Expanding the 3 Wishes Project for compassionate end-of-life care: a qualitative evaluation of local adaptations

Abstract

Background: The 3 Wishes Project (3WP) is an end-of-life program that honors the dignity of dying patients by fostering meaningful connections among patients, families, and clinicians. Since 2013, it has become embedded in the culture of end-of-life care in over 20 ICUs across North America. The purpose of the current study is to describe the variation in implementation of 3WP across sites, in order to ascertain which factors facilitated multicenter implementation, which factors remain consistent across sites, and which may be adapted to suit local needs. Methods: Using the methodology of qualitative description, we collected interview and focus group data from 85 clinicians who participated in the successful initiation and sustainment of 3WP in 9 ICUs. We describe the transition between different models of 3WP implementation, from core clinical program to the incorporation of various research activities. We describe various sources of financial and in-kind resources accessed to support the program. Results: Beyond sharing a common goal of improving end-of-life care, sites varied considerably in organizational context, staff complement, and resources. Despite these differences, the program was successfully implemented at each site and eventually evolved from a clinical or research intervention to a general approach to end-of-life care. Key to this success was flexibility and the empowerment of frontline staff to tailor the program to address identified needs with available resources. This adaptability was fueled by cross-pollination of ideas within and outside of each site, resulting in the establishment of a network of like-minded individuals with a shared purpose. Conclusions: The successful initiation and sustainment of 3WP relied on local adaptations to suit organizational needs and resources. The semi-structured nature of the program facilitated these adaptations, encouraged creative and important ways of relating within local clinical cultures, and reinforced the main tenet of the program: meaningful human connection at the end of life. Local adaptations also encouraged a team approach to care, supplementing the typical patient-clinician dyad by explicitly empowering the healthcare team to collectively recognize and respond to the needs of dying patients, families, and each other.

Clinician Perspectives on Caring for Dying Patients During the Pandemic

“…During this period, the research team liaised regularly with bedside staff to identify patients at high risk for dying, defined as a greater than 95% chance of death in the hospital or planned withdrawal of life support. At this institution, typical end-of-life care includes interventions designed to humanize the experience for patients and families as built into the daily workflow and staff training ( 16 ). To learn more about each patient, the clinical team telephoned family members, collating personal information about patients to share with staff via a whiteboard and in the electronic medical record (EMR) ( 12 ), which served to reassure families that the staff was interested in their loved one as a person ( 20 ).…”

The Good Wishes Project: An End-of-Life Intervention for Individuals Experiencing Homelessness

“…However, the scaleup experience of the 3WP demonstrated that this can be possible. 28 A key learning of the scale-up experience of the 3WP, with relevance to our population, is the importance of local adaptation and a team approach to care. 28 Limitations Two main limitations of the methodology were identified.…”

“…28 A key learning of the scale-up experience of the 3WP, with relevance to our population, is the importance of local adaptation and a team approach to care. 28 Limitations Two main limitations of the methodology were identified. A single researcher coded the responses without benefit of validation by a second coder.…”

“…The project has since been successfully replicated in >20 ICUs in North America. 28 Inspired by the 3WP, the Good Wishes Project (GWP) was created as a partnership between the Inner City Health Associates' (ICHA) Palliative Education and Care for the Homeless (PEACH) program and Haven Toronto. It is funded by the Sovereign Order of St. John of Jerusalem, Knights Hospitaller.…”

Scale-up and Sustainability of a Personalized End-of-Life Care Intervention: A Longitudinal Mixed-Methods Study

“…The 3WP(3) began as a pilot project in a medical-surgical ICU in January 2013, and has been adopted and adapted in several North American centers. (4) Whether healthcare interventions are introduced through research or quality improvement initiatives, scaling up and sustaining them is challenging, even when worthwhile to patients, practitioners, or the public. (5) Program scale-up and sustainability are common terms in implementation science, with variable de nitions.…”