Background An increasing number of our hospice patients (estimated >10%) are openly using cannabis, mainly for pain relief. A dilemma arises on admission when staff, being patient-focused and bound by confidentiality, feel at odds with organisational convention that prevents illicit drug use on our IPU and could require notification of police.

Methods We canvassed three neighbouring hospices regarding illicit drug use on their inpatient unit (IPU). Our Clinical Ethics Committee (CEC) discussed a patient who in weaning herself off cannabis ‘to allow’ admission, lost significant analgesia. The CEC considered the acceptability of illicit drugs on IPUs, documentation issues and the patient/organisational benefits-harms of our approach.

Results The 4 hospices had contrasting levels of tolerance to illicit drugs; one unit had a formal policy. CEC deliberation confirmed inconsistencies and complexities e.g. an array of cannabis-labelled products (kemp/cannabis oil, with varying legality and clinical impact).

The acceptability of ‘products’ (tobacco to cocaine), context (drug dealer or symptom control) and setting (home or IPU) revealed inconsistencies in acceptability of assisting inpatients (allowing, sourcing, documenting, administering).

Defensive IPU practices underpinned different approaches; plausible deniability (don’t tell us), turning a blind eye (typical community approach), or prevent illicit drug use (blanket ban). No-one recommended police involvement. The reputational risk from restricting illicit drug use could do more harm (with societal changes ‘ahead’ of law).

Conclusion Individualised risk assessments, showing discretion and pragmatism are needed. Holistic approaches to cannabis could justify its use in Palliative Care. Without adequate cannabis substitutes, patients cannot be expected to discontinue cannabis abruptly on admission (whether symptom or recreational use). Cannabis use should be documented, for clinical context/drug interactions. Patient confidentiality would normally hold, unless disclosure was necessitated by a more pressing public interest (greater good). Hospices could agree reasonable parameters with local police to prevent unhelpful responses.