Introducing a Compassion-Centered End of Life Project in a Large Community ICU: Facilitators and Barriers
CCCF ePoster library. Levesque K. Nov 7, 2018; 233422; 21
Kelsea Levesque
Kelsea Levesque
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Death in hospital is common but remains a difficult experience for patients, families, and clinicians.1,2  Community ICUs, like other ICUs, may deliver sub-optimal end of life (EOL) care.3 Patients and families desire compassion, defined as an action-oriented expression of empathy.4 The 3 Wishes Project is a compassion-centered EOL project that aims to perform at least three acts of compassion for dying patients and/or their families.5  This project was shown to dignify the patient, create positive memories for families, and call forth compassion in clinicians.5



The objective of this study is to understand facilitators of and barriers to implementing the 3 Wishes Project in a single center community ICU.



We piloted a compassion centered EOL project from January 1st to June 30th, 2018, and assessed its implementation with mixed methods. At inception, an environmental scan was performed with key stakeholders. Based on the perceived gaps, two interventions were applied: engagement (small group sessions, quarterly reports, 1:1 mentoring) and empowerment (resources and financial support).  The main quantitative measure was monthly enrolment rate. Secondary measures included the number of staff who enrolled patients for the first time, the number of compassionate acts per patient enrolled, and the financial cost of each act of compassion. To understand experience during implementation, seven semi-structured interviews with key stakeholders were conducted with six clinicians who implemented the 3 Wishes Project for their patient and one clinician who was involved in the initial environmental scan. Quantitative data were analyzed using appropriate statistical process control while qualitative data were analyzed in triplicate using a qualitative descriptive approach. 



By the end of the pilot phase, 14 patients were enrolled and 61 wishes were implemented. 13.7% of dying patients were enrolled monthly.  In addition, 9 clinicians enrolled a patient for the first time into the 3 Wishes Project. 1.5 clinicians per month enrolled a patient for the first time and 4.6 acts of compassion were performed per patient without additional financial cost. Interviews identified four facilitators: a shared vision for sparking change, research team integration with frontline staff, a collaborative learning environment, and available resources for staff to implement acts of compassion. Two barriers identified were: the differential manifestation of the project within different sub-cultures of the ICU, and the unclear process to fulfill an act of compassion. In addition, qualitative interviews suggested the possible benefits of two next steps: a point of care collaborator across nursing lines to spread awareness and expertise, and maintaining focus on the personalization of acts of compassion. 



The pilot phase of a compassion-centered EOL project was successfully implemented for a small proportion of dying patients and their families in our community ICU. Key facilitators included a shared vision, research-clinical team partnership, a collaborative learning environment, and resources to empower staff. Key areas to be aware of during future implementation include differential uptake of interventions within sub-cultures, and maintaining a clear operational process. Based on staff feedback, we have developed the next steps to expand the 3 Wishes Project in our community ICU.


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