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

项目摘要 临终关怀（EOL）是医学的基础，但为患者和家属提供 安全网医院（SNH）的感觉，他们在身体和情感上的支持， 患者的最终住院治疗可能具有挑战性。SNH是主要提供服务的公立医院， 给低收入和无保险的病人。虽然高质量的EOL护理是一个重要的 由于SNH的需求未得到满足，其提供充满了障碍和挑战。语言障碍，健康状况差 文化差异和文化差异会使SNH中的家庭难以感知同情和支持 在EOL期间。重症监护室（ICU）中的死亡对于服务不足的家庭来说可能是创伤性的， 在重症监护室死亡的病人中，有10%的人经常患有抑郁症和创伤后应激障碍。姑息治疗 需要采取干预措施，但执行工作往往因资源有限而无法进行。 三个愿望项目（3 WP）是一项姑息治疗干预措施，旨在实现一个有尊严的， 富有同情心的EOL经验，使临床团队能够引出并实现危重病患者的小愿望 重症监护室里奄奄一息的病人虽然3 WP已被证明可以改善家庭的体验， 亲人的临终关怀，减轻丧亲之痛，并提高临床医生在学术中心的工作满意度，它已经 没有在低资源医院实施和评估。我们相信，这种以病人为中心， 临床医生合作的倡议可以改善SNH的EOL体验，但必须适应 低资源医院的背景差异和需求。 我们建议获取和使用利益相关者的意见，以定制一个多组件的3 WP工具包， 促进SNH中的3 WP实施。使用定制的工具包，我们将在 洛杉矶县卫生服务部的三个SNH。我们将进行务实的类型2 混合有效性-实施研究，以评估EOL ICU护理的质量， 心理症状和临床医生倦怠相比，通常的护理。我们将利用联合 实施研究框架（CFIR）和RE-AIM（范围，有效性，采用， 实施和维护）框架，以指导3 WP的混合方法评估 在SNH中实现。 我们的临床医生和科学家团队以前曾合作过，并拥有EOL护理方面的专业知识， 实施科学、定性研究、安全网系统研究和3 WP实施。我们 假设我们新的有效性实施方法将证明3 WP解决 SNH在姑息治疗方面存在的主要差距，这些SNH在历史上实施新干预措施的能力较低。 这项研究的结果将提供一个路线图，以实施干预SNH和奠定基础， 在不同的医疗环境中更广泛地传播、采用和维持3 WP。

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.