follow standard methods of symptom management.
A DOCTOR'S OPINION
Claude Cyr, MD, a Canadian family physician and author of “Cannabis in Palliative Care: Current Challenges and Practical Recommendations,” believes that palliative care is especially well-suited to cannabis.(3)
"If we're going to integrate cannabis products into medicine," he told Project CBD, "palliative care is the best entry point because it gives doctors more time, and patients more time, to address potential medication issues."
However, for cannabis to reach its potential in palliative care, Dr. Cyr believes a change in the way physicians view symptom management is needed.
Cannabis is mildly effective for a wide range of symptoms common to people in palliative care.
“What seems to be emerging with the research for symptom management,” Cyr says, “is that cannabis is mildly effective for pain, mildly effective for nausea, mildly effective for insomnia and anxiety. It doesn’t treat any of these conditions dramatically better than the other medications we have. So a lot of doctors are thinking, ‘Why would we take a medication that’s mildly effective when I can take a much more targeted approach to specific symptoms?’ Instead of saying, ‘You have a little bit of pain, a little bit of anxiety, a little bit of insomnia, poor appetite, and a little bit of nausea? So why don’t we start with something that’s mildly effective for all of those, and then we can work on more specific symptoms long term? ’”
Cyr also criticizes the tendency of fellow physicians to rely on clinical evidence while dismissing the validity of their patients' positive experiences.
“Palliative care is a specific situation in which we can question the central philosophy of medicine, which is the evidence-based paradigm. I think doctors need to stop obsessing over evidence when their patients are dying and tell them clearly, ‘I'm really enjoying this, I'm getting great benefits from this, I'm sleeping better, I'm eating better.’ But doctors nod and say, ‘I hear you, but I can't accept this because I still lack evidence.’”
"But I think there's enough data available to convince physicians that it's safe for palliative care patients and that it's predictable."
PSYCHOACTIVITY IN PALLIATIVE CARE
Cyr urges physicians to find peace with the idea that cannabis is psychoactive, which he believes could help patients process the existential anxiety often experienced at the end of life.
“When we look at studies of psychedelics on depression and existential anxiety in cancer patients, some of these results have been dramatic,” Cyr says. “Even though cannabis is not a true psychedelic, there are some similar experiences that patients tell us about. (4) In smaller doses, patients experience a psycholytic effect, a lowering of defenses that allows 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 self, but when you can temporarily dissolve the ego and realize that it’s not all about me, that can be liberating.”
For the past fifty years, activists have been campaigning for the right to use cannabis to treat health conditions and be well. This should also extend to the use of cannabis to maintain quality of life in life-threatening illnesses, and when this is no longer possible, to die well and with dignity.
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