American Journal of Respiratory and Critical Care Medicine
Rationale: The 3 Wishes Project (3WP) is a low-cost palliative-care initiative in which healthcare workers implement small but meaningful wishes for patients and their families to improve the quality of the end-of-life experience. It has been shown to be a transferrable, affordable, and sustainable program in several academic centers, but has never been implemented in safety-net hospitals (SNHs). SNHs provide largely uncompensated healthcare to low-income and uninsured patients, and unfortunately, are often unable to implement novel palliative care interventions. We hypothesized that the 3WP can be successfully implemented in the intensive care units (ICUs) of SNHs when guided by stakeholder engagement. Methods: A stepped-wedge study design, where implementation was staggered by 2 months, was used to implement the 3WP in 3 Los Angeles SNHs. Prior to implementation, stakeholders from each SNH were engaged in individual semi-structured interviews or focus groups to elicit feedback regarding the 3WP implementation strategy. Informational brochures for families and instructional badge buddies for nurses were created and personalized for each SNH. Per stakeholder suggestions, items that met the cultural and spiritual needs of the SNH's majority Catholic patient population (rosaries, flameless prayer candles, crosses) were purchased for each SNH's 3WP inventory. Depending on stakeholder preference, 2 to 8 training sessions were conducted at each SNH to familiarize nurses with the 3WP goals as well as the logistics of eliciting, fulfilling, and documenting wishes. We show results from the initial 7-month period. Results: Across 3 SNHs, 111 ICU nurses, 3 ICU physicians, 1 Social Worker, 10 Palliative Care Team Members, 2 Spiritual Care Team Members, and 12 3WP Team members implemented a total of 314 wishes for 117 patients (60% of eligible patients). Deceased patients who had 3WP as part of their end-of-life care averaged 62.2 years old, were 61% male, 63% LatinX, and 43% Spanish-speaking only. Categories of wishes included keepsakes (50%, e.g. fingerprints, locks of hair), rituals and spiritual support (19%, e.g. rosaries/crosses), and items to humanize the environment (15%, e.g. decorating hospital room, non-hospital blankets). The direct cost of 3WP averaged 0 to $95) per patient. Conclusions: The 3WP is an inexpensive patient and family-centered approach to end-of-life care that can be successfully implemented in culturally diverse SNHs when guided by a methodical implementation strategy. ICU nurses were responsible for the elicitation and implementation of nearly all wishes and are strong champions for this intervention. This abstract is funded by: NIH R01NR020773
