Choice and Control at the End of Life – The 3 Wishes Project

One of the advantages of getting behind in reading medical journals is seeing links between articles when I finally try to catch up in one mind-numbing session.  In reading some articles from this past week’s lineup of journals (which admittedly doesn’t count as “falling behind”), one theme was the choice and empowerment that clinicians do and don’t provide to patients in late life. 

One article in particular caught my eye: a piece by Cook et al in Annals of Internal Medicine on the 3 Wishes Project.  This project encouraged patients dying in the ICU - and their family members and clinicians - to generate and implement at least 3 wishes, for example bringing personal mementos into the hospital room, renewing wedding vows at the bedside, recreating a date night in the ICU, or allowing a mother to lie in bed with her son as he died.  Not surprisingly, the project was well-received, with mixed-methods approaches finding that it helped improve patients’ dignity, give their families a voice, and foster clinician compassion.  But, I found several other findings particularly interesting. 

• Nearly all (98%) wishes were implemented. 
• Half of the wishes (48%) were implemented after the patient’s death.  These included memorials, charitable contributions to causes that were important to patients, and the championing of those causes.  
• The majority of wishes (52%) came from clinicians.  As the article stated: “Based on their knowledge of the patients or families, clinicians may have suggested wishes, which often prompted families or patients to think of wishes themselves.” 

What do these finding mean?  My take is:

• 98% of wishes were implemented. ==> We can do this.
• Half of wishes were implemented after the patient’s death.  ==> When I think about how to improve end-of-life care, I usually focus on improving comfort, dignity, and meaning in the time before the patient dies.  Perhaps I have underappreciated another critical element: helping patients and families continue the meaning of patients’ lives after they are gone.
• 52% of wishes came from clinicians. ==> As clinicians, we can and should be active in helping patients and their families craft and implement their wishes.

This is likely old hat to palliative care physicians, but a good reminder to the rest of us about what we can and should do to help patients and their families at the end of life.

by: Mike Steinman