Background

Multiple organizations recommend that individualized end-of-life (EOL) care should be standard practice. However, a standardized approach does not exist because EOL care should be individually tailored. The 3 Wishes Project is an EOL intervention that provides direction for individualized care with 3 goals: dignify death, celebrate the patient’s life, and support family members and the intensive care unit clinicians caring for the patient. Patients and families are given the opportunity to choose 3 wishes during the dying process.

Objective

To ascertain if the implementation of the 3 Wishes Project allowed the medical team to provide individualized EOL care.

Methods

The Iowa Model was used for this evidence-based project. The project was implemented in the medical intensive care unit at an academic medical center. Outcomes were evaluated by the collection and analysis of qualitative and quantitative data.

Results

From the 57 patients who died during the 2-month implementation period, 32 wish forms were collected; 31 patients participated and 1 declined. Overall participation among patients was 56%. The top 5 wishes were cloth hearts, blankets, heartbeat printouts, fingerprints and handprints, and music. The total cost was $992, and the average cost per wish was $6.98. Eighty-five percent (33 of 39) of the respondents to the medical team survey indicated that they either agreed or strongly agreed that the project allowed the medical team to consistently provide individualized EOL care.

Conclusions

The survey data support the 3 Wishes Project as a method that allowed the medical team to individualize EOL care and as a valuable tool for incorporation at the bedside.

Video

Individualizing End-of-Life Care Using the 3 Wishes Project

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Individualizing End-of-Life Care Using the 3 Wishes Project

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Notice to CE enrollees

This article has been designated for CE contact hour(s). The evaluation demonstrates your knowledge of the following objectives:

  1. Describe the 3 Wishes Project as a method of providing individualized end-of-life care in intensive care units.

  2. Identify the 4 steps of implementation of the 3 Wishes Project.

  3. Identify strengths and weaknesses of the 3 Wishes Project.

To complete the evaluation for CE contact hour(s) for activity A2412, visit https://aacnjournals.org/ajcconline/ce-articles. No CE fee for AACN members. See CE activity page for expiration date.

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The Society of Critical Care Medicine reports that more than 5 million patients are admitted to intensive care units (ICUs) in the United States per year.1  Mortality rates of adult patients admitted to an ICU range between 10% and 29% depending on age, comorbidities, and illness severity.1  The average cost of the ICU stay for a patient who dies in the ICU is approximately $40 000.2 

Leaders in health care and professional societies have published guidelines that provide recommendations for end-of-life (EOL) care in hospitals and ICUs. These include the American Association of Critical-Care Nurses,3  National Consensus Project for Quality Palliative Care,4  End-of-Life Nursing Education Consortium,5  Institute of Medicine,6  Society of Critical Care Medicine,7  and the World Health Organization.8  These societies identify core components of high-quality EOL care, describe the needs of families of patients who are dying, and focus on the ability of the medical team to assess the needs of the patient and family. Individualized EOL care is the standard of care. Although standards of care have been identified, there are no best practice recommendations for how to implement the standards into practice.

Individualized end-of-life care is the standard of care.

Available Knowledge

The 3 Wishes Project (3WP) is an EOL intervention that was originally created by Dr Deborah Cook at McMaster University in Canada. The goals of the project are not only to dignify death and celebrate the patient’s life but to support family members and the ICU clinicians caring for the patient.9  Patients, their families, or both are given the opportunity to choose 3 wishes during the dying process.10  The average cost of a wish in the initial studies was $5.11  A wide range of wishes is possible, including human-izing the environment,12  creating keepsakes and tributes,13  playing music,13  and supporting family engagement during the dying process.13 

The PICOT (patient, intervention, comparison, outcome, and [sometimes] time) question was “In critical care health care providers caring for patients at the end of life, does the ‘3 Wishes Project’ affect individualized end-of-life care?” A comprehensive literature search was completed using the search terms 3 wishes project AND (individualized OR tailored OR personalized). PubMed, CINAHL, APA PsycInfo, and Web of Science were searched. No filters were applied. Nine records were retained for full text review (Figure 1).

Figure 1

PRISMA flow diagram of selection of records reviewed.

Figure 1

PRISMA flow diagram of selection of records reviewed.

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Studies reporting the implementation of the 3WP showed a meaningful impact on patients and families by promoting interpersonal care, reframing the perception of the dying process, providing value-based discussions at EOL, and exemplifying humanism in practice.1116  Studies of the 3WP also reported meaningful impact on teams by strengthening team bonds, leading to a perceived improvement of EOL care.12,13,17  The 3WP was found to be transferable between academic and community settings11,18  and was affordable.11,19 

Rationale

The practice area for this evidence-based practice project was a 28-bed medical ICU at an academic medical center in the mid-Atlantic United States. End-of-life care was a pressing issue given the historically high mortality rate for this unit. On average, more than 22 patients die per month, which does not include patients transferred out of the ICU or to hospice before death. The practice area was also the primary ICU at the medical center caring for patients who were critically ill with COVID-19. Inconsistencies in EOL care practices were acknowledged, and the medical team identified this as an important practice gap.

Specific Aims

The purpose of the project was to ascertain if the implementation of the 3WP allowed the medical team to perceive improvement in the ability to provide individualized EOL care in the medical ICU at a large academic medical center.

The Iowa Model for evidence-based practice was used as the framework for this project.20  Funding was provided by an external award obtained by the project leader (B.H.H.). The project was submitted to the site’s institutional review board and did not require the board’s oversight for protection of human subjects. Internal permission was provided by unit medical and nursing leaders, and external permission was provided by Dr Deborah Cook and Dr Thanh Neville.

The population was any member of the medical team who cared for patients at the EOL in the practice area during study implementation, including registered nurses, respiratory therapists, attending physicians, resident physicians, fellows, advanced practice practitioners, social workers, and chaplains.

Before Implementation

Education was provided to members of the medical team before implementation of the 3WP. Education occurred through email communication, presentations, and anecdotal discussions. The project leader provided additional education with a detailed laminated handout of the project that was hung on every patient’s door for the duration of implementation.

Pilot Study

The pilot study ran between September 1 and November 1, 2022, and included 4 steps. No direct patient data were collected, and compliance with the Health Insurance Portability and Accountability Act was maintained throughout the pilot study.

Step 1: Identified Patients Considered for Participation

Patients considered for participation in the 3WP included patients with a high likelihood of dying in the ICU, patients for whom the decision had been made to withdraw or withhold life support in the anticipation of death, select patients who had recently died in the ICU, or a combination of these. Ineligible patients were those who were under the care of the medical ICU service but located in another ICU or patients who were being discharged home or to a hospice facility.

Two methods were used to identify which patients met these eligibility criteria. First, eligible patients were identified during daily interdisciplinary rounds, after which the bedside registered nurse completed and hung the checklist on the patient’s door. Second, team members could identify eligible patients and initiate the process at any time, outside of formal rounds. The project was not under strict protocols and lent itself to implementation by any member of the medical team.

Step 2: Approached the Patient and Family

Patients and their families were approached by a member of the medical team and provided a 3WP brochure (Figure 2), designed by the project leader, that included information about the project as well as possible wishes that could be easily implemented in the ICU. The process for approaching patients and families for participation in the 3WP was not formalized or scripted and could be performed by any member of the medical team.

Figure 2

First (A) and second (B) pages of the 3 Wishes Project brochure.

Figure 2

First (A) and second (B) pages of the 3 Wishes Project brochure.

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Table 1 lists possible wishes introduced in the brochure, including comfortable blankets, flameless candles, and their favorite music to help humanize the ICU environment for patients and their families. An online streaming music account was created and smartphones were obtained for better sound quality at the bedside and enhanced portability between patients. Other wishes offered in the brochure included keepsakes to memorialize the patient, such as capturing and preserving the patient’s electrocardiography tracing, the sound of their heartbeat, and their fingerprints or handprints (Supplemental Figure 1, available online only, at www.ajcconline.org). Cloth hearts involved pinning 2 or more hearts on the patient’s gown (Supplemental Figure 2, available online only). After the patient’s death, 1 or more hearts went with the family as a symbol of the patient’s enduring love, and 1 heart went with the patient as a symbol of the family’s enduring love. Supplies were readily available on the unit, and no limitations were placed on the number of items used per wish. Families and patients were encouraged to bring items from home, such as favorite items of clothing, family photographs or special pictures, or a patient’s favorite food or drink. In addition to the brochure, patients and families were provided a wish form (Figure 3) to specify the requested wishes. If the patient and the patient’s family declined to participate, the medical team filled out the back of the wish form listing the patient and family’s reason for declining.

Table 1

Offered and requested wishes (n = 114)

Offered and requested wishes (n = 114)
Offered and requested wishes (n = 114)
Supplemental Figure 1

Photograph of electrocardiography tracing and fingerprints.

Supplemental Figure 1

Photograph of electrocardiography tracing and fingerprints.

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Supplemental Figure 2

Photograph of the cloth hearts

Supplemental Figure 2

Photograph of the cloth hearts

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Figure 3

First (A) and second (B) pages of the 3 Wishes Project wish form.

Figure 3

First (A) and second (B) pages of the 3 Wishes Project wish form.

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Wishes included comfort items, music, and items to help memorialize the patient.

Step 3: Implemented Wishes

The medical team obtained supplies for the 3WP from a centralized storage location and implemented the requested wishes. Members of the medical team implemented the wishes with or on behalf of the patient and the patient’s family.

Step 4: Collected Wish Forms

One wish form was completed per patient at the EOL. Completed wish forms were placed in a lockbox near the centralized storage location and collected by the project leader. The brochures, completed wish forms, and lockbox were removed from the centralized storage location at the end of implementation.

Project Data

Mortality data were acquired weekly from the Office of Decedent Affairs. In September, the 3WP collection rate was 69%, as 26 patients died and 18 wish forms were collected. Of the 18 forms, 17 were collected from participating individuals, and 1 was from a patient who declined to participate. The reason for declining was that the family felt adequately prepared for the patient’s death. In October, the 3WP collection rate was 45%, as 31 patients died and 14 wish forms were collected. No patients or families declined to participate. The overall wish form collection rate was 56% (32 of 57) of the patients who died during implementation of the 3WP.

Wish Data

Although participants had the option of choosing 3 wishes, not all opted for 3 wishes. Some participants opted for 1, 2, or 4 wishes, resulting in 114 wishes instead of the anticipated 96 wishes. Table 1 lists the frequency of wishes.

Financial Data

The total cost of the project was $992. The cost of the storage cubes, paper organization, and a lockbox was approximately $200, leaving the total cost of wishes at approximately $800 (Table 2). The average cost per wish was $6.98. If 3 wishes were requested, the average cost per patient was $20.94.

Table 2

Financial analysis

Financial analysis
Financial analysis

Medical Team Survey

At the completion of the pilot implementation period, the medical team was invited to participate in an anonymous Qualtrics survey. Survey participation was elicited via email, flyers with the survey QR code, and anecdotal conversations. Completion of the survey was voluntary, and the survey was not restricted to members who had actively implemented the 3WP with a patient and family. The survey was open between October 31 and November 21, 2022. The survey was fully completed by 39 participants. Two surveys were removed due to incomplete information. The largest percentage of respondents were women (31 [79%]), and 62% (n = 24) identified as a bedside or charge registered nurse (Table 3). Respondents self-selected degree of involvement, and equal numbers of respondents noted either minimal or moderate involvement with the project (Table 3).

Table 3

Demographic characteristics of the medical team (n = 39)

Demographic characteristics of the medical team (n = 39)
Demographic characteristics of the medical team (n = 39)

Table 4 outlines the survey questions. Questions 1 through 6 were taken directly from the survey used by Neville et al13  in their mixed-methods study of clinicians’ experiences with the 3WP. Ninety percent (n = 35) of respondents either agreed or strongly agreed that the 3WP was valuable and that it allowed the respondent to make a meaningful impact on patients and their families. Eighty-two percent (n = 32) of respondents either agreed or strongly agreed that the 3WP had a meaningful impact on the medical team, that it increased professional morale or job satisfaction in the unit, and that it created a more enjoyable atmosphere at work. Eighty-five percent (n = 33) of respondents either disagreed or strongly disagreed that the 3WP was disruptive to their normal duties. One outlier was identified in the data—1 respondent (3%) strongly disagreed that the intervention created a more enjoyable atmosphere at work. The response could not be be clarified because the survey was anonymous.

Table 4

Medical team survey questions and response statistics

Medical team survey questions and response statistics
Medical team survey questions and response statistics

Question 7 was added to directly assess the project question. Thirty-three respondents (85%) indicated that they either agreed or strongly agreed that the project allowed the medical team to consistently provide individualized EOL care.

Free Text

Respondents were invited to provide any additional comments about the project, stories about implementation, favorite memory, and barriers and to consider what they would like to see changed if the 3WP were to be continued. Of 39 respondents, 19 individuals (49%) provided additional comments. Free-text responses were independently reviewed by the project leader and the second reader for common themes. Of the 19 respondents, approximately 60% indicated that the 3WP had a meaningful impact on patients and families, more than 50% indicated meaningful impact on teams, and more than 15% indicated improved individualization of EOL care. Additional feedback included continuing the project at the practice site. Table 5 includes a selection of quotes from the free-text responses.

Table 5

Select medical team survey free-text responses

Select medical team survey free-text responses
Select medical team survey free-text responses

The 3WP was implemented in a 28-bed medical ICU for 2 months in late 2022. The overall wish form collection rate was 56%, which included 32 forms for the 57 patients who died during implementation. The total cost per wish was $6.98. Team members reported that the 3WP was valuable to patients and families, allowed the medical team to make a meaningful impact on patients and families and the medical team, increased professional morale and job satisfaction, and created a more enjoyable atmosphere at work.13  The survey data also indicated that the medical team did not feel that implementation was disruptive to regular duties.13  This project’s survey data support the 3WP as a method of ensuring that the standard of care at the EOL put forth by respected nursing and medical organizations is upheld.

Strengths

Study strengths include its accessibility to individuals with diverse backgrounds, including race, gender, spirituality, country of origin, and sexual orientation.

The project supplies required minimal storage space and used existing storage space in the unit. The main storage space was 34 inches (86 cm) wide and 28.5 inches (72 cm) tall. Larger items such as blankets and stuffed animals were stored in a large drawer near the main storage space.

During the pilot implementation period, the average cost per wish was $6.98. This cost was slightly more expensive than the $5 per wish published in the literature.11  Possible explanations include inflation since 2013 and the excess of supplies present at the end of implementation. It was difficult to anticipate how quickly supplies would be used in a unit with such a high average mortality rate, and there was an excess of supplies at the completion of the project. Funding for the supplies was from an external award, and the project team sought to use cost-efficient methods to implement wishes, including shopping at consignment stores to acquire supplies.

An important aspect of the financial analysis is the time members of the medical team invested in the project. Although these data were not specifically collected, from anecdotal observations, the total time spent implementing the project ranged from about 10 minutes to about 30 minutes depending on the time spent approaching the patient and family and the complexity of the wishes. The survey responses indicated that the project was not disruptive to the medical team’s regular duties.

Limitations

One limitation identified through anecdotal discussions and the completed survey results was the timing of approaching families and initiating the 3WP. During the pilot implementation period, multiple patients rapidly decompensated or died, leaving little time for the medical team to present the 3WP to the family. On other occasions, the family was distraught over their loved one’s rapid clinical decompensation and were unable to make decisions on wishes at that time. Thus, not every eligible patient and family had the chance to participate in the 3WP.

The 3WP allowed a high-intensity medical ICU to uphold the standard of providing individualization of EOL care without disrupting the work flow.

It is possible that the 3WP participation data were incomplete during the pilot implementation period owing to inaccuracies in collecting completed wish forms. Multiple completed wish forms were found at the nurses’ station, and it is possible that wish forms for every participant were not collected during the implementation period.

The practice area followed the national pattern of relying on travel nurses to help support staff levels. Transient members of the medical team in the practice area were often not aware of the 3WP and therefore did not offer it to their patients. During the implementation period, 56% of unit staffing was filled by core staff nurses and 44% was filled by travel nurses.

The 3WP allowed a high-intensity medical ICU to uphold the standard of providing individualization of EOL care without disrupting the usual work flow or process. In this 2-month pilot study, team members found the 3WP to be a feasible, valuable, and cost-effective tool that was meaningful to their practice. Anecdotal feedback from families was also positive.

Based on the results of this evidence-based practice study, it is reasonable to plan implementation of the 3WP in other ICUs.

The authors thank Deborah Cook, md, France Clarke, rrt, and Thahn Neville, md, for allowing this pilot study to capitalize on their 3 Wishes Project work. The authors would also like to thank the practice area’s medical team, including Kris Blackstone, msn, and Jamie Brick, dnp, who were instrumental in the implementation of the 3WP.

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Footnotes

This article is followed by an AJCC Patient Care Page on page 18.

 

FINANCIAL DISCLOSURES

The pilot study was funded by the Beta Kappa Chapter of Sigma Theta Tau.

 

SEE ALSO

For more about end-of-life care, visit the Critical Care Nurse website, www.ccnonline.org, and read the article by Jensen et al, “Practice Recommendations for End-of-Life Care in the Intensive Care Unit” (June 2020).

 

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.