Scale-up and sustainability of a personalized end-of-life care intervention: a longitudinal mixed-methods study

Abstract

Background Scaling-up and sustaining healthcare interventions can be challenging. Our objective was to describe how the 3 Wishes Project (3WP), a personalized end-of-life intervention, was scaled-up and sustained in an intensive care unit (ICU). Methods In a longitudinal mixed-methods study from January 12,013 - December 31, 2018, dying patients and families were invited to participate if the probability of patient death was > 95% or after a decision to withdraw life support. A research team member or bedside clinician learned more about each of the patients and their family, then elicited and implemented at least 3 personalized wishes for patients and/or family members. We used a qualitative descriptive approach to analyze interviews and focus groups conducted with 25 clinicians who cared for the enrolled patients. We used descriptive statistics to summarize patient, wish, and clinician characteristics, and analyzed outcome data in quarters using Statistical Process Control charts. The primary outcome was enrollment of terminally ill patients and respective families; the secondary outcome was the number of wishes per patient; tertiary outcomes included wish features and stakeholder involvement. Results Both qualitative and quantitative analyses suggested a three-phase approach to the scale-up of this intervention during which 369 dying patients were enrolled, having 2039 terminal wishes implemented. From a research project to clinical program to an approach to practice, we documented a three-fold increase in enrolment with a five-fold increase in total wishes implemented, without a change in cost. Beginning as a study, the protocol provided structure; starting gradually enabled frontline staff to experience and recognize the value of acts of compassion for patients, families, and clinicians. The transition to a clinical program was marked by handover from the research staff to bedside staff, whereby project catalysts mentored project champions to create staff partnerships, and family engagement became more intentional. The final transition involved empowering staff to integrate the program as an approach to care, expanding it within and beyond the organization. Conclusions The 3WP is an end-of-life intervention which was implemented as a study, scaled-up into a clinical program, and sustained by becoming integrated into practice as an approach to care.

Sacrifice and solidarity: a qualitative study of family experiences of death and bereavement in critical care settings during the pandemic

“…The 3 Wishes Project is an EOL intervention aimed to honour dying patients and support families in grief. It has grown into a programme of research aimed at improving EOL care across critical and acute care settings 28–30. Many studies have emerged from the larger multicentre research programme,28–30 demonstrating feasibility, scalability, transferability and value.…”

“…It has grown into a programme of research aimed at improving EOL care across critical and acute care settings 28–30. Many studies have emerged from the larger multicentre research programme,28–30 demonstrating feasibility, scalability, transferability and value. Due to expedited study processes during the COVID-19 pandemic, dying patients, their loved ones and the public were not directly involved in the design of this study.…”

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 .…”

“…In Ontario, Canada, 3WP began as a study and, given its effectiveness in supporting and providing comfort to all involved-not only patients and family, but also the multidisciplinary teambecame part of clinical practice, consolidated as an approach that enables more humanized care which is also accessible and sustainable 19 .…”

Palliative-Care-Konzepte für Patienten und Familien

“…Aus der vorliegenden Studienlage lassen sich keine evidenzbasierten Empfehlungen für oder gegen eines der beiden genannten Verfahren ableiten. Vielmehr wird in der intensivmedizinischen Praxis die Entscheidung über die Art der Beendigung der maschinellen bung des Patienten und die Schaffung positiver Erinnerungen[45][47][48][49]. In der Forschung zur Gestaltung von Erinnerungsstücken wird betont, dass nicht nur das Erinnerungsstück als Andenken einen Wert für die Familienmitglieder hat, sondern auch der Prozess der Gestaltung Hoffnung gibt und die Beziehung zum Behandlungsteam dere Bedeutung der Erstellung liegt darin, dass die Familienmitglieder gebeten werden, Begriffe und Wörter zu finden, die den sterbenden Menschen, sein Leben, seine Leidenschaften und Werte repräsentieren.…”