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 Patients and families were invited to participate in the “Three
Wishes Project” after a decision was made to withdraw life support,
or when the patient’s probability of dying in the unit was believed
to be greater than 95 percent.
At St. Joseph's Healthcare Hamilton in Ontario clinicians asked how
to honor patients by eliciting at least three wishes from them or
their families. Then, they worked to implement those wishes - such
as allowing a pet to visit, facilitating a Skype reunion, hosting a
wedding vow renewal, providing Scottish bagpipe music at death or
deferring life support withdrawal until after a holiday.
“We are trying to improve the quality of the dying experience in the
cold, technological, efficiency-driven intensive care unit,” said
Dr. Deborah Cook of McMaster University Health Sciences Center in
Hamilton, one of the authors of a report on the Three Wishes
Project.
“This is a time when compassion is called for from everybody,” she
said.
To study the effects of the project, she and her colleagues enrolled
40 patients, and 159 of their 163 wishes were implemented. The cost
ranged from nothing to $200 dollars per patient. Wishes were
classified into five categories: humanizing the patient (for
example, recreating date night in the ICU), personal tributes
(providing a final meal for the family in an ICU conference room),
family reconnections (dying with all family members present),
rituals and observances (bedside memorial service) and “paying it
forward” (organ donation).
Within six months after a patient’s death, the researchers
interviewed at least one family member. In addition, within two
weeks after a death, three clinicians who had cared for that patient
responded to emailed questions. A qualitative analysis of
transcripts, letters and field notes reflects a personalization of
death by dignifying the patient, extending families a voice and
fostering clinician compassion.
As reported in Annals of Internal Medicine, one mother said the
program “honors the everyday hero: someone who may go unnoticed but
whose life counted.”
A patient’s daughter responded that “it struck a chord because it
allowed me to talk about her, and . . . . give the staff . . . a
vision of who she was.”
A nurse wrote, “This is putting the absolute human side into the
whole experience. I think this project is so powerful.”
Dr. Anne Woods, a co-author and palliative care physician, told
Reuters Health that the project’s strength was in making the dying
visible.
“It let them be seen as people, not as patients,” she said. “The
family knew they were seen, and the patients who were alert knew
they were seen as people, and that they mattered.”
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In fact, solicitation of patient wishes was rare. Due to impaired
consciousness, 33 of 40 dying patients could not express desires.
Family members requested wishes for them.
Because of this, and because there wasn’t a comparison group of
patients and families who didn’t make wishes, the project is
“worthwhile” but “proves little,” said bioethicist Craig Klugman,
chair of DePaul University’s Department of Health Sciences in
Chicago.
“They conclude that this does something for the dying person, but in
fact, of 40 dying people, only seven were able to speak,” Klugman
told Reuters Health. “It’s impossible to claim any benefit for
patients.”
But Patrick Cullinan, medical director of critical care services at
Metropolitan Methodist Hospital in San Antonio, Texas, feels that
any intervention that allows families to feel cared for is valuable.
“It’s giving a face to a faceless process,” Cullinan, who was not
involved in the study, told Reuters Health. “The patient is being
told indirectly that we care about you, we care about your loved one
and we want to help you with the grieving process.”
Perhaps the project’s best result is the recognition by ICU staff
that they can offer meaningful gestures at any time.
“They now know to ask ‘What can I do for you?’ and ‘What could make
this a good day?’ and they do that,” Woods said. “There’s never a
time when someone can say now ‘There is nothing more I can do for
you.’ There is always something more for you to do.”
Funding for the Three Wishes Project came from the Hamilton Academy
of Health Science Research Organization, the Hamilton Chapter of the
Canadian Intensive Care Foundation, the Canadian Tire Foundation
(Hamilton Branch), several physicians and from some of the
relatives, friends and colleagues of the patients.
SOURCE: http://bit.ly/1L78SNK Annals of Internal Medicine, online
July 13, 2015.
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