A central feature of palliative care philosophy is the improvement in quality of life for people with life-limiting illnesses (WHO 2008). Good symptom management and the recognition of physical, psychological and social needs are central to the provision of optimum palliative care and are necessary components of an approach which aims to maximise quality of life. Although there are many treatment options available in palliative care, medications are most often used to combat distressing symptoms (Walker 2010). Optimising medication regimens to decrease the burden of symptoms is not only important for physical comfort but can also impact on spiritual, emotional and psychological well-being. Whilst a palliative care approach currently advocates a wide range of treatments to manage symptoms and improve quality of life, opportunities for the development of new treatment options are constantly being considered and researched to further increase the spectrum of evidence-based therapies.
The literature review by Green and De-Vries (2010) explores the evidence relating to the use of cannabis within palliative care. The review draws on literature which explores the history of cannabis and the debates surrounding its use as an illicit drug. The history of palliative care is deeply rooted within the field of oncology, with the discipline developed to improve the care of patients with terminal cancer (Clark 2007). In recent years, the recognition that patients with non-malignant life-limiting disease have significant needs and requirements at the end of life has led to the focus of palliative care shifting to encompass the care of all patients with life-limiting conditions (Ingleton & Seymour 2008).
The evidence base for the palliative care needs of patients with life-limiting non-cancer conditions is now well established, and research has identified that prevalent chronic conditions such as chronic obstructive pulmonary disease (COPD) and heart failure are associated with high symptom burden and poor quality of life (Barnes et al. 2006, Gardiner et al. 2010, Green et al. 2010). Despite this evidence, pharmaceutical research within palliative care continues to predominantly target cancer as the first-line condition for consideration of new therapies and treatments (Carter & Mackreith 2008). This is evident in the current review by Green and De-Vries (2010) from the high proportion of studies relating to cannabis use in oncology, and the relative dearth of studies relating to non-cancer conditions. Whilst some limited evidence was identified relating to the use of cannabis in neurological conditions such as multiple sclerosis and motor neurone disease, the spectrum of research attention does not seem to accurately reflect the profile of patients with palliative care needs.
Whilst a cancer model is clearly highly relevant for research in palliative care, caution should be exercised when evaluating palliative care interventions based solely on studies in oncology. Establishing the efficacy of cannabis as a viable treatment option for palliative care requires a careful assessment of its effects in a wide range of conditions. Whilst such evidence is not yet available, recognition of the need to pursue research outside the fields of oncology and neurology is necessary in order that the evidence base be expanded appropriately.
Evidence for the efficacy of cannabis in cancer pain control remains inconclusive; however, cannabis derivatives have been approved for use in other areas (e.g. nausea control, sleep improvement, appetite improvement), and it is suggested by Green and De-Vries (2010) that the benefits of cannabis may be most relevant in relation to quality of life. They note that there is a steadily growing research evidence base to suggest that quality of life is enhanced by the use of cannabis in palliative care (Green & De-Vries 2010). Consequently, health professionals may increasingly find themselves faced with patients who are using, or wishing to use, cannabis for therapeutic purposes.
The dilemmas facing such health professionals should not be underestimated, and acknowledgement of issues such as the efficacy of cannabis, patients personal choice and the illegality of ‘street bought’ cannabis must all be considered before advice can be given. In addition, there may be difficulties for many health professionals who provide palliative care for patients in a non-specialist setting. In the UK for example, the majority of palliative care (especially for patients with non-cancer conditions) is provided not by specialist palliative care teams but by ‘generalist’ providers. Generalist palliative care is provided by health care professionals (such as Family Doctors, community nurses and hospital nurses) who provide palliative care as a core component of their usual routine care (Shipman et al. 2008). Generalist palliative care forms a key component of good end of life care; however, evidence suggests that optimum palliative care provision can be hampered by a lack of recognition that patients have palliative care needs (Gott & Ingleton in press). Patients with non-cancer conditions may be particularly vulnerable to suboptimal palliative care provision because of difficulties with forming an accurate prognosis, a focus on curative care and a lack of consensus regarding what constitutes palliative care in non-cancer conditions (Gott et al. 2009).
Generalist providers, especially those in primary care settings, often have long-standing and trusting relationships with patients and are commonly at the front line of enquiries relating to sensitive issues. As a consequence, it may commonly be generalist providers such as community-based nursing practitioners who will be faced with enquiries relating to cannabis use. Whilst Green and De-Vries (2010) recommend that nurses need to be well informed about the medicinal effects of cannabis, caution should be exercised when discussing the use of cannabis given the difficulties that exist with identifying and recognising patients with palliative care needs. In addition, generalist providers of palliative care have reported difficulties with incorporating palliative care into a generalist workload and have questioned the role of palliative care outside a specialist setting (Payne et al. 2008). As such, it can be assumed that significant challenges will exist for ‘generalist’ nurses who are asked to give advice to patients exploring cannabis use for the purposes of palliation.
It is clear that there are many issues and concerns facing health professionals involved in the care of patients who chose to use cannabis for therapeutic purposes. Many of these issues are exacerbated by patients who choose to use cannabis to improve their quality of life or alleviate symptoms in life-limiting conditions. Further research is clearly required to assess the effectiveness of cannabis for use in palliative care. However, without a step change in perceived roles and responsibilities for providing palliative care and improved recognition of patients with potential for palliative care input, any therapeutic advances may be inadequately implemented.