Two ketamine-assisted therapy projects are examining ways to develop training and collaboration models for utilization among palliative care patient populations.
A growing body of research is uncovering the potential benefits of ketamine therapies to help with symptom management. But greater understanding of the drug and its impacts is needed to help palliative care providers and other health professionals guide patient experiences, according to Dr. Michael Fratkin, board president of the Institute for Rural Psychedelic Care. Fratkin is also a palliative care specialist at Humboldt Center for New Growth.
“Ketamine can be a safe, effective, workable and tolerable medicine to explore over these next few years to better understand its healing potential in existential distress – something we have very little to offer to date – as well as its pitfalls,” Fratkin told Palliative Care News.
Ketamine is among the controlled substances permitted for therapeutic use among serious and terminally ill patients. The anesthetic has hallucinogenic and psychedelic properties and can come in liquid or powder form.
Clinical studies have found that ketamine utilization has helped alleviate severe depression and anxiety symptoms in some patients. Some adverse effects associated with the substance include respiratory problems, high blood pressure, impaired motor function, nausea, vomiting, dizziness, dysphoria and drowsiness, among others.
Working with death doulas
Among the driving forces pushing ketamine therapy to the forefront is a growing demand for improved and diverse palliative support avenues, according to Christine Caldwell, founder and executive director of the End-of-Life Psychedelic Care. The nonprofit advocacy group focuses on expanding end-of-life doula professional collaboration on psychedelic care teams and offers educational and training programs.
Seriously ill patients often cope with an array of emotional and spiritual complexities as their health worsens, including processing complicated anticipatory grief, severe agitation, distress and depression, Caldwell said. Ketamine-assisted therapies can help to reduce or relieve these symptoms, she stated.
Navigating ketamine utilization involves a broad spectrum of interdisciplinary support well-trained in the risks, benefits and safe practices, Caldwell stated.
“Really key is a strong need to educate people [on] how to hold a supportive space for a patient’s psychedelic journey,” Caldwell told Palliative Care News. “Another big thing is thinking about how we partner and work together, whether it’s hospices, palliative care providers, end-of-life doulas or psychotherapists. When we understand the value and our role, we can broaden access, awareness and create a foundation of education and collaboration. Doulas can hold space for somebody during their journey, because they can spend that time becoming a trusted and supportive source to that person.”
End-of-life doulas are among the nonmedical professionals who can be instrumental in providing support to patients during and after their ketamine experiences, Caldwell said.
This notion in part sparked the launch of a ketamine clinical study of home-based palliative care patients. Recognition of ketamine’s potential impacts and a strong need to educate providers were two drivers of the pilot project, which unfurled in April.
The grant-funded project studied ketamine-assisted therapy experiences of two patients, guided by Fratkin and Susie Ruth, an end-of-life doula, educator and grief professional. Each patient received two to three ketamine-assisted therapy sessions of low doses distributed via an intramuscular injection, along with follow-up telehealth and in-person visits. The pilot involved developing a cost structure, patient assessment and utilization guidelines, as well as a staff collaboration model.
A main goal of the initiative was to find the “sweet spot” of helping interdisciplinary professionals manage patients’ symptoms through ketamine utilization, Fratkin said.
“A key point we found with this pilot was the important roles of medical and nonmedical professionals in creating a dyadic team-building structure that supports the patient or participant,” Fratkin said. “That could be any professional comfortable with psychedelic experiences who can be trained on the wholeness of the experience for every individual, whether a nurse, social worker, clinician or an end-of-life doula. The doula really helped create a great partnership between the clinician and the person.”
One patient in the ketamine pilot experienced positive spiritual and emotional impacts such as alleviated distress, fear and anxiety associated with their serious illness. Ketamine utilization led to decreased reliance on opiates and pain medications in the other patient who had struggled with substance abuse issues, according to Fratkin. The patient decreased their opioid intake by roughly 50% and has continued to report “persistent and substantially improved” pain control, he stated.
Staff training was pivotal to quality outcomes among patients, according to Caldwell. Important components to include in education are communication and listening skills, understanding some of the potential physical and emotional experiences for patients and having standardized ways to measure and assess pain, anxiety and depression, she stated.
Another key was holding interdisciplinary team meetings to discuss ongoing patient needs, Caldwell stated.
“There’s going to be several factors that will come into play with palliative care and hospice providers embracing the role of an end-of-life doula and how they can be beneficial in ketamine use,” Caldwell said. “But we need to improve the education of medical practitioners. It’s a multi-pronged effort to bring this all together and the foundation has to be education.”
Training components
Another ketamine-assisted therapy project is underway in Boulder, Colorado, at the Integrative Psychiatry Institute with an aim to shape and provide training to community-based care providers. Led by Fratkin, the project is designed to help train providers and build evidence-based patient data on the impacts of ketamine utilization.
Kicking off mid-August, the project features a six-week continuing medical education course offered to a group of roughly 24 health care professionals. The course includes 90-minute training sessions held biweekly, a four-day retreat to experience ketamine-assisted therapy and a peer support group structure.
A key goal of the educational course is to develop community-based interventions that help train palliative professionals and prepare them to deliver empathetic support during ketamine-assisted therapies based on learned lessons, Fratkin said.
“There is a limited amount of work around psychedelic-assisted therapy in palliative or end-of-life settings, although some organizations are developing more interest in curriculum,” Fratkin told Palliative Care News. “An optimal educational process is best balanced by a didactic knowledge base and other elements. This kind of work requires you to do your own personal work in order to create safe containers for people that have extraordinary therapeutic experiences.”
Three essentials for effective ketamine administration involve medical training on the pharmacology and potential adverse effects, ethical and safety education on informed patient consent and personal therapeutic work among staff, according to Fratkin.
Developing a peer-based support structure is among the most significant steps of providing a quality ketamine therapy experience, Fratkin said. Building a community of preceptors to help mentor and supervise other professionals in this work is critical to addressing concerns and questions when they arise, as well as establishing an evaluation process, he added.
“You need to allow for some processing of your own unique and complex trauma set, mortality thoughts and grief,” Fratkin said. “That allows you the potential in relating to patients and guiding them in this experience.”