The language of living and dying

When it comes to caring for people with cancer, how clinicians talk about palliative care can make a huge difference to patients and their families

For many, palliative care means spending more time at home, rather than in hospital.

By Jennifer Philip

As a society, we are not very sophisticated when we talk about serious illness and death. We talk of fighting, of battling against, of staying positive and of not giving up.

Of course, this has implications for those whose illness continues or worsens. Are they losing the fight? And what does it mean about their attitude? Have they given in?

In our research, recently published in Palliative Medicine, we found the power of language is particularly poignant when it comes to how clinicians talk about end of life care. It can lead to misunderstandings, but also sadly, even tragically, to suffering and missed opportunities.

We’re looking into this at the Victorian Comprehensive Cancer Centre’s Palliative Medicine Research Group. Based at St Vincent’s Hospital Melbourne, our group brings together clinicians, researchers and allied health professionals, seeking to effect positive and systemic change in palliative care practice.

Our language around illness is reflected in the media, as we read with excitement of “a breakthrough in the fight against cancer/dementia/heart disease” – insert your illness of interest.

However, palliative care in the media and in the lives of real people, of patients, is often discussed as “there was nothing more that could be done, so they went into palliative care”.

The language that we use has direct and very serious consequences. To say that “there was no more treatment, so they had palliative care” implies that palliative care is not treatment. This language serves to limit possibilities since it negates the opportunity to choose palliative care, and the benefits that it may provide.

Why does this language matter?

Well firstly, it propagates a misperception about palliative care. Contrary to “no more to be done” and “non-treatment”, palliative care is highly effective and beneficial.

It has been proven in clinical trials to ensure better pain and symptom relief and, for many, means better quality of life than when patients are solely cared for by usual health providers such as oncology, respiratory and cardiology services.

Palliative care has also been shown to improve patients’ satisfaction with care, as they have more information and understanding of their circumstances and the choices available to them. It means they are empowered to make decisions that match their values – which, for many, means less time in hospital, and being more likely to die at home.

It can be common for doctors to avoid talking about palliative care until death is very close.

Research has shown that palliative care means that when people do die, their families experience less distress and have better health outcomes themselves.

And it means, based on a number of studies, that people live longer. Yes, palliative care improves survival – as much as a number of newer chemotherapy treatments. And all of these benefits increase if palliative care is introduced early.

None of this sounds like “no more can be done” or a “non-treatment option”. Yet because of the language used and the associated stigma, patients (and doctors) are fearful of mentioning palliative care, much less to introduce it early.

Instead, patients think that palliative care equals death, and worse still, death in an institution “where people do things to you”, as one of our research participants said; where there are no choices.

This is the very antithesis of what palliative care seeks, and is proven to do.

And so, as if even the words ‘palliative care’ will themselves, bring about death, we avoid it until death is very close. Palliative care, raised in these circumstances, becomes linked with imminent death, and the cycle of misperception and missed opportunities (and poor care) continues.

These missed opportunities may include a lifetime of valuable things to be said to someone we love, a trip to a special place, or a chance to think through whether a further round of treatment will enable achievement of an important goal.

And poor care may include pain that is not well managed for six of the last eight months, or a young child that wonders if Dad’s illness was caused by something they did.

So what needs to be done?

Clinical trials into palliative care find ensure better pain and symptom relief, and better quality of life.

We need to listen to the evidence. We need to think about the language that we use to speak about illness and death, to think about its impact for readers of today, and for patients of tomorrow.

We need to be sensitive and direct. And we need to learn to sit with the discomfort that not all is black or white, fighting or giving up, treatment or no treatment. That things that are hard to consider and face will inevitably mean hard conversations are to be had.

These conversations, though difficult, can be immensely rewarding and also may be the most important conversations for a person’s life. We all have a responsibility and a role to ensure our language facilitates understanding and choice, not its opposite.

Complete Article HERE!

Palliative care for the living — more education is needed

A pregnant mother’s 20-week ultrasound often brings feelings of elation and anticipation as she learns the baby’s sex or sees the baby move in her belly.

But when that ultrasound shows a heart defect in her unborn child that will require multiple surgeries and could cause learning difficulties, necessitate a heart transplant, or even lead to an early death, everything changes for her and for her family. Expectations of the future start to change.

Children with complicated medical problems such as heart defects, severe seizure disorders or cancer need care from multiple specialists over their lifetime. As specialists in pediatric cardiology and pediatric intensive care medicine, we have seen too often that one key group — the palliative care team — is often not included.

One reason for this is that many people inaccurately think of palliative care as only care for the dying.

The National Consensus Project for Quality Palliative Care describes palliative care as an interdisciplinary approach to “patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.” There is no mention of dying, death or end-of-life care.

Important legislation under consideration now seeks to expand opportunities for interdisciplinary education, training and research in palliative care. The Palliative Care and Hospice Education and Training Act recently passed the U.S. House of Representatives and is headed to the Senate. This legislation will support educational efforts that inform patients and health-care providers about the benefits of palliative care in supporting individuals with serious illness.

People with complicated medical problems and serious illness need medical specialists. Just as heart doctors treat heart problems and lung doctors treat lung problems, palliative care treats the suffering that results from serious illness.

Sometimes the reasons for suffering are obvious, as with a cancer patient’s excruciating bone pain or unending nausea. Palliative care providers use both medications and less conventional treatments, such as acupuncture or music therapy, to alleviate difficult-to-control symptoms.

Other times, suffering from serious illness can’t be seen easily. A new study published in BMJ (originally the British Medical Journal) found that 20 percent of patients with cancer have depression and 10 percent have anxiety. Often unnoticed or sometimes ignored, these complications can decrease survival.

To be sure, suffering comes in many forms – physical, emotional, spiritual. Many contend that physicians should focus on things such as physical bodily pain, and leave more existential suffering to chaplains or other religious figures. That is why palliative care requires an interdisciplinary team that includes social workers, chaplains, music and art therapists, nurses, physicians and others.

But palliative care providers can only help if they are invited to participate. Some physicians and parents may avoid introducing palliative care because they feel it is tantamount to “giving up hope.”

Yet, in some cases, palliative care may help extend life. In a study in China of adults with metastatic non–small-cell lung cancer, those who received early palliative care lived longer than those who received standard cancer care.

Such improved outcomes are not limited to the patients themselves. A new study published in Cardiology in the Young showed that mothers of children with a serious congenital heart defect (called hypoplastic left heart syndrome) who received early palliative care had less anxiety and improved family relationships compared to mothers who received regular care.

While some physicians may resist involving palliative care, many patients report they are open to the idea. A recent study of oncology patients published in the Journal of American Medical Association network showed, “very few patients or parents in this study expressed negative attitudes toward early palliative care.”

Of course, many patients with serious illness may not need palliative care. Some health-care providers might want to manage all aspects of their patients’ care. Certainly, all physician should have skills to treat difficult symptoms, address emotional challenges, and conduct difficult conversations. But as decision making and suffering become more and more complicated, involving clinicians with specific expertise can make a huge difference.

Unfortunately, access to quality palliative care services is lacking. One-third, or 802 U.S. hospitals with 50 or more beds, report no palliative care services. The Center to Advance Palliative Care gave one-third of states a grade of C or D based on inadequate access to palliative care.

To improve access to palliative care, more health-care providers need this training. According to the data from the National Palliative Care Registry, 1 to 1.8 million patients who could benefit from palliative care services, are not receiving it.

Just 140 existing palliative care training programs graduate only 360 physicians yearly. This is nowhere near enough providers to meet this massive unmet need. And one study published in Palliative Medicine shows that the need will double by 2040.

Fortunately, clinicians and families don’t need to participate in formal training programs to access palliative care education. The National Institutes of Health has a campaign to improve understanding for both patients and providers.

The American Academy of Hospice and Palliative Medicine website provides links to research, videos, training options, and more. The Center to AdvancePalliative Care provides tools, training, and technical assistance to build and sustain palliative care in all health care settings.

Palliative care must not be an afterthought, or a consideration after all other possibilities in care are exhausted. It is urgent that palliative care be accessible to everyone regardless of age at the onset of medical treatment. That way patients can be offered the best possible care and outcomes.

Complete Article HERE!

Medical Marijuana and Terminal Illness

People who have been diagnosed with a terminal illness suffer a broad range of physical and emotional symptoms and other overwhelming struggles. Terminal illnesses are devastating diagnoses, and patients must learn to cope with the news that their disease cannot be cured.

When it comes to terminal illnesses, conventional medicine focuses on palliative treatment goals. This means doctors aim to make their patients feel as comfortable as possible in their last remaining weeks or months. Unfortunately, most of the drugs prescribed to terminally ill patients cause a host of unpleasant side effects, and some people flat out stop responding to conventional treatments. That’s where natural therapies come into play.

Medical cannabis is an excellent option as a complementary treatment solution alongside prescription opiates or other drugs for symptom management, but it can also be an effective alternate solution when patients suffer from side effects and no longer wish to take conventional medications.

Studies on medical cannabis and terminal illness have proven its effectiveness in treating specific symptoms that are often associated with end-of-life difficulties. Medical cannabis is a safe remedy for maintaining quality of life and providing comfort and relief for patients with terminal illnesses.

What Is a Terminal Illness?

Terminal illness is a broad term used to describe any kind of illness that is incurable or untreatable. Patients with a terminal illness have been told by their medical team that they have a certain remaining life expectancy and their disease will likely result in death. Illnesses like AIDS or cancer can be diagnosed as terminal illnesses when the disease is too advanced to be treated.

One of the primary issues surrounding a terminal illness is the psychological trauma associated with the diagnosis. Many patients fall into a deep depression and may even turn to substance abuse. Additionally, many of these patients have such advanced illnesses that they suffer from chronic pain, which only further amplifies their psychological symptoms.

Sadly, terminal illnesses affect far too many families. In 2006, the Pew Research Center reported that 42% of Americans know a friend or relative who is suffering or has suffered a terminal illness. Though this is a shocking statistic, but it’s made clearer when looking at the rates of terminal illnesses among Americans.

n the United States, cancer is the second leading cause of death. On average, more than 1,500 Americans die each day from cancer. HIV/AIDS is another potentially terminal illness taking far too many lives. In 2014, 6,721 Americans died from HIV or its complications, although the death rate associated with AIDS is steadily declining in the United States.

An under-recognized potentially terminal illness in the United States is kidney disease. According to the National Institutes of Health, advanced kidney failure kills more Americans than breast or prostate cancers. In 2013, 47,000 Americans died of kidney disease.

Terminal illness doesn’t just affect adults and seniors. The National Cancer Institute reported that in 2014, 1,960 children and adolescents under the age of 19 died from cancer.

With these high rates of terminal illness in American society, it’s no wonder many of these patients are turning to medical cannabis as a natural end-of-life therapy.

Terminal Illness History and Outlook

The landscape of illnesses has changed drastically in the past 100 years. Thanks to greater global disease awareness and advanced medical technologies, people are living longer than ever. But illnesses themselves have evolved. A hundred years ago, it was common for people to die from infections and other acute conditions that could not be treated medically.

Today, in the industrialized world, it’s less common for people to die from infections. However, chronic illnesses attributed to our environment, lifestyles and the fact that people are living longer are the new medical challenge our society faces. Generally, our high-fat diets, sedentary lifestyles and increased exposure to synthetic products and chemicals have led to new types of terminal illnesses to combat. Cancer is a potentially fatal disease that is claiming lives at an astonishing rate.

In 2003, the World Health Organization, recognizing the global cancer epidemic, published a report estimating that by 2020, cancer death rates would increase by 50% to 15 million annually.

Thankfully, since those findings were published, medical technology has advanced, and many of these expected deaths are now preventable. There are still far too many cases where cancer results in terminal illness. This is why different therapy approaches, such as medical cannabis, can help address the cases where cancer becomes fatal.

Terminal Illness Causes

There are many different types of terminal illnesses all resulting from different causes and risk factors. Here are some of the terminal illnesses patients are diagnosed with as well as their causes:

  • Cancer: Cancer is a broad term used to describe several different diseases that can affect virtually every part of the body. There are many possible causes of cancer depending on where in the body it first develops. All cancers are characterized by the mutation of normal, healthy cells into abnormal, cancerous cells. By nature, cancer cells divide and spread quickly. As they spread, they form tumors — lumps of cancerous tissue. If left untreated, tumors will begin to shut down nearby organs, as the immune system can no longer fight against the attacking cells.

All cancers are terminal if left untreated. Some cancer types are deadlier than others. Two of the deadliest forms of cancer are brain and ovarian cancers. The National Cancer Institute estimates that 16,700 Americans will die of brain cancer and 14,080 will die from ovarian cancer in 2017.

  • HIV/AIDS: HIV is acronym for the human immunodeficiency virus. It’s caused by a sexually or blood transmitted infection that attacks a person’s immune system. After years of being infected with HIV, a person’s immune system eventually becomes so weakened they develop AIDS — acute immunodeficiency syndrome — which is fatal.
  • Kidney Disease: Kidney disease is a serious, potentially terminal illness that damages a person’s kidneys. Damaged kidneys are unable to filter the blood properly, which causes waste and toxins to build up inside the body. Sadly, initial symptoms of kidney disease often go unnoticed until the condition becomes advanced. If kidney disease reaches the most advanced stage — kidney failure — the patient is no longer eligible for a kidney transplant or dialysis and the condition becomes fatal.

These conditions are some of the many well-known terminal illnesses that exist. Countless other diseases and conditions are considered terminal when patients stop responding to treatments or when the illness becomes too advanced to treat.

Terminal Illness Symptoms

While there are many different conditions that cause terminal illnesses, each having their own unique symptoms, most patients experience a similar set of symptoms during the end stages of life. These common symptoms include both physical and emotional or mental symptoms.

Here are the common symptoms experienced by people with terminal illness:

Physical Symptoms. When patients suffer advanced stages of diseases, there are common physical symptoms that occur. These symptoms include chronic pain and general weakness. Chronic pain affects more than 60% of cancer and AIDS patients. Other physical symptoms of terminal illness include:

  • Chronic weight loss
  • Anorexia
  • Loss of appetite
  • Fatigue and insomnia
  • Nausea
  • Vomiting
  • Constipation
  • Difficulty breathing

Emotional Symptoms: A terminal illness diagnosis is tragic and earth-shattering for patients and their families. Because of this, there is a range of different reactions among patients. Patients can experience emotions such as:

  • Anger
  • Fear
  • Shock
  • Denial
  • Blame
  • Depression
  • Helplessness

Many patients diagnosed with terminal illness go on to develop depression and anxiety. The Baylor University Medical Center found up to 77% of terminally ill patients suffer depression symptoms. Other reports indicate up to 20% of terminally ill patients are diagnosed with major depression — a serious and chronic grade of depression. In many cases, anxiety and delirium also accompany feelings of depression.

Conventional Terminal Illness Treatments

Treatments for terminal illness are focused on improving a patient’s comfort and quality of life in their remaining time. Terminal illnesses, however, are untreatable in the sense that they cannot be cured. Terminal illness treatments are referred to as palliative, meaning they reduce pain without an attempt to cure the disease.

Treatments focus on alleviating pain, improving strength and appetite and managing any symptoms of depression, anxiety and grief.

Here are the types of conventional treatments and care given to patients with terminal illness:

  • Opiates. Opiates are a class of drug that suppress the central nervous system and provide pain relief and a sense of euphoria. Morphine and hydromorphone are two of the most commonly prescribed opiates to relieve pain during end-of-life. Fentanyl, oxycodone and methadone are other opiates used to alleviate chronic pain for patients with terminal illness.
  • Anti-nausea medications. Nausea and vomiting are common terminal illness symptoms that can be managed effectively. Haloperidol is an anti-nausea medication that doctors prescribe to control these symptoms. Haloperidol can be taken orally or via injection.
  • Antidepressants. In many cases, doctors may prescribe terminally ill patients with antidepressants (SSRIs). Quite understandably, stress and depression arise with a patient’s knowledge of terminal illness. The physical and emotional suffering coupled with knowledge of impending death make some patients want to commit suicide, become overly stressed or too depressed to respond well to care-giving methods. Unless antidepressants are already part of the medical regimen, the patient may not respond to them in time to have any benefits before death.
  • Psychological/spiritual counseling. Doctors and experts advise patients to seek psychological or spiritual counseling to help cope with a terminal illness. Counseling helps patients better understand their condition, be better equipped to deal with it and address symptoms of depression and anxiety. Often, psychological and spiritual counseling for terminally ill patients will include the person’s family members.

Medical Cannabis for Terminal Illness

Unfortunately, many patients with terminal illnesses struggle with the types of palliative treatments they’re prescribed. Opiates and antidepressants both come with a host of side effects that can aggravate many of the end-stage struggles people experience. Medical cannabis is an alternative or complementary treatment option that many people with terminal illnesses have had success with.

The cannabis plant contains two organic compounds that provide medical benefits: tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the compound responsible for the psychoactive effect associated with cannabis. It’s also shown to possibly reduce pain, relieve nausea and boost appetite.

CDB is the other compound that doesn’t produce psychoactive effects. However, it does treat symptoms like pain, nausea, depression and anxiety, which are all associated with terminal illness.

Legal medical marijuana such as Marinol is approved by the FDA. In some states, smoked marijuana is also legal under state law but still illegal under federal law. Both forms of medical marijuana have been shown to help with pain. They are not pain relievers, but can work with opiates to make them more effective.

According to UCSF, they conducted a study using cannabinoids with opiates and found that patients showed up to 95% decrease in chronic pain when using inhaled marijuana vapor with opiates such as morphine. It also showed that the dosages of opiates could be decreased when opiates are used in conjunction with cannabinoids.

Medical Cannabis for Alleviating Symptoms

One of the strongest arguments for medical marijuana and terminal illness is for the treatment of nausea, vomiting and loss of appetite. Cancer patients that are undergoing chemotherapy have benefited greatly from the availability of FDA approved medical marijuana. It is known to reduce nausea and vomiting, often when more traditional medical treatments for the symptoms fail to produce significant results. Nausea and Vomiting can occur with several terminal illnesses such as cancer and AIDS – related illness.

Cancer and AIDS can also result in loss of appetite. It is expected at the very end of life that appetite decreases until it is nonexistent in many cases. However, it is often good for patients to eat as much as possible until it becomes impossible. Medical marijuana can help with that and is prescribed for just such occasions. In fact, the hunger-inducing effects of medical marijuana are so well known that they are even known colloquially as “the munchies” in the recreational marijuana use community.

Medical marijuana’s effects are felt soon after ingestion and virtually immediately after inhalation. There is no waiting period as there is for antidepressants. There is no guarantee that it will alleviate depression, stress and suicidal thoughts. However, it is useful for its fast-acting benefits. There is some research to suggest that medical marijuana can help some of the symptoms associated with depression, particularly difficulty sleeping, but it is still an under-researched area of medical care.

Best Cannabis Strains for Terminal Illness

Medical cannabis a versatile and natural therapy for people diagnosed with a terminal illness. The diverse health benefits of the cannabis plant address many of the common symptoms terminally ill patients face.

Here are some of the best strains of medical cannabis for terminal illness and the symptoms these strains treat:

  • Northern Lights. Northern Lights is an Indica strain of medical cannabis. Northern Lights help with many of the major symptoms that terminally ill patients experience, including pain, depression, insomnia and loss of appetite.
  • Sour Diesel. Sour Diesel is a Sativa strain of medical marijuana for terminal illness. Sour Diesel is an excellent strain for managing terminal illness symptoms like pain, depression, fatigue and loss of appetite.
  • Sunset Sherbet. Sunset Sherbet is a hybrid strain of cannabis, meaning it’s crossed between the Sativa and Indica strains. Sunset Sherbet helps relieve terminal illness symptoms like nausea, pain, insomnia and depression.

There are countless different strains that can offer relief for terminal illness symptoms. Be sure to consult your local dispensary experts for more information on choosing the right strain for you.

Best Cannabis Uses for Terminal Illness

If you’re planning to use medicinal marijuana to treat your terminal illness symptoms, then it’s important to decide how you’ll consume it. You have a few different options. Here are some of the options for consuming medical cannabis for terminal illness:

  • Inhalation. Smoking marijuana, or inhaling it, is likely the most common method of use for medical cannabis. In addition to being easy and convenient, inhaling marijuana also provides fast-acting relief. For people suffering from chronic pain or depression, this is an important consideration.
  • Edibles. Another option for consuming medical cannabis for a terminal illness is to take it orally. This can be done through a cannabis-infused edible product such as chocolate. While taking cannabis orally delays the effects, it is a much longer-lasting effect than inhaling marijuana. Additionally, many patients prefer edible products over smoking because it doesn’t cause respiratory problems.
  • Drinkables. Drinkable cannabis products are another great innovation when it comes to methods of consuming medical marijuana. Drinkables are cannabis-infused drinks that are easy and convenient to use. Drinkables some in soda-like products, or you can brew cannabis tea. Like edibles, the effects from drinkable cannabis products tend to be stronger and longer-lasting.

Cannabis Side Effects and Precautions

Medical marijuana for terminal illness is generally very safe to use. There are limited side effects for most people who consume medicinal cannabis products. Some patients who are suffering major depression because of their terminal illness diagnosis may be concerned that marijuana products may heighten their depression symptoms. However, there is no research to suggest that prescribed medical marijuana can harm the terminally ill.

Additionally, marijuana does not interact negatively with other end-of-life treatments. No amount of it will result in fatal overdose. Further research is necessary to see if these trends in medical marijuana use hold true. However, its use for terminal illness is promising thus far.

If you’re planning to take medical cannabis for terminal illness symptoms, it’s important to follow the dosage instructions exactly as prescribed. For many people, the effects of marijuana make take a while to kick in. This is why it’s important to start with a small dose and gradually build from there.

Medical cannabis is a safe, alternative remedy for treating many of the terrible symptoms associated with terminal illness. If you or someone you love has been diagnosed with a terminal illness and would like to learn more about medical cannabis as an alternative treatment option, make an appointment with a local, qualified physician through MarijuanaDoctors.com today or sign up for our newsletter.

Complete Article HERE!

Medical Marijuana Infogrphic

By Jessica K

It is known that 42, 249 people died in the United States in 2016 due to overdosing on opiods, as reported by Centers for Disease Control and Prevention (CDC). It began in 1990s with the popularity of prescription pills. In the early 2000s was with the rise in the use of heroin while the previous years have seen the use of fentanyl.

It is sad to know that people are not open to communicate about the opioid addiction so that they get the help they need. Breaking the stigma can support in overcoming the crisis. Moreover, doctors should take extra care while prescribing medications and making the patients aware about the side effects of these drugs as well as looking into alternative forms of medicine.

Cannabis is such an alternate medicine and an excellent natural herb which can help in relieving pain, anxiety, etc. There are various products available in the market, ranging from cannabis seeds to cannabis strains (like laughing buddha cannabis strain), CBD oil etc. Cannabis infused products can prove to be highly beneficial to people suffering from chronic illnesses.

While several countries are far from even considering legalization of medical cannabis, currently 29 states and Washington DC have permitted its legal use.

Why Cannabis For Palliative Treatment Is A Better Choice Than Opioids

By Prakash Janakiraman

Most treatments are meant to heal, but some are for palliative care (end of life care) in terminally ill patients. Palliative care is to provide symptomatic relief from a chronic and serious illness, and to reduce the risk of developing co-morbidities and also to improve the patient’s quality of life. The aim of the palliative care is not to treat or cure the underlying disease, but to treat the bothersome symptoms of the disease. Some of the illnesses that may utilize palliative care treatments include cancer, HIV/AIDS, ALS, multiple sclerosis, etc.

Finding a proper and safer course of treatment (long-term drug safety) is one of the main challenges being faced by palliative care practitioners. The goal of the drug regimen is to alleviate the symptoms as well as to mitigate the adverse events of these drugs. For palliative care of cancer patients, opioid analgesic is the prime choice of physicians, but it can cause serious harm – or even fatal events – in the long run.

The therapeutic potential of cannabinoids to treat sleep problems, pain and anorexia might play an important role in palliative care. Cannabinoids promote analgesia and inhibit inflammation via endogenous signaling, along with other benefits such as neuroprotection and anti-cancer activity, which are significant for terminally ill patients. In cancer patients, exogenous cannabinoids act synergistically with endogenous opioids and provide pain relief, opioid-sparing benefits and reduce opioid dependence and tolerance threshold. Cannabinoids may have palliative benefits not only for cancer patients, but also in neurodegenerative, HIV/AIDS and chronic pain patients. Despite these benefits, the use of cannabinoids in critical and palliative care patients remains controversial.

According to DEA classification, cannabis is a Schedule I drug that is hazardous and without any medicinal value. Most cannabis strains do not exceed 20% THC, whereas prescription drugs, such as Dronabinol, has a 100% THC-like substance, which has been classified as Schedule III drug. Naturally occurring cannabis has several ingredients that augment the treatment benefits and negate the adverse events. However, this is not applicable in synthetic, single compound cannabinoid formulation. To reduce opioid-related morbidity/mortality and improve palliative care in terminally ill patients, considering the cannabinoids as a mainstay pain management drug is the critical need at the moment.  

The risk-benefit profile of cannabinoid-based medicine greatly depends on the drug formulation and route of drug delivery.

Problems Associated with Palliative Care

Opioid overdose-related deaths are rising across the world and in the United States. Increased availability of synthetic opioids worsens the overdose mortalities, and most of the cases are due to misuse or accidental exposure. The widespread expression of mu-opioid receptors in the brainstem leads to increased binding of opioids, which also controls the respiration and is the cause of opioid overdose mortality. Overdose opioids bind with these mu-opioid receptors, which results in the suppression of breathing and death. Long-term opioid treatment also leads to development of tolerance, and the patient often requires incremental dose increases for better pain management. Although, mu-opioid antagonists, such as naloxone, are available to reverse overdose, it must be administered within few minutes of overdose crisis, which is not always possible. In addition to opioid tolerance, opioid dependence or addiction can develop during palliative care. Opioid addiction is a serious, relapsing and chronic neuro-psychiatric illness that requires long-term treatment for recovery.

The complete symptom burden of palliative care patients is poorly understood and opioid treatments may add up to other problems, such as severe constipation and prescription of laxatives to relieve constipation. According to a large assessment study that involved 50,600 Caucasian cancer patients who were on opioid therapy as palliative care, approximately 12% of patients reported moderate or severe constipation at the first assessment, and nearly 19% patients reported the same during the last assessment. All patients were on opioid therapy that resulted in moderate to severe constipation. Prescription of laxatives to treat the constipation is likely in these patients. The goal of the palliative care treatment is to relieve the symptoms, if not to mask the agonizing pain in palliative care patients including terminally ill cancer patients. Opioid therapy appears to be worsening the problems by causing/increasing distressing symptoms that require further treatments, which is undesirable and reflects the complexity and quality of palliative care treatment.

Why Cannabinoids Are Better Than Opioids In Palliative Care

While healthcare practitioners are in dilemma about prescribing medical cannabis for illnesses, the use of medical marijuana for palliative care is trending upward. Medical cannabis significantly reduces the use and dependence of opioids and also opioid overdose-related death. According to a study by RAND Corporation, there is a plausible link between the legal medical marijuana dispensaries and a reduction in opioid-related deaths in those areas. The study compared the rate of opioid-related deaths in states with and without legal marijuana dispensaries. As reported by the study, a lower rate of opioid-related mortalities (16-31%) and fewer reports of hospitalizations (28-35%) for related treatments were observed in states with medical cannabis dispensaries, compared to states without medical cannabis dispensaries. Patients who obtained treatment without legal intervention (penalized due to illegal substance use), further decreased the rate of hospitalization (up to 53%). The duration of the presence of legal marijuana dispensaries were also found to be related with the decline in opioid-related morbidities and mortalities.

Palliative care patients can easily obtain prescription medical cannabis from these legal dispensaries to reduce their reliance on opioids, prevent the opioid-related problems and also for better management of their symptoms. According to Nora Volkow, Director of the National Institute of Drug Abuse, the evidence about the efficacy of cannabinoids is strong and cannabis could ‘provide a powerful new tool’ to combat opioids and their related problems.

According to a comprehensive literature review of available studies, patients reported improvement in quality of life, and the improvements were considered as a therapeutic outcome by the patients. However, the healthcare providers raised concerns, and were in a dilemma about supporting the therapeutic cannabis use, as the used cannabis was illegally obtained.

A Norwegian study concluded that cannabinoids possess therapeutic effects in neuropathic pain, as well as moderate anti-emetic and appetizing effects in certain groups of patients. Due to non-availability of randomized clinical trials, the study authors were unable to recommend the medical use of cannabis. All of these symptoms and indications are applicable for palliative care cancer patients. To treat vomiting, anorexia and pain, a regimen of at least three drugs should be administered, and the patient must go through the side effects of these medicines. Instead of three drugs, cannabinoids as a monotherapy can be considered to treat all three symptoms, which are common in terminally ill cancer patients. Hence there are grounds to employ medical cannabis as a palliative care drug.

Analgesia is a common benefit shared by opioids and cannabinoids. However, cannabinoids differ from opioids in anti-nociception by the involvement of endocannabinoid system. Further studies suggested the additive effects of cannabinoids and opioids in pain modulation. Medications being prescribed to augment the opioid effects and to reduce the opioid doses are called opioid-sparing drugs. Cannabinoids can greatly increase the analgesic potency of opioids and thus relieve pain in lower doses of opioids. According to studies, cannabis greatly reduced the need for opioids, or even complete eliminated the need for opioid use. Additionally, the cannabinoids work synergistically in alleviating some of the symptoms of terminally ill patients, such as pain in end-stage cancer patients.

Clinical trial evidence found that oral cannabinoids (Sativex) provided better pain relief in opioid-refractory cancer pain than long-acting opioids. The treatment was well-tolerated by the palliative care patients. According to three randomized control studies, cannabis use significantly improved the appetite, weight gain and stabilized body weight in AIDS wasting syndrome. These benefits might be helpful for terminally ill patients suffering from cancer-associated cachexia.

Conclusion

Most of the systematic review studies that are inconclusive or even against the use of medical cannabis have assessed the randomized clinical trials of synthetic cannabinoids such as Dronabinol but not plant-derived cannabinoids. Even some of the studies that assessed the natural cannabinoids lacked adequate statistical power due to flawed clinical trial design. Assessing these studies cannot provide a definitive conclusion.

Conventionally, palliative care management for most of diseases – including cancer – is opioids. Due to inevitable risk of tolerance, the patient has to take more and more narcotics, even if the drug provides little relief. Higher doses can make the patients become more confused and lethargic, with the risk of developing depression, anorexia, nausea and vomiting.

Cannabis could definitely reduce the dosage of these narcotics and also improve the symptoms by its synergistic actions. For terminally ill patients, marijuana could reduce the anguish, improve the quality of life and may also add days to their life.

Complete Article HERE!

There is more than one way to die with dignity

By I

“Who are you here to see?”

On this day, I was at Mount Sinai Hospital, in the oncology ward. The receptionist I usually check in with wasn’t at her desk. I was being greeted by a volunteer. Dark hair, wide eyes and a smile like a child’s doll. High school co-op student, maybe?

I handed over my health card and told her my doctor’s name.

“I’m sorry, I don’t know who she is. What are you here for?”

Her smile widens.

“Because I’m a patient?” I retort.

I know I’m being rude. But it’s an oncology ward. What does she think I’m here for? To discuss the weather? The shortage of wheelchair-accessible parking spaces in the lot?

What I really want to say is, my doctor is a palliative-care specialist. I’m seeing her because I have cancer. I’m preparing for my death.

I don’t look like I have cancer, let alone the incurable kind. I have all my hair. My friends and husband assure me my colour is good. Dressed in my normal clothes and not the pajamas I currently favour, I look reasonably well – for a middle-aged woman who also has spinal muscular atrophy, a congenital neuromuscular condition.

I rely on a motorized wheelchair to get around and need personal support workers to assist me in all aspects of daily living. It’s been this way forever, but now I have colon cancer, and two external abdominal bags to collect various bodily fluids.

This, to put it mildly, complicates things.

My palliative-care doctor is a compassionate young woman who wouldn’t look out of place in a medical drama. She has been guiding me through my own recent hospital drama: I was readmitted to hospital a couple of weeks earlier, for yet another emergency.

I’ve been fighting off a major abdominal abscess for more than a year now. At one point, my abscess was so large, one of my doctors admitted surprise that I was upright. This is what initially led to my cancer diagnosis. A colon biopsy confirmed the cancer was malignant. In October, I was told my cancer was inoperable, despite 28 rounds of radiation.

At least it’s not metastatic. Localized, but nowhere else. For now, anyway. Plus, my surgeon tells me, I likely have years with this cancer. Not months or weeks, like some of his other patients.

The challenge now is the infection associated with the abscess. During this current crisis, antibiotics are working. What my surgeon can’t tell me is when the next infection will hit, or when antibiotics may fail.

Some patients reinfect every month, he tells me. I’ve done well, he adds. I tell him I couldn’t handle being hospitalized every month. He acknowledges I would need to evaluate my quality of life, if this became my reality. In that moment, my decision to seek palliative care early seems the smartest decision I’ve made in a while.

Like most Canadians, I had limited understanding of palliative care before I had cancer. To me, “palliative care” was synonymous with “you are about to die.”

That’s not the case. On my first palliative visit, the doctor explains the word is Latin for “to cloak.” She personally likes that, seeing her role as guide and protector to patients who are coping with the most difficult time of their lives.

I need her guidance. There is no clear path around how to deal with cancer while living with a disability. I’m used to being disabled. It’s my normal. My quality of life up to now has been exceptional, complete with a husband I adore, a sweet, sassy daughter and a brand-new career.

Like everyone else diagnosed with cancer, my life has suddenly imploded. I find myself in this new world, navigating how to continue while knowing the end is coming much sooner than I’d like.

That’s why I’ve sought out palliative care. My own research leads me to studies showing that having a palliative-care expert can help me prolong my quality of life through the management of symptoms, such as pain that I know will likely worsen over time. My family doctor concurs, telling me outright that I need this.

This new relationship has enabled me to talk about my greatest fears. After my conversation with my surgeon, I fear dying slowly of sepsis, waiting for my organs to fail. I’ve agreed to a Do Not Resuscitate order, which ensures I won’t be hooked up to machines in the ICU, prolonging The End.

During this particular admission to hospital and based on what my surgeon has said, my choices seem stark. Down the road, I could die slowly from an infection that will shut down my organs, or sign up for a medically assisted death.

Then, my palliative-care doctor arrives at my bedside. She points out I have bounced back from severe, acute episodes before. She also knows I don’t want an assisted death and takes the time to explain there are options available, such as palliative sedation, a process where I can have large doses of morphine to keep me comfortable. She firmly tells me I am not close to needing this. My goal needs to be focused on getting better and getting home, to my daughter.

As she explains this, I start to relax. She’s given me the window I need to live my life, as compromised as it now is. It is not the life I would have chosen, but it still has meaning. My task now is to figure out what that meaning is. And her task is to help me to define my priorities while maximizing the quality of my life with medical therapies and emotional support.

It’s an interesting time to be thinking of my life as a person who is both disabled and has cancer. Less than two years ago, the federal government enacted a new law enabling Canadians with incurable conditions, whose death is foreseeable and are suffering irremediably, to ask a doctor to end their lives.

It’s been called “dying in dignity,” but for me, that’s not the way I want to go, at the hands of a doctor, wielding a poisoned syringe.

I believe no one with a terminal illness should be forced to endure suffering – but, if there is one lesson for me in the past year, death is not the only way to alleviate suffering. Managing physical suffering feels like traveling a winding road. Some days, it feels never-ending; other days, manageable, almost like the life I had before. Some days are so bad, I’m convinced death really is the only relief, but I’m brought back to reality when I think of what I could miss out on.

My life is definitely smaller now. I doubt I will ever work full-time again. I barely leave my apartment. Thanks to my father’s financial generosity, my husband has been able to take unpaid leave from his work to be with me. The time we spend together is precious. Even in its ordinariness, it is meaningful.

I appreciate the world differently now. It is as though time has slowed for me to see the small details of life, whether it be the softness of my bed sheets or watching snow drift down through my apartment window.

I’m trying to live with dignity, as I always have, despite the very real medical indignities I have been subjected to.

Which is why it dismays me greatly there are continuing attempts to make it easier for people without terminal conditions to ask a doctor to end their life. It dismays me that a lobby organization calling itself Dying With Dignity is not actively lobbying for increased access to palliative and hospice care, or advocating for more community supports for people with disabilities to live as productively as possible. In other words, to live with dignity.

We are all going to die, but before we do, each one of us has a right to a good quality of life, even to the very end. Yet too many Canadians do not have adequate access to palliative and hospice care. The lobbying efforts of those to equalize this are rarely discussed in our media.

I’ve chosen my path, thanks to the help of empathetic doctors and my own advocacy. My hope now is that more Canadians have the right to do the same, without the implied suggestion there is only one real way to die with dignity.

Complete Article HERE!

How complementary therapies can positively impact end-of-life care

By Mary K. Spengler

One of the most common misconceptions about end-of-life care is that the focus is solely on pain management. While that is a key component of any hospice care program, many providers, including Hospice of Westchester, recognize the importance of a holistic approach to treating the patient, not just their symptoms. It is a proven fact that patients diagnosed with a life-limiting illness greatly benefit from alternative therapies, in addition to medical treatment.

Often called complementary care, these therapies can maximize patients’ comfort and peace of mind and provide relief for their primary caregivers.

Caring for the “whole” patient is an essential feature of hospice. Mind-body complementary therapies such as massage, reflexology, music therapy, art therapy and pet therapy can help ease tension, reduce anxiety levels and improve the overall comfort of the patient.

A good hospice provider should arrange for these therapies to be provided in the patient’s residence, whether that be their home, a hospital or a skilled nursing facility. Together, the patient, their family and hospice team decide which therapy would best address symptoms of pain, stress and anxiety.

We are proud to offer all of the above therapies, at no cost to our patients, through The Anna & Louis H. Shereff Complementary Care Program. While they all can be useful depending on a patient’s needs, here is a closer look at how massage therapy and reflexology can positively benefit hospice patients and their families.

MASSAGE THERAPY
It is widely accepted that power of touch can have a healing impact on pain and decrease stress. Massage is a form of structured therapeutic touch, which can relax patients, relieve muscle tension, reduce anxiety levels and blood pressure, boost the immune system and moisturize the skin.

Licensed massage therapist Maria MacIlvane first recognized the positive effect of touch years before she started her massage career. When her mother was on hospice care, MacIlvane was awed that simply rubbing her mother’s shoulders would instantly bring upon relaxation.

“I continued to massage her every day. It was so beneficial and I could not believe that just touching someone compassionately could affect the process they were going through so deeply,” MacIlvane said.

After the death of her husband in 2007, MacIlvane needed a change and wanted to pursue a career she was truly passionate about. She became a licensed massage therapist in 2010 and expanded her therapies to hospice patients three years ago.

MacIlvane said there are many benefits of massage therapy on patients diagnosed with a life-limiting illness, including helping with muscle tension, circulation and anxiety. She also works with patients’ family members to teach them what they can do in between sessions to help their loved one, and even gives them tips for acupressure that can help with their own anxiety and stress.

“When patients know that someone is with them, holding their hand and providing a compassionate touch, the effects are amazing,” MacIlvane said.

REFLEXOLOGY
Reflexology is based on the belief that specific areas of the feet and hands correspond with specific parts of the body. Gentle stimulation of these areas with the thumbs and fingers relieves stress and tension, improves circulation, promotes normal body function and results in a feeling of deep relaxation.

Gabrielle Zale, a nationally certified reflexologist, began working with hospice patients shortly after starting her career 17 years ago. However, her knowledge of how touch could help those with an illness started many years earlier. She remembered how people pulled away from her own mother when she was sick, as if they were afraid to touch her.

“No one should feel that alone,” Zale said. “Ultimately, touch is the greatest healer, particularly at this final journey in life. Even though some patients may not be awake and alert, by touching them in this way you are acknowledging that they are still there and still part of the world.”

Zale said that, even if a patient can’t speak, she is able to sense small body changes that show the effects of her practice. “It’s a subtle energy shift. Their breathing slows down — you can tell they are relaxing and may be feeling less pain and anxiety. They can tell that you are acknowledging them and are really present with them,” she said.

“This work is a really sacred thing for me. I’m not just holding another person in my hands, I’m holding their soul in many ways.”