As a Direct Primary Care physician and an active hospice medical director, I practice at both ends of the spectrum of care—helping patients build health over time, and helping them find comfort and dignity at the end of life. It is from this perspective that I see, with absolute clarity, where our system is failing patients most.
In hospice care, our responsibility is simple and sacred: relieve suffering and preserve dignity at the end of life. Yet every day, we are forced to practice within a system that actively limits our ability to do just that.
Patients dying from conditions like pancreatic cancer do not experience mild discomfort. They experience relentless, escalating pain driven by tumor burden, inflammation, and nerve invasion—pain that is constant, crushing, and inescapable.
Patients often struggle to even find words for it. Some describe it as if their internal organs are on fire and being stabbed at the same time. Others describe a sensation of being torn apart from the inside, or as if their body is trapped in a vice that never releases. It is not intermittent. It does not let up. It follows them through every moment—awake or asleep—eroding both physical comfort and emotional resilience.
And despite this, our primary tools remain opioids.
Opioids can be helpful, but they are profoundly limited. Many patients do not achieve adequate relief, even with escalating doses. And the cost of those higher doses is significant: sedation, confusion, delirium, nausea, and severe constipation that can progress to bowel dysfunction or even small bowel obstruction—creating an entirely new source of suffering.
And then there is the most serious limitation of all: respiratory depression.
At a certain threshold—one that varies by patient tolerance—opioids suppress the drive to breathe. This creates a ceiling effect in real-world practice. There are patients who want to remain as alert and present as possible, who do not want to be pushed toward heavy sedation or risk further respiratory compromise. Yet we are constrained by the reality that increasing doses to chase pain relief can come at the cost of suppressing breathing itself.
So we are left balancing on a narrow edge—trying to relieve severe, complex pain with medications that are both incomplete in their effectiveness and significant in their burden.
Even beyond opioids, so-called “standard” adjuncts are not the solution we wish they were. Medications like dexamethasone—a corticosteroid intended to decrease inflammation—are commonly used for cancer-related pain, particularly with bone metastases. And while they are often presented as part of the standard approach, the reality at the bedside is far less reassuring. Sometimes they help. Often, they provide only minimal or temporary relief—or none at all. And they come with their own burden of side effects: insomnia that robs patients of rest, agitation and mood instability that affect both patients and families, muscle wasting that worsens already profound weakness, and metabolic disruption that further stresses a declining body.
For many patients, these medications do not meaningfully relieve suffering—they simply add to the complexity of it.
We know this. We see it every day.
And yet, we continue to operate within a system that offers a narrow, often inadequate set of tools—while restricting access to others that may meaningfully improve comfort and quality of life.
Medical cannabis is one such option. When used thoughtfully, it has the potential to support pain control, reduce anxiety, improve appetite, and sometimes decrease reliance on opioids. In hospice care, this does not require inhalation—liquid tinctures allow for precise, titratable dosing, and topical formulations can be used for localized symptoms. These are practical, clinically informed approaches.
I understand how to use these tools. I understand how to dose them. I understand how to integrate them safely into care.
And yet, I am prohibited from doing so.
Because cannabis remains federally illegal, and because hospice care is governed and reimbursed under Medicare, I cannot prescribe it, formally recommend it, or incorporate it into a patient’s care plan—even when I believe it could meaningfully reduce suffering.
And cannabis is only part of the conversation.
There are additional therapies—some already in clinical use, others emerging with growing evidence—that could expand how we care for patients at the end of life. Ketamine has demonstrated benefit in refractory pain and existential distress. MDMA and psilocybin are being actively studied for their potential to alleviate profound psychological and existential suffering in terminal illness. Even broader therapeutic frameworks, including plant-based medicines such as ayahuasca, are being explored for their ability to help patients process fear, find meaning, and experience peace at the end of life.
If our mission is truly comfort care, then we have to ask a difficult question:
Why are we not making these patients comfortable by every safe and thoughtful means available to us?
Why are we limiting care based on outdated policy rather than patient-centered outcomes?
This is not a failure of medicine.
This is a failure of policy.
And it is patients—real people, at the most vulnerable moment of their lives—who are left to suffer within these constraints.
Until our regulatory systems evolve to reflect both current evidence and the true mission of hospice care, physicians will continue to stand in this space of tension: knowing more is possible, yet being legally prevented from offering it.
That should not be acceptable in modern medicine.
If this doesn’t sit right with you, it shouldn’t. Talk about it. Share it. And most importantly, ask your elected representatives why end-of-life patients are still being denied access to therapies that could ease their suffering.
