Where: Ronald Reagan UCLA (University of California, Los Angeles) Medical Center, a 520-bed teaching hospital in Los Angeles.
The issue: Improving the end of life for patients and their families.
Beeping machines or a humming ventilator in the ICU can be a disturbing soundtrack to the end of life. To provide a better experience for these patients, the 3 Wishes Project fulfills small, joyful requests, such as one final date night with a spouse or a holiday celebration in the hospital room.
“Our goal is to dignify the dying process and honor who the person is. By doing so, we hope to create a better end-of-life experience where everyone who is involved has a better experience, and that includes the patient, the family, and the clinician,” said critical care physician Thanh Neville, MD, MSHS, cofounder and medical director of the program at UCLA.
So far, UCLA Health is the only U.S. hospital that has implemented 3 Wishes, she said. Critical care physician Deborah Cook, MD, launched the original project in 2013 at St. Joseph's Healthcare Hamilton in Ontario, Canada. After Dr. Cook's group published favorable results in August 2015 in Annals of Internal Medicine, Dr. Neville's palliative care colleague Peter Phung, MD, suggested bringing the project to UCLA. Dr. Neville applied for and received a $10,000 seed grant to pilot the project and launched it in December 2017 in the medical ICU at Ronald Reagan UCLA Medical Center.
How it works
Clinicians approach suitable patients and their families about the concept in a conversational way. This often doesn't immediately lead to a particular request. “This is when we use this as an opportunity to get to know the patient,” Dr. Neville said. “We might even say, ‘Can you tell me a little bit more about your loved one? What did they like when they were not in the hospital?’”
The first 3 Wishes patient was a young, active man whose wife said he would hate the thought of dying in the ICU. To fulfill his wish of being outdoors, clinicians rolled his bed outside onto an open terrace and removed life support as the sun began to set. When his wife crawled into bed with him for the last time, Dr. Neville handed her a nonhospital blanket. “She told me that she sleeps with that blanket every night, and that's the only way she falls asleep,” she said.
So far, UCLA has fulfilled more than 700 wishes for more than 200 patients at an average cost of $30 per patient, Dr. Neville said. “We have accomplished from one to 10 wishes per patient,” she said. “I know we call it the 3 Wishes program, but we're not stuck on that number.” Examples of wishes include playing the patient's favorite music, decorating patients' rooms with their favorite memorabilia, and creating thumbprint or hand sculpture keepsakes for a grieving family.
Dr. Neville, whose background is in critical care research, has been studying the program's effect by conducting surveys and focus groups with clinicians and interviews with family members. The response has been very positive. “Families tell me that the program allows them to have a level of support that they weren't expecting from a health care system,” she said.
In addition, some clinicians (especially nurses) have said the project reminds them of why they went into their profession in the first place. “It allows them to provide compassionate care for patients and families in people's darkest moments, at a time when medicine has nothing left to offer,” said Dr. Neville, whose paper about the project's effects on clinicians has been recently accepted for publication.
In the beginning, the biggest challenge was not cost, but time and effort. The first wish, for example, cost only $20 for the blanket, “But it was not an easy feat to move the hospital bed outside to an area that's not used to patient care,” said Dr. Neville. “The cost of the program isn't much, but it doesn't take into account all the time that I dedicated to make sure that it runs smoothly, and it doesn't take into account all the countless hours that nurses and physicians contribute to fulfilling the wishes.”
From the medical ICU at Ronald Reagan, the project has now expanded to an ICU and an oncology unit at UCLA Medical Center, Santa Monica. In the coming year, Dr. Neville hopes to expand to all five ICUs at Ronald Reagan. “In the years to come, I really hope that this becomes a program that hospitals outside UCLA will want to emulate,” she said.
Dr. Neville has learned that each time she wants to expand the program to a new unit, she needs to speak with the nursing and physician leadership and ask them to identify a 3 Wishes champion to take the lead in implementing the project in a unit. “I can talk to a few people, but the goal is for the champions to spread it within their unit and teach it back to others,” she said. “What I have pleasantly found is that most doctors and nurses really fully embrace this program, really want to do the best for their patients.”