Enhancing end of life care on general internal medical wards: the 3 Wishes Project

Timelines for 3WP Expansion

Figure 1 shows a timeline of expansion events. In early January 2020, preparatory activities were underway with the development of the Expansion Coordinator role, submission of internal grants to support expansion activities, and an off-site introductory event. Please see Additional file 1: Appendix 1 (section A1.3) for further detail about this and 3WP Resource Group Activities.

Fig. 1figure 1

Timeline of 3WP expansion activities from January 2020 – November 2021. Legend: This figure shows the timeline of formal 3WP expansion activities in the context of the various waves of the COVID-19 pandemic in dark green pattern from March 2020 to November 2021 in Ontario, Canada (showing patterns of hospitalized patients) [20, 21]. Abbreviations: EMR – electronic medical record; WHO – World Health Organization; GIM – general internal medicine; CIHR – Canadian Institutes of Health Research; EOL – end-of-life care

3WP resource group activities

Between May 2020 and November 2020, the 3WP Expansion Coordinator facilitated orientation activities including presentations, webinars, orientations, and drop-in sessions (Additional file 1: Appendix 1, section A1.3, E-Table 1). She also conducted weekly check-ins with each ward for the first 6 months, which were paused when the pandemic burden increased. The Expansion Coordinator and the Research Coordinator also created a ‘badge buddy’ adapted from 3WP ‘badge buddies’ developed at the UCLA to give to interested nursing staff (Additional file 1: Appendix 1, section A1.4, E-Fig. 2; T. Neville, personal communication, Aug. 10, 2019). As of September 2021, co-funded by Canadian Institutes of Health Research, the hospital, and the Academic Critical Care Research Office, the 3WP Post-Doctoral Fellow assisted with the 3WP expansion and developed additional health services approaches to enhance end-of-life care practices on the GIM wards.

3WP patients and wish characteristics

The first patient enrolled with assistance from the Expansion Coordinator was on March 3, 2020, and the last patient for whom data were collected in this phase was on November 8, 2021. We enrolled 62 patients in the 3WP from the 4 GIM wards. Most were female (53.2%), and the mean age was 78.6 years. Three patients (4.8%) died after being transferred home (n = 2) or to a continuing care facility (n = 1). Table 1 summarizes patient demographics and characteristics of their hospital stay. Patients are continuing to receive care aligned with the 3WP as initiated by staff on the wards and supported by the 3WP Resource Group as needed.

Table 1 Patient demographics and hospital stay characteristics

Enrolment in the 3WP was most often initiated by a bedside nurse (16, 25.8%), followed by a palliative care clinician (13, 21.0%), an attending physician (10, 16.1%), social worker (5, 8.1%), and spiritual care clinician (5, 8.1%). Patients were admitted to the hospital for a median of 10 days prior to enrolment; the median time from enrolment to death was 3 days.

There were 281 wishes documented for the 62 patients with a median [1st, 3rd quartiles] number of wishes/patient of 4 [4, 5]. Figure 2 shows the number of wishes for each of the 11 wish categories (category descriptions have been published previously [17]). Wishes were most commonly made by family or friends (145 wishes, 51.6%), followed by clinicians (89 wishes, 31.7%). Nearly half of patients (n = 30, 48.4%) engaged in some aspect of the wish process (i.e., making or implementing); direct patient participation informed the selection of 73 wishes (26.0%). Patients most requested to taste a favorite food or drink, go outside, or have their family pet visit (personalizing the patient category, 24.7%), while family and friends most often wished to facilitate connections (28.3%), and clinical teams wished to personalize the environment (41.3%) including providing a handmade blanket or transferring the patient to a private room or palliative care suite when possible.

Fig. 2figure 2

Proportion of wishes for 62 dying patients distributed amongst 11 wish categories. Legend: Wish categories: personalizing the environment (n = 67, 23.8%), rituals and spiritual support (n = 42, 14.9%), facilitating connections (n = 39, 13.9%), personalizing the patient (n = 32, 11.4%), family care (n = 29, 10.3%), preparations and final arrangements (n = 28, 10.0%), music (n = 17, 6.0%), keepsakes and tributes (n = 16, 5.7%), word clouds (n = 9, 3.2%), providing food and beverages (n = 1, 0.4%), paying it forward (n = 1, 0.4%)

Nearly all wishes (276, 98.2%) were implemented; only 5 wishes were not possible for medical (n = 3) or logistical (n = 2) reasons. Most wishes (n = 268, 95.4%) were made ante-mortem but 13 wishes (4.6%) were made post-mortem. Post-mortem wishes included keepsakes (n = 9, e.g., word clouds and fingerprint keychains), prayers (n = 2), playing a favorite radio station at the bedside (n = 1), and donating to the 3WP (n = 1). Wishes were most often implemented by nurses (90 wishes, 32.6%), followed by family (46 wishes, 16.7%), and spiritual care clinicians (46 wishes, 16.7%). Others implementing wishes were either hospital-based (e.g., charge nurse, security staff, medical learners (resident and student), recreational therapist, Infection Prevention and Control staff, and nursing and hospital administrators) or community-based (e.g., primary care physician, Indigenous elder, priest).

The median [1st,3rd] cost per wish was $0 [0,0] and the median [1st, 3rd] cost per patient was $0 [0, $10.00]. Seventy-two wishes (26.1%) were donated (n = 70) or discounted (n = 2), and 251 wishes (90.9%) incurred no additional cost to the program (i.e., wish cost = $0).

Influence of the pandemic

During the pandemic, SJHH cared for patients with COVID-19 in several areas of the hospital, including the ICU, a dedicated COVID ward, and on the GIM wards as additional beds were needed to care for patients under surge conditions. Because of the influx of patients with COVID-19 and ongoing high patient volumes, the Expansion Coordinator was redeployed back to clinical nursing duties in the ICU between December 2020 and October 2021 (Fig. 1). Thereafter, the 3WP Research Coordinator supported the wards by coaching staff, stocking supplies, and facilitating wishes such as keepsakes as requested.

Strict visiting restrictions were implemented in March 2020. Under special circumstances such as end-of-life, brief, single visits by one or a limited number of family or friends were sometimes permitted. By June 2020, visitation became less restrictive, particularly for dying patients, but this was not universal for patients with COVID-19 infection. Restrictions fluctuated in terms of how many visitors could attend, if they could enter the patient’s room, and the duration of the visit depending on location, shifts, clinician discretion, and pandemic burden. For 7 patients (11.3% of total cohort) with COVID-19 enrolled during this study, 29 wishes were implemented. Only 3 of these patients (42.9%) had family or friends present at the time of death compared to 73.1% of patients without COVID. Compared to patients without COVID, those with COVID were more likely to have wishes facilitated by clinicians only (41.4% vs. 18.7%, respectively).

Comparison to pilot wish characteristics

There were differences in terms of wish elicitation and wish categories between patients in the pilot phase and in this expansion study (Table 2). For example, more clinical team members were engaged in wishes (28.5% in this expansion compared to 11.1%). Given limited family and friend presence at the bedside during the expansion phase, clinician wishes for family care were less common than in the pilot (18.8% compared to 46.2%). Patient wishes for food and beverages occurred less commonly than in the pilot (0% compared to 6.3%). Clinician wishes for rituals and spiritual support were higher in this expansion period than in the pilot (16.4% compared to 3.1%).

Table 2 Percent of patient, family, and clinical team wishes in the pilot and expansion phase

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