Palliative care and psychedelics: 5 Questions for physician Rachel Rackow

Rackow discusses the intersection of psychedelic-assisted therapy and palliative care

In medical school, Rachel Rackow thought she’d specialize in primary care or women’s health. But when her younger sister suddenly died, she started to rethink her plans. “I found myself frustrated and morally distressed by some of the ways the American medical system works when people are at end-of-life,” she said. After medical school and a residency in internal medicine, she completed a fellowship in palliative care. 

Rackow became a hospice and palliative care physician in Portland, Oregon, and when the pandemic hit, she found herself in deep burnout. To recover, she tried psychedelics as a form of personal healing, and became interested in using the drugs as a tool for her patients as well. As she learned more about psychedelics use in palliative care, she completed a certificate from the SoundMind Institute in Foundations of Psychedelic Therapies for Clinicians and connected with other professionals interested in the topic and together, they formed the Advanced Illness Coalition of Oregon, which seeks to educate providers, facilitators, and patients about about accessing psychedelics. The Microdose spoke with Rackow about the intersection of psychedelic-assisted therapy and palliative care.

People often experience anxiety or depression during palliative care or end-of-life treatment. What are the typical ways of addressing those issues? 

It's kind of the same cocktail we offer for people with anxiety and depression outside of the setting of a serious illness. There are antidepressants, which don't work for everybody and can take weeks to ramp up to an effect sometimes. But in palliative care, some of these patients don't have that time. 

There are also medications used to treat anxiety, like benzodiazepine, which can numb people, blunt their experiences, and make them sleepy. They also don't always work for people and don’t get at the root cause of why people are having these symptoms to start with, which is the goal of psychedelic therapy. But that’s not to say there aren’t amazing benefits to hospice and palliative care — and I think a lot of people have misunderstandings about what those things really are.

How would you describe hospice and palliative care, then? And while we’re talking about terminology, what’s the difference between end-of-life care and advanced illness?

Hospice is a form of palliative care, but not all palliative care is hospice. People can access and benefit from palliative care at any stage of a serious illness that may be life threatening, and hospice is the care that people access when they have a prognosis of less than six months. Both palliative care and hospice are aimed at addressing end of life issues and helping people have the best quality of life in the time that they have. It’s about not only addressing people’s biomedical needs, but the whole human experience, including emotional and social issues. The gold standard in doing that is working in an interdisciplinary team that includes a provider or prescriber, whether that’s a physician or a nurse practitioner, a social worker and a chaplain. 

For the Advanced Illness Coalition, we specifically chose the term “advanced illness” over “end of life” because people may get more benefit from psychedelics early on — when they first get a diagnosis of a life threatening illness. Advanced illness can include chronic progressive illnesses, like congestive heart failure, chronic obstructive pulmonary disease (COPD), cancer, dementia. These are illnesses that are going to get worse over time no matter what we do with them; we can manage them for a time, but ultimately they're terminal illnesses. A lot of people don't think of congestive heart failure or COPD as a terminal illness but chronic illness is ultimately terminal, and it affects the way people live, their quality of life and their relationships. Anybody who's living with a serious illness can potentially benefit. Ultimately, I think there's a lot of shared history and overlap between the goals and philosophies of palliative care and psychedelics.

What are those intersections between palliative care and psychedelics?

The hospice and palliative care movement came out of the work of Dame Cicely Saunders in the UK in the 1960s, which was the same time that psychedelic research into LSD and death-related anxiety was happening. That was all before the War on Drugs. Both fields also incorporate humanistic principles: trying to improve the experience of dying, which is a human experience, not a medical experience. Tending to the personal and social domains that are inherent to the human experience, and going beyond just treating someone's pain or biomedical needs — that’s something psychedelics and palliative care share. One of the goals of people seeking psychedelic experience is to be able to open their or, you know, change their perspective in order to be able to have a better quality of life and that's really what palliative care is about, too.

How do people with advanced illness typically find out about psychedelic-assisted therapy as an option, and who might be a good fit for exploring it?

Anyone really suffering with anxiety, depression or existential distress for whom the typical treatments are not helping might benefit from exploring psychedelics. I’ve had some patients who have asked about access to services, and sometimes friends and family will bring it up to them, too. 

If people do a psychedelic session, it's really important for them to have good support around them, because not all sessions are beautiful and transformative. Some are really hard and challenging and require a lot of unpacking and integration afterward. That support system — whether that's family and friends, a therapist, a palliative care or hospice team — can continue to support them in that work. 

A lot of us in this field are really interested in the idea that maybe patients and their families, or whoever their support system is, could potentially have a psychedelic experience together. Sometimes a patient undergoes a session and gains some really important insights that help them live differently, but their family or their support system has not had those same insights or experiences. What kind of conflicts might that cause? Can that change be helpful without taking into account the whole care unit? 

Your group, the Advanced Illness Coalition of Oregon, partnered with non-profit Healing Advocacy Fund to publish a guide for clinicians on best practices for using psychedelics with people who have advanced illness. What other considerations are there for people with advanced illness seeking psychedelic facilitators, or for facilitators working with people with advanced illness?

If a patient came to me and asked who they should work with, I would encourage them to seek out people who have experience working with people with advanced illness. There are a number of facilitators who have, say, worked in hospice for many years and have an understanding of this particular population. There are some considerations that facilitators should be aware of when working with a patient with advanced illness, like is the patient going to need any medications during administration? These sessions are up to eight hours, and patients with advanced illness often have medicines that need to be administered throughout the day. 

Another consideration: are they on medication with particular care interactions? Facilitators should also make sure they're in contact with the patient's physician or, or other health care provider team. Also, if someone is truly homebound, they're not going to be able to get into a service center to have a session, and that's something that our group is looking into. We want to advocate for potential change to the rules or other ways to work around that. 

There may also be a need for additional support for people with advanced illness that somebody who's otherwise healthy might not need. For instance, the Oregon model only requires one preparation session and one integration session, but for individuals who are dealing with chronic or serious and advanced illness, I would imagine that it would be beneficial to have more preparation and potentially more integration. 

I want to be clear that we don't yet know exactly what are the best practices for this population. We're hoping that there will be more real-life research done so we can learn from not just what's happening in clinical trials, but what's happening in real life settings. And then we can take what we're learning to develop best practices. 

This interview has been edited and condensed for clarity and length.