06 December 2019

End-of-Life Caring

Comfort care is an essential part of medical care at the end of life…The goals are to prevent or relieve suffering as much as possible and to improve quality of life while respecting the dying person's wishes. (National Institute on Aging)

End-of-life care for the terminally ill
(photo from www.nia.nih.gov/).
Welcome back. Although I’m not yet dying or attending to someone who is, I came across two recent end-of-life studies you might find of interest. One focuses on the dying patient and family, the other addresses the surrogate who makes life-sustaining decisions for the patient.

The 3 Wishes Project
The 3 Wishes Project is an end-of-life program that seeks to bring peace to terminally ill patients and ease the grieving process.

The program involves implementing wishes identified by the patient, family, clinicians or project team in an effort to dignify the death and celebrate the life; humanize the dying process and create positive memories; and foster patient and family-centered end-of-life care while inspiring a deeper sense of vocation for clinicians.

The 3 Wishes Project began at St. Joseph's Healthcare Hamilton, an academic and research hospital affiliated with McMaster University and Mohawk College, in Hamilton, Ontario, Canada.

Can Project Sites be Added?
Researchers led by those with McMaster University conducted a study to determine if the program could be implemented by intensive care units of other hospitals.

Three additional hospitals participated, one each in Toronto, Vancouver and Los Angeles. Together with the Hamilton hospital, the study fulfilled 3,407 wishes for 730 dying patients.

The wishes, usually more than three per patient, included bringing personal items, pictures and pets from home, providing favorite music or spiritual support, connecting long lost family, celebrating weddings, watching a sporting event together with a favorite beverage, and a "date night" with local restaurant food.

3 Wishes Project--family, friends and staff get together in patient's room (photo from brighterworld.mcmaster.ca/articles/project-to-answer-last-wishes-spreads-successfully/).
Judging Success
The researchers assessed results using a mixed-methods formative evaluation, which entailed collecting, analyzing and integrating quantitative and qualitative data from 75 family members, 72 clinicians and 20 managers or hospital administrators.

Program value encompassed comforting families while inspiring compassionate clinical care. Transferability was promoted by family appreciation and the intensive care unit culture committed to dignity-conserving, end-of-life care. As for affordability, there was a required minimal investment for reusable materials, but the average cost per wish was just over $5.00 since most wishes cost nothing. Sustainability was demonstrated by each site continuing the program after the study.

Clinician and family perspectives on the 3 Wishes Project
(photo from 11-minute video youtu.be/CkWjlcl4BA4).
There seems no question that the 3 Wishes Project can and should be implemented at other tertiary care centers.

Religion, Spirituality and Surrogate Decisions
A team of investigators, led by a researcher with the Regenstrief Institute, set out to determine the relationships between religion and spirituality and the treatment decisions made by health care surrogates.

Decision-makers consent for Do-Not Resuscitate status
(from Patricia Bomba’s slides on “Medical decision-making
capacity: Legal, Ethical and Clinical Considerations”
They enlisted 291 patients and their health care surrogates from three hospitals. The patients were age 65 or older and admitted to the intensive care services. The surrogates were predominately Protestant.

Baseline surveys completed between the second and tenth day assessed dimensions of religion and spirituality. Review of medical records and health information six months later identified life-sustaining treatments and hospice for patients who died.

Key Factors Influencing Surrogates
After adjusting for other religious dimensions, demographic and illness factors, the surrogates' belief in miracles was the only factor significantly associated with lower preference for do-not-resuscitate status--59% believed a miracle might save the patient.

Higher surrogate intrinsic religiosity (religion that is an end in itself) was associated with lower receipt of life-sustaining treatments during the patients’ final 30 days.

Together, belief in miracles and higher intrinsic religiosity were associated with lower hospice utilization.

To reduce effects on end-of-life treatment, the investigators recommend that chaplains or appropriately trained clinicians identify and explore surrogates’ belief in miracles and intrinsic religiosity.

Wrap Up
If you’re seeking end-of-life information, you’ll find an excellent series of articles on the National Institute on Aging’s website--providing care and comfort, palliative and hospice care, caring for a dying relative or someone with dementia, healthcare decisions, what happens when someone dies, what to do after someone dies and mourning the death of a spouse.

Thanks for stopping by.

National Institute on Aging’s End of Life website: www.nia.nih.gov/health/end-of-life
3 Wishes Project website: 3wishesproject.com/
3 Wishes Project study in Annals of Internal Medicine: annals.org/aim/article-abstract/2755629/compassionate-end-life-care-mixed-methods-multisite-evaluation-3-wishes
Article on study on EurekAlert! website: www.eurekalert.org/pub_releases/2019-11/mu-pta110619.php
Surrogate decision maker study in Journal of Pain and Symptom Management: www.sciencedirect.com/science/article/abs/pii/S0885392419305263
Article on study on EurekAlert! website: www.eurekalert.org/pub_releases/2019-11/ri-fso110419.php

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