Implementing Ryan’s Law on an Inpatient Medical Oncology Unit

Abstract

In September 2021, California Governor Gavin Newsom signed Senate Bill 311 (Ryan’s Law), mandating that healthcare facilities permit terminally ill patients to use their own medical cannabis under the Compassionate Access to Medical Cannabis Act. This law challenged an inpatient oncology unit to develop a policy and clinical workflow to allow eligible patients to self-administer oral and topical cannabis. A case study illustrates how oncology nurses implemented Ryan’s Law for patient symptom management during hospitalization. Nursing satisfaction surveys revealed that oncology nurses felt comfortable adopting Ryan’s Law into their practice postimplementation.

AT A GLANCE

• ■ Medical cannabis can be effective in managing a variety of cancer-related symptoms, including pain, nausea, anxiety, and sleep disorders.

• ■ As more states legalize the use of cannabis, medical facilities may be challenged to integrate state cannabis laws into clinical oncology practice.

• ■ Oncology nurses can feel confident implementing patient self-administration of cannabis during hospitalization when institutional policies guide safe care delivery.

Medical cannabis can palliate some of the most limiting side effects of cancer and its treatments (Kleckner et al., 2019). Cannabinoids typically contribute to symptom relief by affecting two receptors: cannabinoid 1 receptors, which are largely found in the central nervous system (Bodine & Kemp, 2023), and cannabinoid 2 receptors, which are found in the periphery and immune cells (Finn et al., 2021). When substances such as delta-8 tetrahydrocannabinol and cannabidiol interact with these receptors, they can produce corresponding effects in the body. For example, cannabinoids can produce analgesic effects by targeting cannabinoid 1 on nociceptors throughout the body to regulate peripheral sensations of pain (Kleckner et al., 2019). Cannabinoids can also inhibit serotonin receptors and target cannabinoid 1 and 2 in the brain stem and gastrointestinal tract to reduce nausea (Kleckner et al., 2019). Research suggests that medical cannabis can be effective in the treatment and management of several oncology-related symptoms, including chronic pain, nausea, vomiting, anorexia, chemotherapy-induced peripheral neuropathy, and sleep disorders (Banerjee & McCormack, 2019; Bodine & Kemp, 2023; Finn et al., 2021; Kleckner et al., 2019; McDonagh et al., 2022).

Although recreational cannabis use was legalized in California in 2016 under Proposition 64, delta-8 tetrahydrocannabinol and cannabidiol were still considered Schedule I substances, making their use in California medical facilities illegal under federal law (California Department of State Hospitals, 2020). Because most healthcare facilities are accredited through the Centers for Medicare and Medicaid Services, the prescription or provision of cannabis could have led to a penalty or loss of federal funding, despite the passage of the state recreational law (Borgelt & Franson, 2017). This prevented patients with cancer from accessing cannabis products during hospitalization.

California Senate Bill 311: Ryan’s Law

Ryan Bartell was a 41-year-old man with terminal pancreatic cancer in California. Although Bartell underwent various treatments, his disease continued to progress. He remained hospitalized and on numerous opioid medications that caused him to be sedated and unable to spend quality time with his loved ones. He expressed his desire to spend his remaining weeks awake and interactive by using cannabis for symptom management rather than sedative narcotics. Because medical facilities in California did not allow the use of cannabis products despite their legalization, Bartell had to relocate to Washington to receive this benefit. By doing so, he was able to spend his remaining weeks awake and lucid, with improved quality of end-of-life care (Americans for Safe Access, 2021).

This case led to the passage of California Senate Bill 311 (Ryan’s Law). This bill requires healthcare facilities in California to allow the compassionate use of medical cannabis on their premises for terminally ill patients (Americans for Safe Access, 2021). Under Ryan’s Law, hospitals allow patients to access their own medical cannabis. The facility does not provide cannabis, and its supply remains the patient’s responsibility.

With the passage of Ryan’s Law in 2021, medical facilities are now required to allow patients with a prognosis of life of one year or less to have access to their own medical cannabis. This article provides an overview of how an inpatient oncology unit at the University of California, Los Angeles, Santa Monica Medical Center developed an institutional policy and nursing workflow to adopt Ryan’s Law into clinical practice. A review of participating patients’ stated experiences and a nursing satisfaction survey evaluated interventional effects.

Methods

The 26-bed solid tumor oncology unit at the University of California, Los Angeles, Santa Monica Medical Center cares for patients with a variety of diagnoses and progressive care needs throughout the cancer care continuum from diagnosis and treatment to end of life. The unit oversees the care of people with cancer outside of the oncology unit as well, with an average daily census of 40 patients. Patient diagnoses include lung, breast, pancreatic, renal, colon, and prostate cancer, as well as melanoma, sarcoma, and lymphoma. In November 2022, the healthcare system was challenged to implement Ryan’s Law into clinical practice using a regulated approach to support safe patient care.

An interprofessional work group, which included medical providers, nurses, pharmacists, regulatory affairs, informatics, and executive leadership, met over the course of several months. The group sought to develop a process adherent with Ryan’s Law that also maintained safety standards and regulations for patients and staff. In accordance with the requirements outlined in Figure 1, the work group used the Donabedian model (Agency for Healthcare Research and Quality, 2015) to ensure a balance among structures, processes, and outcomes (see Figure 2). This work culminated in the development of an institutional policy outlining the safe inpatient use of oral and topical cannabis for terminally ill patients.

FIGURE 1.

SUMMARY OF HEALTHCARE FACILITY REQUIREMENTS FOR CA SB 311

CA SB—California Senate Bill

Note. Based on information from California Health and Safety Code, 2023; Compassionate Access to Medical Cannabis Act or Ryan’s Law, 2021.

FIGURE 2.

DONABEDIAN MODEL FOR CALIFORNIA SENATE BILL 311 ON THE INPATIENT ONCOLOGY UNIT

The interprofessional team closely monitored patient experiences through a combination of real-time observations and follow-up debriefings. Nursing documentation in the electronic health record system tracked patient cannabis self-administration. Regular debriefing sessions were also used to discuss patient experiences and gather feedback. These conversations were integral in continually reviewing the process and ensuring patient safety standards were being met.

Case Study

K.M. was a female aged 53 years who had retroperitoneal liposarcoma and was admitted to the solid tumor oncology unit for a scheduled inpatient chemotherapy treatment with doxorubicin, ifosfamide, and mesna. Clinicians assessed K.M.’s condition as terminal and offered treatment for palliation and potential life-extending benefits. K.M. experienced nausea, pain, and anxiety secondary to her diagnosis and chemotherapy treatments, and took medical cannabis as part of her at-home regimen for symptom management.

On admission, the solid tumor oncology provider determined K.M.’s eligibility for compassionate access to medical cannabis under Ryan’s Law. The provider placed the order to approve K.M.’s self-administration of medical cannabis after reviewing her medical cannabis identification card and completing the medical cannabis patient consent form. This form requires the patient’s signature as an agreement that the patient is exclusively responsible for the ordering, delivery, self-administration, storage, and disposal of their medical cannabis. Once the clinician placed the order, nursing staff contacted the pharmacy for delivery of the medical cannabis lockbox and education for setting her own personalized code to access and store her supply.

During the course of six months, K.M. received six cycles of cancer treatment. The team reviewed and obtained eligibility and patient liability on each subsequent admission. K.M. typically self-administered oral cannabis once per day and notified the staff each time she self-administered. K.M. mainly self-administered to manage her pain, anxiety, and nausea. The staff nurse documented each instance of use on the medication administration record as “administered by patient.” K.M. found the lockbox easily accessible and expressed satisfaction with the security of the lockbox and the ability to continue her home regimen for symptom management while admitted. She stated medical cannabis was most effective in managing her pain levels, which allowed her to be comfortable without being overly sedated.

Outcomes

From implementation in May 2022 to June 2024, the University of California, Los Angeles, Santa Monica Medical Center’s solid tumor oncology unit had eight eligible inpatients who used medical cannabis. Team members did not submit any safety events to the internal reporting system concerning the new workflow or eligible patient encounters. To measure the success of the new workflow, the project team sent a survey to nurses who provided care to patients with cancer utilizing Ryan’s Law during their inpatient stay. The survey measured nurses’ comfort with implementing Ryan’s Law into their practice and their perceptions of its effects on patients’ symptom management and experience (see Table 1).

TABLE 1.

NURSING SATISFACTION WITH IMPLEMENTING RYAN’S LAW (N = 8)

PROMPT	SOMEWHAT DISAGREE	NEITHER AGREE NOR DISAGREE	AGREE OR STRONGLY AGREE
I feel comfortable implementing Ryan’s Law into my practice.	1	2	5
I feel that Ryan’s Law helped my patients with their symptoms on reassessment.	–	1	7
I feel that Ryan’s Law had a positive effect on my patient’s stay.	–	1	7

Note. Ryan’s Law is California Senate Bill 311.

Five of eight surveyed nurses felt comfortable implementing Ryan’s Law into clinical practice, and seven of eight nurses felt medical cannabis was effective for symptom management. Based on nursing documentation in the medication administration record, patients self-administered medical cannabis to manage the following symptoms: anxiety (n = 6), sleep (n = 6), nausea (n = 3), pain (n = 2), and appetite stimulation (n = 1).

Discussion

Reported patient experiences and positive nursing satisfaction suggest that the adaptation of Ryan’s Law into clinical practice is feasible within the inpatient oncology setting. With stakeholder involvement, interprofessional discussions can support safe implementation while remaining adherent to state laws and regulations. Team members considered and addressed several barriers during workflow creation. There were concerns surrounding the accuracy and reliability of patient self-reported medical cannabis administration and the potential liability, particularly as it relates to drug interactions, oversedation, and the loss of belongings. Nurses also worried about documenting a patient’s self-administration in the medication administration record without validating the information. To address these barriers, the work group discussed guidance for provider oversight, medication management, and nursing assessments for pain and sedation. The health system adopted a comprehensive policy in partnership with the legal and regulatory departments. These measures gave the healthcare team confidence in implementing Ryan’s Law.

Limitations

Although the outcomes of the nursing survey and patient testimonials on the oncology unit are promising, data are limited by small sample sizes and the experiences of a single institution located in a state that has a law for inpatient medical cannabis use. In addition, these outcomes reflect only the anecdotal experiences of people with terminal cancer diagnoses and did not include patients with other terminal illnesses. Although no patient safety events were reported, the possibility of underreporting cannot be excluded. Despite these limitations, the development of an institutional policy and nursing satisfaction with its implementation demonstrates how healthcare policy can be successfully translated into clinical practice.

Implications for Nursing

The implementation of Ryan’s Law into hospital policy represents a significant shift in how oncology nurses approach symptom management for patients with cancer. Understanding the principles of this law helps nurses to support patients who choose to use cannabis for relief from pain, nausea, and other treatment-related symptoms, while remaining vigilant about any potential interactions with other treatments. By embracing Ryan’s Law in their practices, nurses can encourage patient autonomy, provide more personalized care, and create an open dialogue about treatment options, ultimately leading to a more compassionate and holistic approach to cancer care.

Conclusion

The use of cannabis products has been shown to improve symptom management for patients with cancer. With the passage of Ryan’s Law, healthcare facilities in California, as well as other states with similar laws, can safely integrate patient self-administration of medical cannabis into the clinical setting. This quality improvement process serves as an important reminder about healthcare policy’s influence and advocacy within cancer care, and how adopting policy into practice can support patient-centered care.

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Quality & Safety provides readers with an update on innovative work in the area of practice and safe care delivery. If you are interested in writing for this department, contact Associate Editor Tia T. Wheatley, DNP, RN, AOCNS^®, AGACNP-BC^®, at twheatley@mednet.ucla.edu.