Compassionate End of Life Care in the ICU: Multicenter Evaluation of the Scalability, Transferability, Affordability, Sustainability, and Value of the 3 Wishes Project
CCCF ePoster library. Clarke F. Nov 7, 2018; 234196; 19
France Clarke
France Clarke
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Background: The 3 Wishes Project offers an opportunity for loved ones and clinicians to honour and celebrate the dying person. The overall objective of this multicenter study is to evaluate the feasibility of implementing the 3 Wishes Project in 3 other centers by assessing  if this project is: 1) Scalable: can be implemented independent of the research team at St. Joseph's Healthcare; 2) Transferable: can be implemented in other ICUs; 3) Affordable: wishes cost less than $50/patient; 4) Sustainable: manifested by project continuation to July 2019; and 5) Valuable: as experienced by clinicians, ICU managers and hospital administrators. The specific aims are: 1) For patients, to provide compassionate end-of-life care consistent with their values and preferences; 2) For families, to evaluate the project's impact on family views; 3) For clinicians, to explore the project's impact on their work experience; 4) For ICU managers, to identify barriers and facilitators for implementation; and 5) For hospital administrators, to understand project costs and benefits. .


Setting: 1) 23-bed mixed medical-surgical ICU in St. Joseph’s Healthcare, Hamilton, 2) 19-bed trauma-neurological ICU and 24-bed medical-surgical ICU in St. Michael's Hospital, Toronto, 3) 30-bed medical-surgical-trauma ICU in Vancouver General Hospital 4) 24-bed medical ICU at Ronald Regan Hospital, Los Angeles.


Design: Mixed-methods formative evaluation using quantitative and qualitative data.  


Results: Over 500 patients have been enrolled in the 3 Wishes Project, prompting over 2,000 acts of compassion at the end of life in the ICU. Scalability has occurred in the original hospital with ICU bedside staff now initiating this as a clinical program. Expansion to other wards has started with research team support. While wishes have expanded in scope, the vast majority remain simple and inexpensive, yet described by participants as valuable or priceless (e.g., getting outside, favourite music, a final toast, etc.). Transferability is demonstrated by operationalization in these 3 additional centers and elsewhere, implemented by a different mix of clinicians at each center (nurse, physician, social worker, chaplain, etc.) with research support for data collection. Affordability is demonstrated by a low mean cost per wish, per patient, at each center. Sustainability is evident with the project continuing for over 5 years at the original hospital and since launch in the other 3 hospitals. Value is supported by qualitative data underscoring how the project fosters organic ante mortem and post-mortem connections between and among clinicians, patients and families. Clinicians report how the 3 Wishes Project helps them to feel inspired, mitigates compassion fatigue and makes work meaningful. Managers and administrators perceive that the project could ameliorate staff burn-out, and that it aligns with their organizational culture, creating institutional pride.


Conclusions:  The 3 Wishes Project is a low-technology, low-risk, low-cost intervention with high face validity that positively influences those involved in the unique ‘eco-system’ of different ICUs. Fostering interdependent palliative practice, any staff member can elicit and/or enable the wishes.  It also facilitates role-modelling regarding acts of compassion at the end-of-life. Grounded in authentic personalized interactions, the 3 Wishes Project promotes humanistic ethical practice from a systems-level perspective.





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