Cannabis Use in Hospice and Palliative Care: Promise, Pitfalls, and Patient Education

Cannabis Use in Hospice and Palliative Care: Promise, Pitfalls, and Patient Education

The use of cannabis for symptom management in hospice and palliative care patients is an evolving and often controversial topic. As families increasingly inquire about or even initiate cannabis use for their loved ones, healthcare providers must be prepared with balanced, evidence-based guidance. While cannabis may offer some relief for symptoms like pain, anxiety, nausea, and agitation, it carries important risks that can undermine the goals of palliative care if not carefully managed.

Cognitive and Psychiatric Risks

Cannabis use can worsen cognitive impairment, a particularly troubling risk in hospice populations where delirium and confusion are already common. Tetrahydrocannabinol (THC), the primary psychoactive component, is well-known to cause sedation, memory impairment, and in some cases, acute delirium. Such effects can rob patients of meaningful interaction with loved ones in their final days. Additionally, psychiatric side effects like anxiety, paranoia, mood disturbances, or even psychosis may emerge or worsen, particularly at higher doses of THC.

Cardiovascular Risks

The cardiovascular effects of cannabis are significant yet often under appreciated. THC can acutely increase heart rate and blood pressure. In frail hospice patients, particularly those with congestive heart failure, arrhythmias, or severe coronary artery disease, these effects can increase the risk of cardiac events. Conversely, cannabis-induced hypotension can lead to falls, a major safety concern among palliative patients with fragile mobility.

Pulmonary and Gastrointestinal Risks

Smoked or vaporized cannabis can irritate the respiratory tract, posing dangers for patients with chronic obstructive pulmonary disease (COPD), lung metastases, or pulmonary infections. Sedation from cannabis can also impair the swallow reflex, raising the risk of aspiration pneumonia, a life-threatening condition in compromised patients.

On the gastrointestinal front, providers must be vigilant for the paradoxical cannabinoid hyperemesis syndrome, a cyclic vomiting illness triggered by chronic heavy cannabis use. Though rare, it can cause profound dehydration and complicate symptom management.

Drug Interactions

Cannabis compounds, particularly cannabidiol (CBD), inhibit cytochrome P450 enzymes, which metabolize many medications common in palliative care. This interaction can unpredictably increase or decrease blood levels of opioids, benzodiazepines, anticoagulants, and other critical medications. Such changes can lead to oversedation, inadequate symptom control, bleeding complications, or withdrawal phenomena, necessitating close monitoring and medication adjustment.

Legal and Ethical Considerations

The legal landscape surrounding medical cannabis remains fragmented. While many U.S. states allow medical use, cannabis remains federally illegal. Hospice agencies receiving federal funding may have policies restricting the use of cannabis in their programs. Providers must balance legal compliance with patient autonomy and advocate for transparent, well-documented discussions when cannabis use is considered.

Impact on Symptom Management Goals

Perhaps the most under-appreciated risk is how cannabis can subtly shift the focus away from symptom assessment and best-practice interventions. Excessive sedation, masking of pain, or worsening psychiatric symptoms can erode the fundamental hospice goals of maximizing comfort, enhancing quality of life, and preserving meaningful communication at the end of life.

Best Practices for Providers

When approached about cannabis use or considering its incorporation into a care plan, hospice and palliative care providers should:

1. Conduct a Comprehensive Assessment: Carefully evaluate the patient’s symptom burden, prior responses to standard therapies, and goals of care.
2. Educate Patients and Families: Clearly outline the known risks, potential benefits, and limitations of cannabis use, emphasizing that cannabis is not a benign or universally appropriate intervention.
3. Advocate for Safer Options: When possible, recommend CBD-dominant formulations, which may have fewer psychoactive and cardiovascular side effects. Avoid smoked forms.
4. Monitor Closely: Initiate cannabis treatments cautiously and monitor for changes in cognition, sedation, falls, appetite, psychiatric symptoms, and drug interactions.
5. Collaborate Across Disciplines: Engage pharmacists, social workers, legal counsel, and hospice leadership to create consistent policies and support safe use.
6. Document Thoroughly: Ensure all discussions, consents, and treatment outcomes related to cannabis are well documented in the medical record.

Essential Family and Caregiver Education on Cannabis Risks

Education for families and caregivers should address several critical points:

• Acknowledge Their Concerns: Recognize the family's desire to ease suffering and validate their efforts to seek comfort for their loved one.
• Limited Evidence: Explain that while cannabis may help some symptoms, scientific studies are limited and generally low in quality.
• Specific Risks: Review the dangers of worsened confusion, sedation, falls, psychiatric disturbances, cardiovascular effects, lung complications, drug interactions, and paradoxical vomiting syndromes.
• Formulation and Dosing Matters: Emphasize that edibles or tinctures are safer than smoking and that CBD-dominant products are generally preferred. Stress "start low and go slow."
• Cannabis as Adjunctive Treatment: Reinforce that cannabis should complement, not replace, standard hospice symptom management.
• Monitoring and Red Flags: Educate caregivers to watch for new or worsening confusion, sedation, agitation, breathing issues, and falls, and to report concerns promptly.
• Legal Considerations: Clarify that cannabis remains federally illegal, and hospice organizations may have specific policies limiting involvement with its use.
• Offer Compassionate Support: Reassure families that providers are committed to optimizing comfort and dignity, whether or not cannabis is included in the care plan.

Example closing message to families:

"We understand you want to do everything possible to make your loved one comfortable. Cannabis might help in some cases, but it also carries important risks, especially when a person is already frail or medically complex. We're here to work closely with you, guide you through all options, and make sure that any decision we make together honors your loved one's comfort, safety, and dignity."

Conclusion

Cannabis may offer select hospice and palliative care patients symptom relief when conventional therapies fall short. However, its use demands a sober and cautious approach. The risks — cognitive, psychiatric, cardiovascular, pulmonary, gastrointestinal, pharmacologic, and ethical — are real and can be devastating if not properly anticipated and managed. 

Providers must prioritize thorough assessment, honest education, close monitoring, and interdisciplinary collaboration to ensure that cannabis use, if pursued, aligns with the ultimate goals of palliative care: comfort, dignity, and quality of life at the end of life.

References

Doppen, M., Kung, S., Maijers, I., John, M., Dunphy, H., Townsley, H., Eathorne, A., Semprini, A. and Braithwaite, I., 2022. Cannabis in palliative care: a systematic review of current evidence. Journal of Pain and Symptom Management, 64(5), pp.e260-e284.

Herbert, A. and Hardy, J., 2021. Medicinal cannabis use in palliative care. Australian Journal of General Practice, 50(6), pp.363-368.

Green, A.J. and De‐Vries, K., 2010. Cannabis use in palliative care–an examination of the evidence and the implications for nurses. Journal of clinical nursing, 19(17‐18), pp.2454-2462.

Kogan, M. and Sexton, M., 2020. Medical cannabis: A new old tool for palliative care. The Journal of Alternative and Complementary Medicine, 26(9), pp.778-780.

Razmovski-Naumovski, V., Martin, J.H., Chye, R., Phillips, J.L., Lintzeris, N., Solowij, N., Lee, J., Lovell, M., Noble, B., Galettis, P. and Brown, L., 2025. Design Considerations for Medicinal Cannabis Clinical Trials in People Receiving Palliative Care. Journal of Pain and Symptom Management, 69(5), pp.e395-e408.