Background: Evidence shows the effectiveness medical cannabis (MC) for symptoms experienced at the end of life including as pain, muscle spasms, anorexia, nausea/vomiting, and cachexia.¹ Despite widespread interest in using plant-based cannabis in hospice, a number of problems exist that are barriers to its use, including that hospice is a federally funded program and MC is not legal federally.²

Design and Participants: An anonymous 37-item online survey was disseminated through a national full-service hospice benefit manager (Enclara Pharmacia) and through promotion on the National Hospice and Palliative Care Organization (NHPCO.org). Survey questions were from four domains: respondent characteristics; practice, experiences, and opinions regarding MC; concerns related to MC use; and hospice processes and education. Survey was sent to over 500 hospice organizations, and participants who responded received free access to an online course about medical cannabis use in hospice and palliative care.

Results: Respondent characteristics: 310 respondents: 40 states; 62% from states where MC ,+/- recreational cannabis is legal; representative sample of hospices by organization size but higher % of not-for-profit hospices compared to national statistics; 58% nurses, 12% physicians.

Practice, experiences, and opinions regarding MC: 91% report support for MC use in hospice patients yet hospice physicians rarely write orders to certify patient for MC use (50% never) and only 3% prescribe more than one time a month. 90% of physicians regularly respond to questions about its use, yet only 37% initiate discussion on MC. 84% think that health care professionals would benefit from standardized protocols to better manage MC. Most have cared for a patient with MC; have found it most often helpful with pain, nausea/vomiting, and anxiety; and almost all have observed no serious toxicities or adverse events.

MC is usually documented within the medical profile or progress note. Clinicians and patients often do not know the chemical composition of the MC and administrations and dosage formulations vary considerably with the highest categories smoked, edibles, vaporized. 

Most hospices have no policy on MC; most do not assist with the procurement, use or disposal of MC. Hospices do not cover the cost of MC, so patients pay out of pocket.

Commentary: Hospice providers were supportive of the use of MC. If they lived in a state where MC was illegal, they wished it wasn’t. The current state represents a patchwork of barriers that result in underutilization, lack of awareness and access, and myriad unregulated formulations used by a minority of patients who can get it. Many hospice physicians are not certified to recommend MC and don’t discuss it unless asked. The survey points to the need for education, protocols, and standardization in the use of MC in hospice care. 

Bottom Line: Survey shows consensus for MC in hospice as a safe and effective treatments for several symptoms, but barriers are preventing its safe, equitable and effective use. 

Reviewer: Erin Salvador MS MD, Baystate Health System, Springfield, MA

References:

1. Strouse TB. Cannabinoids in palliative medicine. Journal of Palliative Medicine. 2017 Jul 1;20(7):692-4.
2. Aggarwal SK. Use of cannabinoids in cancer care: palliative care. Current Oncology. 2016 Feb;23(s1):33-6.

 Source: Costantino RC, Felten N, Todd M, Maxwell T, McPherson ML. A survey of hospice professionals regarding medical cannabis practices. Journal of palliative medicine. 2019 Oct 1;22(10):1208-12.