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\begin{document}

\title{Initiating and integrating a personalized end of life care project in a
community hospital intensive care unit: a mixed-method study of
clinician and key stakeholder perspectives}



\author[1]{Eugenia Yeung}%
\author[2]{Laurie Sadowski}%
\author[2]{Kelsea Levesque}%
\author[2]{Mercedes Camargo}%
\author[2]{Allen Vo}%
\author[2]{Elayn Young}%
\author[2]{Erick Duan}%
\author[2]{Jennifer Tsang}%
\author[3]{Deborah Cook}%
\author[2]{Benjamin Tam}%
\affil[1]{University of Ottawa Faculty of Medicine}%
\affil[2]{Niagara Health System}%
\affil[3]{McMaster University}%


\vspace{-1em}



  
  \date{May 16, 2024}


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\selectlanguage{english}
\begin{abstract}
Rationale The end of life (EOL) experience in the intensive care unit
(ICU) can be psychologically distressing. The 3 Wishes Project (3WP)
personalizes the EOL experience by carrying out wishes for dying
patients and their families. While the 3WP has been integrated in
academic, tertiary care ICUs, implementing this project in a community
ICU has yet to be described. Objectives To examine facilitators of, and
barriers to, implementing the 3WP in a community ICU from the clinician
and key-stakeholder perspective. Methods This mixed-method study
evaluated the implementation of the 3WP in a 20-bed community ICU in
Southern Ontario, Canada. Patients were considered for the 3WP if they
had a high likelihood of imminent death or planned withdrawal of
life-sustaining therapy. Quantitative data include patient demographic
data and wishes implemented. Following the qualitative descriptive
approach, semi-structured interviews were conducted with purposively
sampled clinicians and key-stakeholders. Data from transcribed
interviews were analyzed in triplicate through qualitative content
analysis. Results During the 10-month period, 66 of 67 wishes were
completed, with a median of 4.5 wishes per patient-family dyad.
Interviews with 12 participants indicated that the 3WP personalized and
enriched the EOL experience for patients, families and clinicians.
Interviewees indicated higher intensity education strategies were needed
to enable spread as the project grew. Clinicians described many physical
resources for the project but required more non-clinical project support
for orientation, continuing education and data collection. Instead,
these roles were completed by clinicians with saturated work capacity
which may have inhibited the spread of the project. Conclusions In this
community hospital, ICU clinicians and key stakeholders reported the 3WP
improved EOL care for patients, families, and clinicians. Project
implementation in a community ICU requires investigators take into
account project characteristics and adapt the intervention to the
community hospital context.%
\end{abstract}%



\sloppy


\textbf{Initiating and integrating a personalized end of life care
project in a community hospital intensive care unit: a mixed-method
study of clinician and key stakeholder perspectives}

Eugenia Yeung\textsuperscript{1} BHSc MD (cand.), Laurie
Sadowski\textsuperscript{2} MA, Kelsea Levesque\textsuperscript{2} RN
MSc (cand.), Mercedes Camargo\textsuperscript{2} MSc, Allen
Vo\textsuperscript{2} RN MN (cand.), Elayn Young\textsuperscript{2} RN
MBA, Erick Duan\textsuperscript{2,3} MD, Jennifer LY
Tsang\textsuperscript{2,3} MD PhD, Deborah Cook\textsuperscript{3,4} MD,
Benjamin Tam\textsuperscript{2} MD MSc

1 Department of Medicine, University of Ottawa, Ottawa, Canada

2 Division of Critical Care Medicine, Niagara Health, St. Catharines,
Canada

3 Department of Medicine, McMaster University, Hamilton, Canada

4 Department of Medicine and Health Research Methods, Evidence, and
Impact, McMaster University, Hamilton, Canada

\textbf{MeSH Keywords} : experience, healthcare, humanity,
patient-centered care, patient-centered medicine

\emph{Abstract}

\emph{Rationale}

The end of life (EOL) experience in the intensive care unit (ICU) can be
psychologically distressing. The 3 Wishes Project (3WP) personalizes the
EOL experience by carrying out wishes for dying patients and their
families. While the 3WP has been integrated in academic, tertiary care
ICUs, implementing this project in a community ICU has yet to be
described.

\emph{Objectives}

To examine facilitators of, and barriers to, implementing the 3WP in a
community ICU from the clinician and key-stakeholder perspective.

\emph{Methods}

This mixed-method study evaluated the implementation of the 3WP in a
20-bed community ICU in Southern Ontario, Canada. Patients were
considered for the 3WP if they had a high likelihood of imminent death
or planned withdrawal of life-sustaining therapy. Quantitative data
include patient demographic data and wishes implemented. Following the
qualitative descriptive approach, semi-structured interviews were
conducted with purposively sampled clinicians and key-stakeholders. Data
from transcribed interviews were analyzed in triplicate through
qualitative content analysis.

\emph{Results}

During the 10-month period, 66 of 67 wishes were completed, with a
median of 4.5 wishes per patient-family dyad. Interviews with 12
participants indicated that the 3WP personalized and enriched the EOL
experience for patients, families and clinicians. Interviewees indicated
higher intensity education strategies were needed to enable spread as
the project grew. Clinicians described many physical resources for the
project but required more non-clinical project support for orientation,
continuing education and data collection. Instead, these roles were
completed by clinicians with saturated work capacity which may have
inhibited the spread of the project.

\emph{Conclusions}

In this community hospital, ICU clinicians and key stakeholders reported
the 3WP improved EOL care for patients, families, and clinicians.
Project implementation in a community ICU requires investigators take
into account project characteristics and adapt the intervention to the
community hospital context.

Introduction and Objectives

Advances in health care have changed the fundamental human experience of
death. Though dying at home has been consistently described as the
preferred location for death, more Canadians now die in an intensive
care unit (ICU) than before.\textsuperscript{1,2} This presents an
environment replete with technology within an institutional setting that
propagates the medicalization of death as the backdrop for end of life
(EOL) care. This setting can obscure humanity in the dying process for
patients, and perpetuate grief, anxiety, depression and post-traumatic
stress disorder in bereaved family members.
\textsuperscript{1,3}Moreover, clinicians experience disengagement and
moral distress when death is dehumanized.\textsuperscript{4--8}

The 3 Wishes Project (3WP), an innovative project implemented in
academic ICUs in both Canada and the United States, aims to improve EOL
care by personalizing and humanizing the EOL experience through the
elicitation and implementation of wishes for patients, family members
and/or clinicians. It was created for the purpose of strengthening the
relationships among patients, family members, and clinicians that are
crucial for empathic EOL care.\textsuperscript{9} The wishes implemented
are classified into 11 categories: facilitating connections with
families/ friends/ pets, celebrations involving food/beverages,
humanizing the ICU room, humanizing the patient, music, family care,
religious rituals \& spiritual ceremonies, preparations and final
arrangements, keepsakes and post mortem tributes, organ \& tissue
donation and paying it forward for the 3WP.\textsuperscript{10} A
mixed-method, multi-site study conducted in an academic, tertiary level
ICU demonstrated that the 3WP helped personalize the dying process
through explicit integration of palliative and spiritual care into
critical care practice.\textsuperscript{10} Additionally, a recent study
conducted by Vanstone et. al concluded that the 3WP is an affordable,
transferrable and sustainable clinical project that facilitates
collaborative care that honors a person's identity and
preferences.\textsuperscript{9}

Personalizing EOL care can take on various forms and as such, the 3WP
may have unique features in different
environments.\textsuperscript{9,11} The adaptable nature of this EOL
project may facilitate spread to community ICUs, which may not have a
robustly developed EOL infrastructure.\textsuperscript{12,13} Clinicians
responsible for EOL care in the ICU are instrumental to 3WP
implementation; therefore in order to introduce the 3WP in community
ICUs and facilitate its uptake, this mixed-methods study describes the
clinician and key stakeholder perspective of a 3WP implementation in a
large, community ICU.

Methods

\textbf{NH SCS ICU}

Context

Niagara Health St. Catharines Site (NH SCS) ICU is a 509-bed community
teaching hospital in Southern Ontario, Canada, which includes a 20-bed
ICU. The mortality rate of the ICU is 14.5\%, in line with the mortality
rate at other community hospital ICUs.\textsuperscript{2,14} There are 8
physicians who rotated on a 5 day, 2 night rotation, along with 100
nurses who were rostered among nine full-time staff divisions. In
addition, palliative care and spiritual care staff were available by
consultation Monday to Friday from 9 am to 5 pm. A multi-disciplinary
team championed the project implementation and, included both clinical
and non-clinical staff. The 3WP physician lead had completed part of his
critical care fellowship training at St. Joseph's Healthcare Hamilton
(SJHH), where the 3WP was first implemented, which inspired the
implementation of the project at NH SCS with the executive support of
the ICU manager. Frontline nurse champions included a senior ICU nurse,
as well as a junior ICU nurse. A part-time ICU research coordinator
collected quantitative data, while a research assistant collected
qualitative data alongside an ICU nurse with previous qualitative
research experience. Mid-way through implementation, the spiritual care
staff, palliative care team, and research coordinator involved in the
project implementation moved on from their positions.

\emph{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,\textsuperscript{10} a list of common
wishes by patients/ families/ clinicians as described by Clarke et.
al\textsuperscript{15} and protocols for implementing commonly used
items at SCS such as music, refreshments, and
keepsakes.\textsuperscript{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 SJHH\textsuperscript{10} 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.

\emph{Measurement}

\textbf{A Mixed-Method Approach}

A mixed-method approach was used. Quantitative data described the
patients enrolled in the 3WP during the times the 3WP physician lead was
on service. Qualitative data described the clinician and key-stakeholder
perspectives on the project initiation and implementation process. The
Standards for Quality Improvement Reporting Excellence (SQUIRE)
guidelines (\emph{Appendix A} ) and the Standards for Reporting
Qualitative Research (SRQR) guidelines were completed.

\textbf{Quantitative Measures}

Quantitative data was extracted from patient records which included
baseline data such as age, ICU admission date, admission diagnosis,
spiritual beliefs and APACHE II score. Information on advanced life
supports administered during the ICU stay was also recorded along with
patient final status including the location and date of death. The
process of enrollment in the 3WP was collected including the reason for
enrollment, project initiation and wish details (wish category,
completion, costs and implementation). Wishes were classified into 11
categories.\textsuperscript{10} Other consultations including spiritual
care, palliative care and social work involvement was also recorded, as
well as involvement of the Trillium Gift of Life for organ donation.

\textbf{Qualitative Interviews}

A qualitative description (QD) approach was employed for the analysis of
qualitative data. QD yields pragmatic and straightforward descriptions
that stays close to the language of informants with minimal
interpretation from investigators.\textsuperscript{17} The QD approach
aligns with the goals of this mixed-methods study since it is applicable
for needs assessment as well as intervention development and
refinement.\textsuperscript{17} Individual semi-structured interviews
with open-ended questions (\emph{Appendix B} ) were used for data
collection focusing on the clinician and key-stakeholder experience of
the implementation process. Interviewees were selected through
purposively sampling clinicians and key stakeholders who had experience
with project implementation and use.\textsuperscript{18,19} The only
exclusion criterion was if clinicians and key stakeholders declined to
participate in the interviews. Interviews were conducted either in
person or on the phone by both an independent research assistant who was
not previously involved with project implementation, its use, or with
the ICU, as well as an ICU nurse with previous qualitative research
experience. Interviews were digitally recorded, transcribed verbatim and
anonymized.

\emph{Analysis}

Quantitative data were analyzed using descriptive statistics while
qualitative data was analyzed in triplicate using the qualitative
content analysis, according to the QD approach.\textsuperscript{20} No
preconceived themes were derived prior to interviews, and codes were
collected directly from the interview transcripts. These codes were
updated regularly after each interview in order to determine when the
saturation point in the data collection process was attained in which no
new codes were identified, and new themes emerged
infrequently.\textsuperscript{19} Three investigators (BT, LS, EY)
independently reviewed the 12 transcripts in a process of open coding.
The codes were sorted and organized into clusters and upon looking for
commonalities and differences among the data, themes were derived from
the various categories. After thorough reflection and analysis, the
investigators came together with their own insights and discussed
potential relationships in light of existing knowledge.

To enhance the trustworthiness and credibility of the analysis, data
were triangulated by involving a heterogenous sample of participants
from different disciplines and varied ICU experience. In addition,
member checking involved emailing the final results to interviewees and
researchers to allow for comments and verification.

\emph{Ethics}

This study was approved by the Hamilton Integrated Research Ethics Board
(HiREB Project\# 4736).

Results

\textbf{Quantitative}

\emph{Patients}

Patients were enrolled in the 3WP between January 2019 to October
2019.\emph{Table 1} summarizes the patient characteristics. 14 eligible
patients were included in the study with a mean age of 63.4 (SD, 17.1)
and mean APACHE II score of 17.8 (SD, 6.8). Most patients were admitted
to the ICU from the emergency department (11.0 {[}78.6\%{]}) and all
patients were admitted with a medical diagnosis (14.0 {[}100.0\%{]})
rather than surgical issue. The mean duration between hospital admission
to death was 7.5 days (IQR, 3.3-12) and enrollment duration (e.g.,
enrolment to death) was 0.5 days (IQR, 0-1).

\emph{Wishes}

\emph{Table 2} summarizes the wish categories including additional
characteristics of the wish implementation process. Overall, 66 of 67
(98.5\%) wishes were completed with at least 3 wishes for each
patient-family dyad (median, 4.5 {[}IQR, 3.3-6.0{]}). The wishes were
elicited by the family (32.0 {[}47.8\%{]}), staff (28.0 {[}41.8\%{]})
and patient (7.0 {[}10.4\%{]}) with a majority implemented by staff
(44.0 {[}65.7\%{]}). The most common category of wishes made included
facilitating connections with family, friends or pets, and keepsakes and
post-mortem tributes as per the categories defined by Cook et al (Refer
to \emph{Appendix C} for examples of wishes). The wishes were
inexpensive with a range from \$0 to \$30 and mean cost of wishes was
\$0.87. The cost was minimized by donations from staff and community
members with 19.0 (28.4\%) of wishes donated.

\textbf{Qualitative Frontline feedback}

Qualitative data from 12 clinician and key stakeholder interviews showed
that the 3WP led to personalized patient and family experience at EOL,
and enriched clinician experience when caring for dying patients.
Participants suggested that more communication strategies were needed to
scale the project and ensure its growth, describing communication
strategies to consider. Finally, participants noted many physical
resources to support the project (e.g., supplies, designated space for
storage) but a scarcity of non-clinical support specifically in the
dimensions of staff education and data collection after the project
expanded to include all potential dying patients. \emph{Table
3}summarizes the characteristics of interview participants.

\emph{Personalized Patient and Family Experience at EOL}

The 3WP was perceived by clinicians and key stakeholders to improve the
patient experience by personalizing EOL care, prompting important
conversations, and returning some decision-making to the patient and
family. Nurses and the physician indicated that the 3WP helped to
individualize care in the patient's final moments. A physician shared
one of the wishes where a nurse, ``\ldots{} got the frame and some ink
and she made a thumbprint heart with the grandma's thumb and the
grandchild's thumb. I just thought that was so beautiful, and it's easy
to do, it's personalized.'' {[}\textbf{P4} {]} Others discussed that by
eliciting wishes, they were encouraged to engage in conversations to
better understand what is important to the patient. A bedside nurse
commented that the 3WP, ``sparks a conversation, which I think we should
all have in those moments, or even before EOL\ldots{} what is important
to us and what is important in our care.''{[}\textbf{P1} {]} Another
nurse observed that, ``it gives decision making back to the family and
the patient.'' {[}\textbf{P1} {]} A clinician emphasized how the 3WP
``gives {[}the family{]} permission to ask for {[}something{]} or gives
them permission to say ``Yeah, I would love that,'' or ``He would love
that.'' {[}\textbf{P2} {]} Eliciting wishes from families was perceived
to give families a voice and seemed to help address common feelings of
overwhelming helplessness through acknowledging these wishes.

\emph{Enriching the Clinician EOL Experience}

The implementation of the 3WP produced several benefits for clinicians
as well by fostering collaboration and increasing job satisfaction.
Since the 3WP incorporated multiple disciplines from spiritual care to
social work, the project connected individuals who would not have
originally worked together within the context of EOL care. A nurse
reflected that, ``what I valued the most out of it was the
interdisciplinary teamwork. It's not a project that is just for the
nurses, or just for the doctors. It's everybody who works at the
hospital even beyond the ICU and the community\ldots{}everybody just
coming together to help the patients and the families together.''
{[}\textbf{P6} {]} The project facilitated bonding within the unit as
staff worked as a team towards a common goal of understanding what
matters most to patients. Some observed an increase in nurse-physician
collaboration in incorporating the 3WP in EOL care. Another nurse stated
that, ``I just valued the camaraderie of our unit sort of coming
together and recognizing how pivotal this moment is in our patients'
lives.'' {[}\textbf{P10} {]}

Many participants reported that the project was rewarding as it offered
a larger sense of purpose. One participant explained that it
``{[}felt{]} like you're building something a bit bigger than yourself,
you're contributing to something.'' {[}\textbf{P4} {]} The project
allowed clinicians to connect and care for patients and families, when
medical interventions may have become futile. A nurse shared that,
``this is something tangible that you can do to give to people and feel
like you are not just left without helping them in some
capacity\ldots{}this lets us help people but just in a different way.''
{[}\textbf{P6} {]} Another nurse expressed, ``it honestly made me feel
proud to make change here in the ICU\ldots{}proud of my coworkers, proud
that we could get it up and running.'' {[}\textbf{P3} {]} The adoption
of this patient-centred project empowered clinicians with the resources
to provide meaningful and quality EOL care, and reportedly improved job
satisfaction.

\emph{Communication strategies need to expand with project growth}

The initial communication strategies generated immediate momentum as
seen in the early staff buy-in and support for the project. A nurse
explained that healthcare workers were motivated to engage in the 3WP by
``seeing the wishes, and just talking about it more and hearing about
other people's experiences.'' {[}\textbf{P3} {]}. The ICU manager
further described how the ICU first bought into the project. ``{[}The
3WP physician lead{]} was not expecting the level of ownership and how
much it was embraced by {[}the{]} core group\ldots{}{[}they{]} really
blew our minds with how {[}they{]} just took over and ran with it.''
{[}\textbf{P2} {]}

However, communication and education strategies may not have kept pace
with project growth. A nurse commented that, ``getting the word out
there, I feel was not the greatest. There were only a handful of nurses
that seemed to know a lot about it and if they weren't working then the
word wasn't getting out there.''{[}\textbf{P3} {]} The research
coordinator described differences in clinician buy-in, ``some {[}were{]}
really on board, some {[}were{]} kind of still getting a hand of
remembering that 3 Wishes is an option when you have a palliative
patient.'' {[}\textbf{P5} {]}

\emph{Communication strategies to consider to facilitate project growth}

Participants described three strategies to promote communication as the
project grew; increased dissemination of standardized protocols,
clinician-centered education interventions, and constant communication.
Though protocols were located in nursing stations, more deliberate
dissemination was desired. A nurse suggested, ``definitely more of a
guideline or policy or procedure or something for people to refer to
because I think a lot of the staff feel uncomfortable.'' {[}\textbf{P11}
{]} Another nurse advocated for ``lunch and learns involving staff,''
{[}\textbf{P9} {]} and more take-home material including ``handing out
educational material.'' {[}\textbf{P9} {]} One common suggestion was
that communication intensity should increase as the project grows. A
nurse stressed that, ``there was not enough communication surrounding
the whole unit and I think that was the biggest barrier.''
{[}\textbf{P12{]}} Another participant emphasized, ``there needs to be
better communication to everybody in the staff.'' {[}\textbf{P2} {]}
Participants discussed the importance of ``spreading it throughout the
unit,'' {[}\textbf{P2} {]} needing to, ``publicize it a bit more just
within our own department,''{[}\textbf{P2} {]} and ``rolling it out to
the larger group.'' {[}\textbf{P2} {]}

\emph{Abundance in physical resources but lack of human resources for
education and data collection}

Participants described the influence of various resources on the
project's implementation. On one hand, the project implementation was
well supported by physical resources. A nurse shared, ``whether it be
funding so we could offer parking passes for our patient's loved ones or
funding so we could buy them something to eat that we otherwise couldn't
do so\ldots{}it offered resources that allowed us to go that extra
step.'' {[}\textbf{P10} {]} Another nurse reflected, ``I think that it
provides us with the tools we need to better the EOL experience in the
ICU.'' {[}\textbf{P11} {]} In contrast, the human resources may have
been insufficient to facilitate rapid, sustainable widespread expansion.
A nurse emphasized the barrier of inadequate staffing, ``{[}it's{]}
different in terms of even just like people. For example, if you are at
a teaching hospital, you have medical students, residents, you have
nursing students through the unit more. Perhaps if the bedside nurse has
two patients, and he is busy or she is busy with next door but they need
help implementing a wish, a resident could do that or they might have
more time, because they are learning to talk to the patients and
families and have the opportunity to find wishes.'' {[}\textbf{P6} {]}
Many clinicians also mentioned the heavy workload as an ICU staff in
which they are ``in and out of the room, {[}they're{]} busy, {[}their{]}
day is filled with tasks.''{[}\textbf{P4} {]} Given the shift based
nature of the physician lead and frontline champions, there was not
always someone who was there to support staff education and data
collection. A nurse added that ``in other centres they may have somebody
that's just dedicated to doing just 3 wishes and keeping track of this
inventory, whereas we don't have it and it's kind of
piecemeal.''{[}\textbf{P6} {]} The lack of mobilization of a
non-clinical project support team left the scaling process to be taken
up by clinicians who were already working at full capacity. A physician
confirmed that, ``\ldots{}Part of it is also the infrastructure of our
site in that we didn't have a horizontal point of care person for a
while..'' {[}\textbf{P4} {]}

Discussion

This mixed-method study evaluated the implementation of the 3WP in a
large community ICU in Canada from the perspectives of the clinicians
and key stakeholders. The 3WP was perceived to improve the EOL
experience for patients and families by personalizing care and
encouraging meaningful conversations. The 3WP also promotes
collaboration and job satisfaction amongst the interdisciplinary
healthcare team. There is a desire from frontline staff to implement
this kind of project, however there needs to be careful consideration of
commensurate strategies to facilitate education and delivery including
consistent communication to staff as the project spreads. Finally, in a
community hospital ICU setting, physical resources can be collected and
donated to empower staff to support patients and families through EOL,
though limited human resources may strain project implementation as
frontline staff take on additional duties beyond their normal workflow.

This study confirms the previously reported benefits of the 3WP for ICU
patients, families and clinicians when implemented. Literature supports
the findings that this individualized approach provides opportunities
for more personalized discussions with families while honouring the
patient's identity and preferences.\textsuperscript{9} Similar to
implementation outcomes at academic centers, the 3WP serves to make
clinical work more meaningful and improves interdisciplinary team
cohesion when working towards a shared
purpose.\textsuperscript{9,21}Moreover, our study adds to current
literature by recognizing the complexities involved in implementing an
EOL program in a community hospital.

Qualitative results indicate that the project spread was variable in the
unit. Spread is defined as the process of communicating and implementing
a project within a new environment, and can be influenced by project
attributes.\textsuperscript{22} Based on the customizable nature of the
project whereby the main focus is personalizing care, the key
characteristic of the 3WP is that the output -- terminal wishes
implemented - depend on the patients, families, and clinicians involved
in the care. This characteristic, which allows clinicians to be creative
in the process of personalization, likely drives the sense of meaning
derived from the project. Conversely, the complexity of implementing
both individualized and meaningful wishes likely caps the rate of spread
as clinicians are learning `in vivo' a new skill set. Thus, the
implementation team must plan and dedicate an additional period of time
for ongoing education, practice and re-exposure for optimal retention in
the case of a complex intervention.\textsuperscript{23,24} Spaced
learning with a broader time horizon for implementation may be necessary
to integrate this type of project effectively. This may be achieved
through multi-modal techniques which take into account infrastructure
capability and learning preferences of the
clinicians.\textsuperscript{23--26}

Another characteristic of the 3WP which may influence spread is the
adaptable nature of the 3WP to the setting. Though a community ICU may
be able to procure physical resources to support the implementation of
the 3WP, there may be a limited rate at which the project can spread
given human resource constraints including research project supports.
Similar studies found staffing to be an issue when implementing
evidence-based projects in community hospitals. Kim et. al implemented
guidelines for targeted temperature management after cardiac arrest in
21 community and tertiary care centres and the most frequently mentioned
and agreed upon barrier was the lack of manpower and increased
workload.\textsuperscript{27} In order to facilitate implementation
where human resources may be strained, the project adapted to local
needs and capacities.\textsuperscript{22} In our study, a majority of
the completed wishes (37 {[}55.2\%{]}) relied on physical resources
including keepsakes, music, celebrations involving food and beverages,
humanizing the ICU room and family care. Keepsakes such as a printed
copy of patients electrocardiogram or a computer generated word cloud
image, facilitate a personalized memory-making experience for patients,
families, and clinicians.\textsuperscript{16,28} Moreover, keepsakes are
an intervention which are less dependent on clinicians which may
facilitate spread, particularly in community-based settings. Thus,
spread can be achieved in a community ICU through contextual adaptation
focusing on interventions derived from more readily available physical
resources, as opposed to interventions dependent on a fixed human
resource.

There are several strengths of this study. First, this project explores
project implementation in a Canadian community ICU where academic
activity is generally less intense, given the lack of institutional
mandate, financial support, research experience, and clinician
workload.\textsuperscript{13} Another strength is exploring the
clinician and key stakeholder experience through qualitative
interviewing. Understanding the clinician and key stakeholder
perspective is instrumental when studying the implementation of the 3WP
since they directly deliver the intervention and support the project's
growth and buy-in. Finally, this study explores a project led by
frontline staff who were involved in the initiation, adaptation and
activation of this project. These findings may help other centers
seeking to integrate similar projects at their own sites.

In terms of limitations of this study, only wishes elicited when the 3WP
physician lead was on duty were recorded. Though the 3WP operated
outside of these specified time periods, data were not collected due to
human resource limitations, particularly in dedicated research staff.
Patient and family views were not sought since our lens was that of
clinicians and key stakeholders at this stage. In addition, one of the
qualitative reviewers was a frontline clinician involved directly in the
3WP implementation which may have influenced analysis and
interpretation. To attenuate this risk of bias, qualitative analysis was
performed in triplicate and results underwent member checking. Finally,
this study is a summative description of the implementation process in
early stages of spread. Given the short and sparse period of
quantitative data, temporal analysis, in the form of run charts or
standard process control, relating implementation interventions to
project process and outcomes was not performed.

In conclusion, this study describes the implementation of the 3WP in a
Canadian community hospital ICU from the perspective of clinicians and
key stakeholders. The 3WP is a valuable EOL intervention for patients,
families, and clinicians. When implementing the project in the community
ICU, investigators will need to consider adaptations to match the nature
of the project with characteristics of the environment to facilitate
spread.

\emph{Acknowledgements}

Investigators would like to thank the PSI Foundation funding this
project and facilitating research by community clinicians. In addition,
the investigators would like to thank the Niagara Health Auxiliary, Tim
Horton's at St. Catharines Site Hospital, Niagara Folk Arts
Multicultural Centre, Parking Office at Niagara Health, Walmart at St.
Catharines, Finance Team at Niagara Health, and frontline staff for
donating the resources to implement wishes. The authors thank the
patients and families that they had the honor of caring for and
appreciate the dedication and compassion of the Niagara Health St.
Catharines Site ICU team in implementing the 3WP. The investigators
would also like to thank the scholars from St. Joseph's Healthcare
Hamilton for their ongoing academic mentorship.

\emph{Conflict of Interests}

Dr. Benjamin Tam and Dr. Jennifer Tsang reports grants from the PSI
Foundation during the conduct of the study. Authors not named here have
disclosed no conflicts of interest.

\emph{Authors Contribution}

KL, JT, DC, BT designed the study. KL, MC, AV, EY, ED, JT, BT
participated in the implementation of the intervention. MC and EY
performed quantitative data collection while EY and KL performed
qualitative data collection.~EY, LS and BT participated in data
analysis, interpretation and drafted the manuscript. All authors have
critically reviewed and approved~the final~manuscript.

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