Project Initiation and Implementation
The idea for this study was sparked during a national conference where the results of the 3WP in SJHH was reported. Staff at NH SCS believed it would be feasible to adopt the project in a community ICU and believed it would benefit the care of dying ICU patients. Thereafter, an environmental scan of existing EOL practices was conducted through a clinician focus group and a desire to initiate a more formalized EOL project was confirmed. Anticipated barriers included competing clinical demands on time, lack of supplies for implementing wishes, and the ICU’s readiness for change.
The initial implementation plan considered patients to be candidates for the project if they had a high likelihood of imminent death as judged by the most responsible physician or planned withdrawal of life-sustaining therapy. In addition, the plan was to only enroll patients during the days where the 3WP physician lead was on service to allow the project to iteratively and organically develop in the ICU. During the first month, the frontline staff and implementation team both believed that the 3WP should consider all dying patients including when the 3WP physician lead was not on service, as the risk of patient harm was likely low, and the benefits for patients, families, and clinicians were likely to be high. The only exclusion criterion for enrollment in the 3WP was a patient or family member declining to participate.
A three-pronged strategy was used to support implementation: communication and education, collection of point-of-care resources and promotion of multidisciplinary collaboration. Communication and education interventions included emails to staff, in-person updates about the project during rounds, champion training retreats co-hosted with the founding 3WP team from SJHH, an information binder at nursing stations with guides on how to introduce the project, a list of wish ideas as described by Cook et. al,10 a list of common wishes by patients/ families/ clinicians as described by Clarke et. al15 and protocols for implementing commonly used items at SCS such as music, refreshments, and keepsakes.16 The 3WP physician lead and other nurse champions assisted clinicians with the implementation of the project at the bedside during care. The frontline staff and implementation team also collected point-of-care resources to facilitate wishes based on common wishes at SJHH10 such as blankets, and candles. In addition, keepsakes such as EKG strips in glass vials or ink thumbprint picture frames were used to help memorialize dying patients. At the start of the project, the implementation team met with palliative care staff and spiritual care staff to promote inter-disciplinary collaboration during EOL. Patient enrolment and wishes implemented were self-reported and documented by the 3WP physician lead and clinicians enrolling patients.