Personalized End of Life Care in Safety-Net hospitals: Implementation of the 3 Wishes Project

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Project Summary Compassionate end-of-life (EOL) care is foundational to medicine, but providing patients and families in safety-net hospitals (SNHs) with the sense that they are physically and emotionally supported during a patient’s terminal hospitalization can be challenging. SNHs are public hospitals that primarily provide services to low-income and uninsured patients on a minimal budget. Although high quality EOL care is an important unmet need in SNHs, its provision is fraught with barriers and challenges. Language barriers, low health literacy, and cultural differences can make it difficult for families in SNHs to perceive empathy and support during the EOL. Deaths in the intensive care unit (ICU) for underserved families can be traumatic, and families of patients who die in the ICU often suffer from depression and post-traumatic stress disorder. Palliative care interventions are needed, but implementation is often resource-prohibitive. The 3 Wishes Project (3WP) is a palliative care intervention that aims to achieve a dignified and compassionate EOL experience by empowering the clinical team to elicit and fulfill small wishes for critically ill patients who are dying in the ICU. Although the 3WP has been shown to improve a family’s experience of their loved one’s EOL care, ease bereavement, and enhance clinician work satisfaction in academic centers, it has not been implemented and evaluated in low-resource hospitals. We believe that this patient-centered and clinician-partnered initiative can improve the EOL experience in SNHs, but that it must be adapted to the contextual differences and needs of low-resource hospitals. We propose to obtain and use stakeholder input to customize a multi-component 3WP Toolkit that will facilitate 3WP implementation in SNHs. Using the tailored Toolkit, we will implement and evaluate the 3WP in the three SNHs of the Los Angeles County Department of Health Services. We will conduct a pragmatic type 2 hybrid effectiveness-implementation study to evaluate the quality of EOL ICU care, bereaved families’ psychological symptoms, and clinician burnout as compared to usual care. We will use the Consolidated Framework for Implementation Research (CFIR) and the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to guide a mixed-methods evaluation of the 3WP implementation in SNHs. Our team of clinicians and scientists have collaborated previously and have expertise in EOL care, implementation science, qualitative research, research in the safety-net system, and 3WP implementation. We hypothesize that our novel effectiveness-implementation approach will demonstrate that the 3WP addresses key gaps in palliative care in SNHs, which have historically had less ability to implement novel interventions. The results of this study will provide a roadmap to implement interventions in SNHs and lay the foundation for broader dissemination, adoption, and sustainment of the 3WP in diverse healthcare settings.