Skip to main content

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





Comments

Harshil Patel said…
Amazing! Thanks a lot for sharing the good humor. US Open Live Streaming You can also check the live scores by checking this US Open Live Scores
August 18, 2015 at 11:55 PM
Post a Comment

Popular posts from this blog

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…
5 comments
Read more

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …
7 comments
Read more

Language Matters: Podcast with Brian Block and Anna DeForest

One of our first GeriPal posts was titled "Rant on Terminology," by Patrice Villars, NP.  In the spirit of looking back over our first 10 years, here is the opening paragraph to that post:

News Headlines read: Sen. Edward Kennedy loses battle with cancer. Really, he lost? I thought he died from a malignant brain tumor, an “aggressive” brain tumor. The median survival is less than a year for people for his particular tumor. Kennedy was diagnosed in May of 2008. He lived over 15 months after diagnosis. What a loser. He must not have fought hard enough. Huh? I thought he spent most of his life battling for social and health care reform in America. In this week's GeriPal podcast we take a deeper dive into this issue of language and medicine.  We are joined by guests Anna DeForest, MD, MFA, a resident in Neurology at Yale, and Brian Block, MD, a pulmonary critical care fellow at UCSF.  

Anna recently published a paper in the NEJM describing her reaction to hearing terms like, &…
1 comment
Read more