Medical Marijuana

This is a controversial subject, so please keep an open mind as you read.

Disclosure: I do not use marijuana. I smoked a little in high school and during college, but like a lot of things I did when I was young, I out grew it. Getting high is not fun to me. I do not like the way drugs or alcohol make me feel and I do not condone recreational use of any drug.

Another Disclosure: I have worked with patients who used medicinal marijuana, legally prescribed and obtained in the state of California or Oregon. I support the legalization for medicinal purposes only – not recreational. Please, if this treatment is desired, do so legally and let your doctors know. This is a drug, and it may react with other medications.

Okay, now with that out of the way, I hope you understand I would not publicly support the use of medicinal marijuana unless I knew it would benefit my patients, other patients, and babies. Yes, babies, adults, senior citizens. Terminal conditions, chronic conditions, and temporary conditions. It is not for everyone, and does not treat all conditions. I am most familiar with cancers, seizures, nausea, anxiety, and pain.

Kentucky Senator Morgan McGarvey filed a bill in the 2017 legislative session, and he recently spoke in front of the Interim Joint Committee on Health and Welfare and Family Services. If passed, medicinal marijuana will be available through physician recommendations and only for extreme end of life cases. Some believe the bill is too restrictive and the much needed drug should be more accessible for chronic conditions and for those going through cancer treatment, not just at the end of life. Any legislation is better than no legislation, I believe, because it initiates discussions about the therapeutic effects of cannabis. It would also prevent the arrest of dying patients who buy weed from the neighbor’s kids so he can eat a meal without vomiting.

Cannabis plants have over 300 identified cannabinoids. Hemp cannabis contains very few cannabinoids and those that are present have nearly no medicinal properties. Medicinal marijuana comes mainly from two types of cannabis plants: sativa and indica. Each strain, or unique breed, has a different ratio of cannabinoids (see links below for more information). I can attest that patients do benefit from use of THC, CBD, CBC, or a hybrid, but the CBD oils and tinctures do not have the “high” that most people associate with marijuana as that comes from the THC.  Clinical trials support the use of CBD oil to control seizures in children and adults.

I will not disclose the identity of any patients, but here are some of my experiences of those using medicinal marijuana:

A 92 year old female, stomach cancer spread to bones in hospice. She couldn’t tolerate narcotics, so she smoked a joint every morning and ate a brownie at night.

A 75 year old woman with colon cancer in hospice developed severe abdominal pain with intractable vomiting and pharmacy prescriptions didn’t work.  The family begged for another option. I said I’d call the doctor for a recommendation, but they had their own plan. I never asked where they got it but within 24 hours her pain and vomiting was gone. She was sitting up eating tapioca pudding, smile on her face.

A 50-something year old man, had never used marijuana until diagnosed with brain cancer. Used it to control seizures by inhaling nebulizer tincture of CBD. He was a physicist, and felt the CBD kept his mind more clear than narcotics.

A very ill 6 year old boy, on hospice due to a genetic disorder that caused multiple seizures daily, as many as 200 a day…nearly constant seizures. He took multiple medications, all given through a tube in his belly. The family moved from their life-long home to a state with legalized CBD oil and a clinical trial.  A month later, he talked for the first time and started eating real food. Three months later, he discharged from hospice and the feeding tube removed. Six months later, he went to school for the first time. Today he takes CBD oil three times a day and just a couple other medications. Best happy ending I’ve seen.

 

Check out these links:

Senator pushes to legalize medical marijuana in Kentucky
http://www.wlky.com/article/senator-pushes-to-legalize-medical-marijuana-in-kentucky/10203686

THC, THCA, CBD, CBC, CBN: Medical Marijuana Composition, The Chemicals in Cannabis
https://unitedpatientsgroup.com/blog/2014/04/11/thc-thca-cbd-cbn-the-chemicals-in-cannabis

The ‘nuns’ that grow medical marijuana
http://www.cnn.com/2016/04/07/health/cnnphotos-marijuana-nuns-sisters-of-the-valley/index.html

Why I changed my mind about medicinal cannabis | Hugh Hempel | TEDxUniversityofNevada

Cannabis oil treatments are helping children with seizures

Marijuana saves father’s son

 

The Inpatient Hospice

Hospice works to provide caring, compassionate care while death occurs naturally.

There are many patients who I will never forget.  Some died in my arms.  Some had amazing families.  Some lived in abusive conditions, extravagant homes, or on the streets.  What I’ve learned in my adventures is that everyone has a story, and I am honored and humbled to be a part of and to witness a few moments at the end of their story.

One of the first nights I worked at the inpatient unit I admitted a young man.  He was in his twenties, over 400 pounds, and trached (this is when a tube is placed through the throat in order for you to breathe, sometimes with a ventilator).  The ambulance bought him in after his family called; they could not care for him and they wanted him transferred out of their home right away.  He was dying.

Hospice transfers patients from home to the inpatient unit during periods of crisis, uncontrolled pain, new onset of seizures, or other medical reasons.  Transfers were not uncommon, even during night shift. It was the middle of the night and he arrived alone, no one but uniformed paramedics accompanied him.  This was a young man who required a lot of help – he couldn’t move himself, clean himself, or communicate easily.  He was alert; he was having difficulty breathing, and he seemed to be in pain.  Did I mention he was actively dying?

I assured him I would do everything to help get him comfortable.  He tried so hard to say something to me, but the tube in his throat that kept him breathing also prevented his vocal cords from working.  I got closer, listened as best I could, and was shocked.  “Kill me,” whispered through his trach.  I pulled back with wide eyes, not sure if I’d heard correctly.  That’s not how hospice works!  Hospice provides caring, compassionate care while death occurs naturally, but we do not euthanize patients.  He grabbed my wrist, using every bit of energy to repeat “kill me, please.”  It was clear that time, said with his pleading eyes and his trembling body.

His breathing was labored and he grimaced when moved, so I said “I’ll get you some pain medication.”  His eyes squeezed shut, tears rolling to his side.  He was in pain and I could treat that, but I couldn’t kill him… that’s not what hospice does!  But he was saying it, no doubt in my mind.  It seemed he’d been through so much and a young man in his condition was not what someone would think of as dignified.  He was in pain, so the Dilaudid and Ativan I gave helped him relax.  I was still at a loss.

Thank goodness the other nurses on duty where experienced and I asked them to take a look, curious to see what they thought.  “He’s still in pain,” the charge nurse said, “give him another dose of Dilaudid with Ativan.”  I gave the maximum the doctor ordered three more times before my shift ended.  The next night I worked, he was gone.  No one mentioned him, but I had to ask.

“The doctor came in and increased his medications.  He died peaceful around noon.”  The nurse told me she was with him when he took his last breath.  No family came; no one at their home even pick up the phone when she called so a message was left that his remains were sent to the mortuary.  They still hadn’t called back when I arrived that night.

I was appalled at how the family treated this young man during his last days.  Thank God they had the decency to send him to hospice and allow the loving, compassionate nurses there to take care of him.  No one should be in pain – physical, emotional, or spiritual.  The hospice nurses, including myself, made sure this young man was cared for, comfortable, and died with as much dignity as possible.

Why Hospice?

Anne showed me my path in nursing.

I am often asked why I chose to work in hospice and palliative care.  There isn’t one answer to this question other than to say it was a calling. There is such a spiritual side to hospice; it’s so much more than giving IV medications and changing bandages.  I don’t consider myself an expert in end of life care, and I know I’m not the best hospice nurse in the world, but I find caring for those facing the end of their time to be extremely rewarding. I know it’s a totally selfish reason, but the people I have met in this journey have given me purpose, inspiration, insight, love, and hope. I have seen pain and bliss, anxiety and peace, loneliness and friendship. I have seen things that are difficult to explain.

The first time I thought about becoming a hospice nurse did not involve a patient transitioning to hospice.  A recently employed RN coordinator at a skilled nursing facility, I was still adjusting to the change from acute care on a busy post-surgical unit to long-term care.  My office was across the hall from assisted living rooms where the frail, elderly residents sat at their doors waiting for someone – anyone – to visit.

I realized that many of the wonderful residents of this facility did not have family nearby, including a lovely 99 year old lady who we’ll call Anne. Born in England in 1896, the 75 years living in the U.S. has faded her British accent so just a trace remained.  She was elegant, polite, kind, and amazingly fit for nearly a century of wear and tear.  We started with simple greetings in the hallway, then like a moth I was drawn to the light in her gentle soul and started visiting her as much as possible.  At times we would eat lunch together in her room or I’d bring her homemade cookies. We became close, maybe because my grandmother passed the year before, maybe because we were kindred spirits.

Anne may have been the most independent resident in the assisted living rooms.  The nursing home was square with a courtyard in the middle, and I remember she walked the inside circle after every meal, pushing that walker with the pink basket as fast as she could go.  I was not aware at the time, but now I recognize much of her routine is common among centenarians. She ate mostly vegetables; she always had an afternoon nap and went to bed early.  She maintained friendships with many other residents and staff, and she always saw the glass half full.  Anne was always a positive ray of sunshine in the dismal surroundings of a nursing home.

As her 100th birthday approached, her family contacted the facility to arrange a space for a celebration. Family came from New York, Tennessee, Colorado, and Hawaii where she spent most of her married life as a Navy wife.  She moved to the mainland when her husband retired, and she joked that most people in Indiana want to retire in Hawaii yet she did the opposite and ended up in Indiana. Her husband died decades before and was buried in Indianapolis next to their oldest son; she remained there because it had become her home.  To her five children, 17 grandchildren, and many great-grandchildren, Indiana had become the central meeting point for family reunions, including her 100th birthday party.

I remember family showed up a week before the celebration, trickling in for visits as they arrived.  Anne was the happiest I’d ever seen her.  No more waiting at the door for visitors – they waited at her door to have one-on-one time with this amazing family matriarch.  She pulled volumes of photo albums from the top of her closet and went through photos from England, Italy, Hawaii, and from every vacation she had taken with her husband.  She reminisced with family right up to the afternoon she blew out 100 candles (she had a little help).  After the cake was devoured and the guest had left, Anne went to her room to eat her dinner like it was any other day.  I stopped by before going home to see how she was doing.

“I’ve had the best time today.” She remarked. “Seeing my family together again warms my heart.”

“That’s great, Anne,” I replied.  “You will have so many new pictures that you’ll need another album.  You can share them with your family next year on your 101st birthday.”

“Oh no,” she said matter-of-factly.  “That will be the last time my family gets together like we did today.”

“I will have the film developed when I go to the store tonight.  They have a instant photo booth.”  I planned to surprise her with a new photo album.

“I have lived 100 years and I think that is enough for me.  I’m ready to go home now.  I’m ready to be with the Lord.”  She seemed at peace, staring into the distance. I didn’t think much of that comment because most older people talk like their next birthday isn’t a given, and I suppose it isn’t for any of us.  Besides, she was exhausted.  She might have been spry for 100 years old, but she missed her nap and all the visitors during the week had been a little overwhelming at times.

“You get some rest tonight.”  That’s all I said before I left.

The next morning I noticed she wasn’t in her room watching the national news headlines during breakfast, which was part of her daily routine. I stepped in and saw her bed was not made and her dentures were still in the cup on her night stand.  I immediately checked with the nurse’s station to see what was going on.

“I don’t know, she just died,” the night nurse said as she was leaving.  “She was fine at 4:00 a.m. bed checks, then at 6:00 o’clock she was gone. Died peacefully in her sleep.”

“She went as gracefully as I’ve ever seen anyone die,” commented another nurse.

“That’s crazy!”  It’s all I could think, because it was absolutely bonkers that this perfectly healthy woman died on her 100th birthday, or technically the day after. Sure, she was a centenarian, but there were no medical issues that would have caused her to die suddenly.

“Oh Sweetie,” the older nurse commented. “After you’ve been around a while, you will see a lot of crazy things.”

Looking back I believe Anne had simply decided to die.  I can’t explain how someone could do that – to control their body or have it cooperate with their decision, but I certainly understand why Anne would have if she could have.  She told me herself she was ready to go.  I heard her but I did not listen, something I vowed to change going forward.

This is when I realized the magnitude of the nurse’s presence with those facing end of life.  I was one of the last people to speak with Anne.  I also witnessed how death can be a moving, miraculous event. Most of Anne’s family was still in town, and those who could, stayed for the service. Those who had to leave were grateful they had the chance to see her once more. What an honor to have known her, to spend time with her in her final days. It was Anne who showed me how natural and beautiful the end of a life can be, and it was Anne who inspired me to walk the path to hospice nursing.