Community implementation of the 3 Wishes Project: an observational study of a compassionate end-of-life care initiative for critically ill patients

Abstract

Background:The 3 Wishes Project (3WP) promotes a personalized dying experience by eliciting and facilitating individualized terminal wishes for patients, families and the clinicians caring for them. We aimed to evaluate the adaptability of the 3WP to a community intensive care unit (ICU), and to describe the patients cared for with this palliative approach, as well as local implementation strategies. Methods:The 3WP was implemented in a 15-bed community hospital ICU in southern Ontario from 2017 to 2019. In this observational, descriptive study, we invited adult patients (≥ 18 yr) whose risk of death was deemed to be 95% or greater by the attending physician, or patients undergoing withdrawal of life-support to participate. We abstracted patient data from medical records, as well as the type, timing and cost of each wish, which person or service made and facilitated each wish, and if and why wishes were completed or not. We summarized data both narratively and quantitatively. Results:The 3WP helped to realize 479 (99.2%) of 483 terminal wishes for 101 dying patients. This initiative was introduced as an interprofessional intervention and championed by nursing staff who were responsible for most patient enrolment and wish facilitation. Wishes included humanizing the ICU environment for the patient with belongings and blankets, musical performances, smudging and bathing ceremonies, and keepsakes. The cost was $5.39 per patient (standard deviation $22.40), with 430 (89.8%) wishes incurring no cost. Wishes made directly by patients accounted for 30 (6.2%) of wishes; those from family members and ICU staff accounted for 236 (48.9%) and 238 (49.3%) of wishes, respectively. The program comforted patients and their loved ones, motivating clinicians to sustain this end-of-life intervention. Interpretation:We documented successful implementation of the 3WP in a community hospital, showing program adaptability and uptake outside of academic centres at relatively low cost. The lack of strict protocolization and personalized design of this intervention underscores its inherent flexibility, with potential to promote individualized end-of-life care in nonacademic hospital wards, homes or hospice.

The 3 Wishes Program Improves Families’ Experience of Emotional and Spiritual Support at the End of Life

“…However, the 3WP has been implemented in multi-center studies, 18 , 19 , 23 including community hospitals. 38 , 39 Although our response rate was low (30%), this is not uncommon for studies evaluating the quality of dying that are outside the integrated VA system. 40 – 42 …”

The 3 Wishes Program Improves Families’ Experience of Emotional and Spiritual Support at the End-Of-Life

“…However, the 3WP has been implemented in multicenter studies, 18,19,23 including community hospitals. 38,39 Although our response rate was low (30%), this is not uncommon for studies evaluating the quality of dying that are outside the integrated VA system. [40][41][42] Although a simple concept, the 3WP seeks to change the perspective around death, such that dying is also seen as an opportunity to honor a patient's wishes, celebrate the patient's life, and create peaceful memories during final moments.…”

Palliative care in intensive care units: an integrative review

“…Two studies used for this purpose the 3 Wishes (3WP) project, a program aimed at terminally ill patients that upholds the dignity of these people, providing meaningful connections between patients, families and physicians in intensive care. Such connections are encouraged with a focus on patients' preferences and legacies-one of the program's strengths 18,19 .…”

“…As shown in the study by Reeve and collaborators 18 , 3WP made it possible to meet more than 99% of terminal wishes, at low or no cost. Wishes range from enhancing the clinical environment with personal belongings to celebrations of life and musical performances.…”