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IMPROVING PATIENT CARE

Personalizing Death in the Intensive Care Unit: The 3 Wishes Project: A Mixed-Methods StudyThe 3 Wishes Project

Deborah Cook, MD; Marilyn Swinton, MSc; Feli Toledo, MDiv; France Clarke, RRT; Trudy Rose, BA, MTS; Tracey Hand-Breckenridge, MDiv; Anne Boyle, BScN, MD; Anne Woods, MD, MDiv; Nicole Zytaruk, RN; Diane Heels-Ansdell, MSc; and Robert Sheppard, MD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 14 July 2015.


From McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada, and North Cypress Medical Center, Cypress, Texas.

Acknowledgment: The authors are grateful for the compassion of the clinicians at St. Joseph's Healthcare Hamilton ICU. They also thank all of the patients, families, clinicians, students, and others who participated in this project. In addition, the authors thank Lois Saunders and Melissa Shears for helping to realize several wishes, Diana Clancy and Laurel Grainger for the transcriptions, and Carola Brunner and Tony LaRocca of the St. Joseph's Foundation for financial management. They also thank Drs. Graeme Rocker, Daren Heyland, and Randy Curtis for helpful comments on this project. This work was inspired by the work of the Sisters of St. Joseph in Hamilton.

Financial Support: By the Hamilton Academy of Health Science Research Organization and by donations from the Hamilton Chapter of the Canadian Intensive Care Foundation, Canadian Tire Foundation (Hamilton Branch), and several physicians. Family members, friends, and colleagues also donated to the 3 Wishes Project.

Disclosures: Dr. Cook reports grants from Canadian Intensive Care Foundation (Hamilton Chapter), Covenant Health, Canadian Tire Foundation (Hamilton Branch), and Hamilton Academy of Health Sciences Research Organization during the conduct of the study. Ms. Swinton reports grants from the Canadian Intensive Care Foundation (Hamilton Chapter), Covenant Health, and Canadian Tire Foundation (Hamilton Branch) outside the submitted work. Ms. Toledo reports grants from the Canadian Intensive Care Foundation, Covenant Health, Canadian Tire Foundation, and Hamilton Academy of Health Science Research Organization during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?ms Num=M15-0502.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol: Available from Dr. Cook (e-mail, debcook@mcmaster.ca). Statistical code and data set: Not applicable.

Requests for Single Reprints: Deborah J. Cook, MD, Departments of Medicine and Epidemiology and Biostatistics, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada; e-mail, debcook@mcmaster.ca.

Current Author Addresses: Dr. Cook: Departments of Medicine and Epidemiology and Biostatistics, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.

Ms. Swinton: Research Coordinator, McMaster University, 1280 Main Street West, HSC-2C20, Hamilton, Ontario L8S 4K1, Canada.

Ms. Toledo, Ms. Rose, and Ms. Hand-Breckenridge: Spiritual Care Department, St. Joseph's Healthcare, Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.

Ms. Clarke: Research Coordinator, St. Joseph's Healthcare, Critical Care Research, Room D-176, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.

Drs. Boyle and Woods: Palliative Care Service, Room F803, Fontbonne Building, Charlton Site, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.

Ms. Zytaruk: Research Coordinator, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Martha Building H327, Hamilton, Ontario L8N 4A6, Canada.

Ms. Heels-Ansdell: Biostatistician, Department of Clinical Epidemiology, McMaster University, 1280 Main Street West, HSC-2C20, Hamilton, Ontario L8S 4K1, Canada.

Dr. Sheppard: Emergency Medical Associates, North Cypress Medical Center, 21214 Northwest Freeway, Cypress, TX 77429.

Author Contributions: Conception and design: D. Cook, M. Swinton, F. Toledo, A. Boyle, A. Woods, R. Sheppard.

Analysis and interpretation of the data: D. Cook, M. Swinton, F. Toledo, T. Rose, T. Hand-Breckenridge, A. Boyle, A. Woods, D. Heels-Ansdell, R. Sheppard.

Drafting of the article: D. Cook, M. Swinton, F. Toledo, T. Rose, T. Hand-Breckenridge, A. Boyle, A. Woods, R. Sheppard.

Critical revision of the article for important intellectual content: D. Cook, M. Swinton, F. Toledo, F. Clarke, T. Rose, T. Hand-Breckenridge, A. Boyle, A. Woods, N. Zytaruk, R. Sheppard.

Final approval of the article: D. Cook, M. Swinton, F. Toledo, F. Clarke, T. Rose, T. Hand-Breckenridge, A. Boyle, A. Woods, N. Zytaruk, D. Heels-Ansdell, R. Sheppard.

Provision of study materials or patients: D. Cook.

Statistical expertise: D. Cook, D. Heels-Ansdell.

Obtaining of funding: D. Cook, M. Swinton, F. Toledo, A. Woods, R. Sheppard.

Administrative, technical, or logistic support: D. Cook, F. Toledo, F. Clarke, T. Rose, N. Zytaruk.

Collection and assembly of data: D. Cook, M. Swinton, F. Toledo, F. Clarke, A. Boyle, N. Zytaruk.


Ann Intern Med. 2015;163(4):271-279. doi:10.7326/M15-0502
Text Size: A A A

Background: Dying in the complex, efficiency-driven environment of the intensive care unit can be dehumanizing for the patient and have profound, long-lasting consequences for all persons attendant to that death.

Objective: To bring peace to the final days of a patient's life and to ease the grieving process.

Design: Mixed-methods study.

Setting: 21-bed medical–surgical intensive care unit.

Participants: Dying patients and their families and clinicians.

Intervention: To honor each patient, a set of wishes was generated by patients, family members, or clinicians. The wishes were implemented before or after death by patients, families, clinicians (6 of whom were project team members), or the project team.

Measurements: Quantitative data included demographic characteristics, processes of care, and scores on the Quality of End-of-Life Care–10 instrument. Semistructured interviews of family members and clinicians were transcribed verbatim, and qualitative description was used to analyze them.

Results: Participants included 40 decedents, at least 1 family member per patient, and 3 clinicians per patient. The 159 wishes were implemented and classified into 5 categories: humanizing the environment, tributes, family reconnections, observances, and “paying it forward.” Scores on the Quality of End-of-Life Care–10 instrument were high. The central theme from 160 interviews of 170 persons was how the 3 Wishes Project personalized the dying process. For patients, eliciting and customizing the wishes honored them by celebrating their lives and dignifying their deaths. For families, it created positive memories and individualized end-of-life care for their loved ones. For clinicians, it promoted interprofessional care and humanism in practice.

Limitation: Impaired consciousness limited understanding of patients' viewpoints.

Conclusion: The 3 Wishes Project facilitated personalization of the dying process through explicit integration of palliative and spiritual care into critical care practice.

Primary Funding Source: Hamilton Academy of Health Science Research Organization, Canadian Intensive Care Foundation.

Figures

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Figure.

Example of a word cloud.

This word cloud was generated for a young man with chronic end-stage respiratory illness. As part of the 3 Wishes Project, we explained to his parents, sister, and some friends in his room that we hoped to create a framed collage of words as a keepsake for them. We showed them an example. We asked them to tell us more stories about his life to help us get to know him, asking what was important to him—his personality and passions and persons in his life. Unpressured and without expectation, we asked which concepts or memories they thought would be meaningful to represent. His family and friends reminisced, making direct suggestions about words to include. Listening to their narratives, we suggested other words. Later that afternoon, we chose words from the stories to make a framed word cloud that we placed in the patient's room. The word cloud prompted recollections among family and friends who attended until his death a few days later. For clinicians, it served as a touchstone to appreciate the footprint of his life and learn about what mattered most to him. The family later told us that they displayed the word cloud at his funeral. Reprinted with permission from the patient's parents.

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