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Background A recent randomized trial of bereaved family members of patients who died in an intensive care unit identified symptoms of depression and posttraumatic stress in recipients of semistructured condolence letters. Objectives To explore family member and clinician experiences with receiving or sending handwritten sympathy cards upon the death of patients involved in a personalized end-of-life intervention, the 3 Wishes Project. Methods Interviews and focus groups were held with 171 family members and 222 clinicians at 4 centers to discuss their experiences with the 3 Wishes Project. Interview transcripts were searched to identify participants who discussed sympathy cards. Data related to sympathy cards were independently coded by 2 investigators through conventional content analysis. Results Sympathy cards were discussed during 32 interviews (by 25 family members of 21 patients and by 11 clinicians) and 2 focus groups (8 other clinicians). Family members reported that personalized sympathy cards were a welcome surprise; they experienced them as a heartfelt act of compassion. Clinicians viewed cards as an opportunity to express shared humanity with families, reminding them that they and their loved one were not forgotten. Signing cards allowed clinicians to reminisce individually and collectively with colleagues. Family members and clinicians experienced sympathy cards as a meaningful continuation of care after a patient’s death. Conclusions Inviting clinicians who cared for deceased patients to offer personalized, handwritten condolences to bereaved family members may cultivate sincere and individualized expressions of sympathy that bereaved families appreciate after the death of patients involved in the 3 Wishes Project.

Background Infection control protocols, including visitor restrictions, implemented during the COVID-19 pandemic threatened the ability to provide compassionate, family-centered care to patients dying in the hospital. In response, clinicians used videoconferencing technology to facilitate conversations between patients and their families. Objectives To understand clinicians’ perspectives on using videoconferencing technology to adapt to pandemic policies when caring for dying patients. Methods A qualitative descriptive study was conducted with 45 clinicians who provided end-of-life care to patients in 3 acute care units at an academically affiliated urban hospital in Canada during the first wave of the pandemic (March 2020-July 2020). A 3-step approach to conventional content analysis was used to code interview transcripts and construct overarching themes. Results Clinicians used videoconferencing technology to try to bridge gaps in end-of-life care by facilitating connections with family. Many benefits ensued, but there were also some drawbacks. Despite the opportunity for connection offered by virtual visits, participants noted concerns about equitable access to videoconferencing technology and authenticity of technology-assisted interactions. Participants also offered recommendations for future use of videoconferencing technology both during and beyond the pandemic. Conclusions Clinician experiences can be used to inform policies and practices for using videoconferencing technology to provide high-quality end-of-life care in the future, including during public health crises.

Background Scaling-up and sustaining healthcare interventions can be challenging. Our objective was to describe how the 3 Wishes Project (3WP), a personalized end-of-life intervention, was scaled-up and sustained in an intensive care unit (ICU). Methods In a longitudinal mixed-methods study from January 12,013 - December 31, 2018, dying patients and families were invited to participate if the probability of patient death was > 95% or after a decision to withdraw life support. A research team member or bedside clinician learned more about each of the patients and their family, then elicited and implemented at least 3 personalized wishes for patients and/or family members. We used a qualitative descriptive approach to analyze interviews and focus groups conducted with 25 clinicians who cared for the enrolled patients. We used descriptive statistics to summarize patient, wish, and clinician characteristics, and analyzed outcome data in quarters using Statistical Process Control charts. The primary outcome was enrollment of terminally ill patients and respective families; the secondary outcome was the number of wishes per patient; tertiary outcomes included wish features and stakeholder involvement. Results Both qualitative and quantitative analyses suggested a three-phase approach to the scale-up of this intervention during which 369 dying patients were enrolled, having 2039 terminal wishes implemented. From a research project to clinical program to an approach to practice, we documented a three-fold increase in enrolment with a five-fold increase in total wishes implemented, without a change in cost. Beginning as a study, the protocol provided structure; starting gradually enabled frontline staff to experience and recognize the value of acts of compassion for patients, families, and clinicians. The transition to a clinical program was marked by handover from the research staff to bedside staff, whereby project catalysts mentored project champions to create staff partnerships, and family engagement became more intentional. The final transition involved empowering staff to integrate the program as an approach to care, expanding it within and beyond the organization. Conclusions The 3WP is an end-of-life intervention which was implemented as a study, scaled-up into a clinical program, and sustained by becoming integrated into practice as an approach to care.

The COVID-19 pandemic is changing the way we provide end-of-life care for patients who are in the hospital. This article documents how those changes are affecting nurses, physicians, and other hospital caregivers, using their own words., Visual Abstract. Preserving Compassion in the Pandemic The COVID-19 pandemic is changing the way we provide end-of-life care for patients who are in the hospital. This article documents how those changes are affecting nurses, physicians, and other hospital caregivers, using their own words. Visual Abstract. Preserving Compassion in the Pandemic The COVID-19 pandemic is changing the way we provide end-of-life care for patients who are in the hospital. This article documents how those changes are affecting nurses, physicians, and other hospital caregivers, using their own words., Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has affected the hospital experience for patients, visitors, and staff. Objective: To understand clinician perspectives on adaptations to end-of-life care for dying patients and their families during the pandemic. Design: Mixed-methods embedded study. (ClinicalTrials.gov: NCT04602520) Setting: 3 acute care medical units in a tertiary care hospital from 16 March to 1 July 2020. Participants: 45 dying patients, 45 family members, and 45 clinicians. Intervention: During the pandemic, clinicians continued an existing practice of collating personal information about dying patients and “what matters most,” eliciting wishes, and implementing acts of compassion. Measurements: Themes from semistructured clinician interviews that were summarized with representative quotations. Results: Many barriers to end-of-life care arose because of infection control practices that mandated visiting restrictions and personal protective equipment, with attendant practical and psychological consequences. During hospitalization, family visits inside or outside the patient's room were possible for 36 patients (80.0%); 13 patients (28.9%) had virtual visits with a relative or friend. At the time of death, 20 patients (44.4%) had a family member at the bedside. Clinicians endeavored to prevent unmarked deaths by adopting advocacy roles to “fill the gap” of absent family and by initiating new and established ways to connect patients and relatives. Limitation: Absence of clinician symptom or wellness metrics; a single-center design. Conclusion: Clinicians expressed their humanity through several intentional practices to preserve personalized, compassionate end-of-life care for dying hospitalized patients during the SARS-CoV-2 pandemic. Primary Funding Source: Canadian Institutes of Health Research and Canadian Critical Care Trials Group Research Coordinator Fund.

Background The 3 Wishes Project (3WP) is an end-of-life program that honors the dignity of dying patients by fostering meaningful connections among patients, families, and clinicians. Since 2013, it has become embedded in the culture of end-of-life care in over 20 ICUs across North America. The purpose of the current study is to describe the variation in implementation of 3WP across sites, in order to ascertain which factors facilitated multicenter implementation, which factors remain consistent across sites, and which may be adapted to suit local needs. Methods Using the methodology of qualitative description, we collected interview and focus group data from 85 clinicians who participated in the successful initiation and sustainment of 3WP in 9 ICUs. We describe the transition between different models of 3WP implementation, from core clinical program to the incorporation of various research activities. We describe various sources of financial and in-kind resources accessed to support the program. Results Beyond sharing a common goal of improving end-of-life care, sites varied considerably in organizational context, staff complement, and resources. Despite these differences, the program was successfully implemented at each site and eventually evolved from a clinical or research intervention to a general approach to end-of-life care. Key to this success was flexibility and the empowerment of frontline staff to tailor the program to address identified needs with available resources. This adaptability was fueled by cross-pollination of ideas within and outside of each site, resulting in the establishment of a network of like-minded individuals with a shared purpose. Conclusions The successful initiation and sustainment of 3WP relied on local adaptations to suit organizational needs and resources. The semi-structured nature of the program facilitated these adaptations, encouraged creative and important ways of relating within local clinical cultures, and reinforced the main tenet of the program: meaningful human connection at the end of life. Local adaptations also encouraged a team approach to care, supplementing the typical patient-clinician dyad by explicitly empowering the healthcare team to collectively recognize and respond to the needs of dying patients, families, and each other. Trial registration NCT04147169, retrospectively registered with clinicaltrials.gov on October 31, 2019.

Context Keepsakes are a relatively unexplored form of bereavement support that is frequently provided as part of the 3 Wishes Project (3WP). The 3WP is a palliative care intervention in which individualized wishes are implemented in the adult intensive care unit for dying patients and their families. Objectives We aimed to characterize and enumerate the keepsakes that were created as part of the 3WP and to understand their value from the perspective of bereaved family members. Methods We performed a secondary analysis of family interviews during a multicenter study on the 3WP and characterized all wishes that involved keepsakes. Sixty interviews with family members regarding the 3WP were reanalyzed using qualitative analysis to identify substantive themes related to keepsakes. Results Of 730 patients, 345 (47%) received keepsakes as part of their participation in 3WP. Most keepsakes were either tangible items that served as reminders of the patient's presence (thumbprints and locks of hair) or technology-assisted items (photographs and word clouds). The median cost per keepsake wish was $8.50 (interquartile range $2.00–$25.00). Qualitative analysis revealed two major themes: keepsakes are tangible items that are highly valued by family members; and the creation of the keepsake with clinical staff is valued and viewed as a gesture of compassion. Conclusion Keepsakes are common wishes that clinicians in the intensive care unit are able to provide and sometimes cocreate with families when patients are dying. Both the offering to create the keepsake and receipt of the final product are perceived by family members as helpful.

Background Little is known about the effect of chaplains on critical care nurses who are caring for critically ill patients and their families. Objective To understand nurses' experiences when they make a referral to the Spiritual Care Department for a patient or the family of a patient who is dying or deceased. Specific aims were to explore spiritual care's effect on nurses and how nurses understand the role of spiritual care in practice. Methods A qualitative descriptive study using in-person, semistructured interviews in a 21-bed medical-surgical intensive care unit in a teaching hospital. Purposeful sampling identified nurses who had at least 5 years of experience and had cared for at least 5 patients who died on their shift and at least 5 patients for whom they initiated a spiritual care referral. Interviews were digitally recorded and anonymized; conventional content analysis was used to analyze transcripts. Three investigators independently coded 5 transcripts and developed the preliminary coding list. As analysis proceeded, investigators organized codes into categories and themes. Results A total of 25 nurses were interviewed. The central theme that emerged was presence, described through 3 main categories: the value of having chaplains present in the intensive care unit and their role, nurses' experiences working with chaplains, and nurses' experiences providing spiritual care. Conclusion Nurses considered spiritual care essential to holistic care and valued the support chaplains provide to patients, families, and staff in today's spiritually diverse society.

BackgroundPandemic-related restrictions are expected to continue to shape end-of-life care and impact the experiences of dying hospitalised patients and their families.ObjectiveTo understand families’ experiences of loss and bereavement during and after the death of their loved one amidst the SARS-CoV-2 (COVID-19) pandemic.DesignQualitative descriptive study.SettingThree acute care units in a Canadian tertiary care hospital.ParticipantsFamily members of 28 hospitalised patients who died from March–July 2020.Main outcome measuresQualitative semistructured interviews conducted 6–16 months after patient death inquired about family experiences before and beyond the death of their loved one and garnered suggestions to improve end-of-life care.ResultsPandemic restrictions had consequences for families of dying hospitalised patients. Most family members described an attitude of acquiescence, some framing their experience as a sacrifice made for the public good. Families appreciated how clinicians engendered trust in the name of social solidarity while trying to mitigate the negative impact of family separation. However, fears about the patient’s experience of isolation and changes to postmortem rituals also created despair and contributed to long-lasting grief.ConclusionProfound loss and enduring grief were described by family members whose final connections to their loved one were constrained by pandemic circumstances. Families observed solidarity among clinical staff and experienced a sense of unity with staff, which alleviated some distress. Their suggestions to improve end-of-life care given pandemic restrictions included frequent, flexible communication, exceptions for family presence when safe, and targeted efforts to connect patients whose isolation is intensified by functional impairment or limited technological access.Trial registration numberNCT04602520; Results.

Key Points Question What potential role do personalized paintings that are created to honor the lives of deceased patients in the intensive care unit have for grieving family members, and how might they influence family members’ experiences with bereavement? Findings In this qualitative study, families described personalized paintings as representing a legacy of their loved one. Participants indicated that the paintings were symbolic of the care their loved one received, validated the sentiment that the patient was remembered, and helped the families feel less alone during their time of grief. Meaning The creation of personalized patient paintings may foster postmortem connections between family members and clinicians and may ease bereavement following a death in the intensive care unit setting., This qualitative study uses semistructured interviews to explore the influence of personalized paintings of patients who died in the intensive care unit on family members’ bereavement experience and grief process., Importance Although family members of patients who die in the intensive care unit commonly experience long-term psychological distress, end-of-life bereavement support programs for such relatives are uncommon. Whether art influences the grief experience of families is largely unexplored. Objective To explore the influence of personalized paintings created to honor deceased critically ill patients on family members’ bereavement experience. Design, Setting, and Participants A qualitative descriptive analysis was conducted of semistructured interviews of grieving relatives who received a painting after the death of their loved one. The deceased patients were from a 21-bed medical-surgical intensive care unit. Eleven families were invited to receive a painting, of whom 1 family declined. A total of 22 family members of 10 patients who died in the intensive care unit were interviewed in the study between July 11, 2017, and May 19, 2019. Interventions Patients were enrolled in an end-of-life care program that elicits and implements wishes of patients and their families to bring peace during the dying process. Selected families of 10 decedents were invited to receive a painting to honor their loved one 1 to 10 months after the patient’s death. Using details about the patient’s life story, the artist created individualized paintings to commemorate each patient. Main Outcomes and Measures The experiences of family members receiving a personalized painting and its reported influence on their grieving experience. Results The family members of 10 decedents (mean [SD] age, 60 [14] years; 5 women [50%]; 8 White patients [80%]) were interviewed. The central theme of art to facilitate healing was illustrated through the following domains: the cocreation process, painting narratives, postmortem connections, and legacy. The process of cocreating the paintings with the artist and family members involved reminiscing, storytelling, and creativity. Family members emphasized the role of art to facilitate healing, exemplified through connections with images portrayed that deeply resonated with memories of their loved one. Participants indicated that the paintings validated that the patient was remembered, helped families feel less alone during a time of grief, honored the loved one’s life, and enhanced connections between family members and clinicians. Conclusions and Relevance This qualitative study’s findings suggest that the creation of personalized paintings commemorating the lives of patients may help foster legacy and postmortem connections with clinicians and may help family members in their healing process.

IntroductionVentilator-associated pneumonia (VAP) is a common healthcare-associated infection in the intensive care unit (ICU). Probiotics are defined as live microorganisms that may confer health benefits when ingested. Prior randomised trials suggest that probiotics may prevent infections such as VAP and Clostridioides difficile–associated diarrhoea (CDAD). PROSPECT (Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial) is a multicentre, double-blinded, randomised controlled trial comparing the efficacy of the probiotic Lactobacillus rhamnosus GG with usual care versus usual care without probiotics in preventing VAP and other clinically important outcomes in critically ill patients admitted to the ICU.Methods and analysisThe objective of E-PROSPECT is to determine the incremental cost-effectiveness of L. rhamnosus GG plus usual care versus usual care without probiotics in critically ill patients. E-PROSPECT will be performed from the public healthcare payer’s perspective over a time horizon from ICU admission to hospital discharge.We will determine probabilities of in-ICU and in-hospital events from all patients alongside PROSPECT. We will retrieve unit costs for each resource use item using jurisdiction-specific public databases, supplemented by individual site unit costs if such databases are unavailable. Direct costs will include medications, personnel costs, radiology/laboratory testing, operative/non-operative procedures and per-day hospital ‘hoteling’ costs not otherwise encompassed. The primary outcome is the incremental cost per VAP prevented between the two treatment groups. Other clinical events such as CDAD, antibiotic-associated diarrhoea and in-hospital mortality will be included as secondary outcomes. We will perform pre-specified subgroup analyses (medical/surgical/trauma; age; frailty status; antibiotic use; prevalent vs no prevalent pneumonia) and probabilistic sensitivity analyses for VAP, then generate confidence intervals using the non-parametric bootstrapping approach.Ethics and disseminationStudy approval for E-PROSPECT was granted by the Hamilton Integrated Research Ethics Board of McMaster University on 29 July 2019. Informed consent was obtained from the patient or substitute decision-maker in PROSPECT. The findings of this study will be published in peer-reviewed journals.Trial registration numberNCT01782755; Pre-results.

ObjectivesThe objectives of this mixed-methods study were to assess the uptake, sustainability and influence of the Footprints Project.SettingTwenty-two-bed university-affiliated ICU in Hamilton, Canada.ParticipantsICU patients admitted and their families, as well as clinicians.InterventionsWe developed a personalised patient Footprints Form and Whiteboard to facilitate holistic, patient-centred care, to inform clinical encounters, and to create deeper connections among patients, families and clinicians.Outcome measuresWe conducted 3 audits to examine uptake and sustainability. We conducted semi-structured interviews with 10 clinicians, and held 5 focus groups with 25 clinicians; and we interviewed 5 patients and 13 family representatives of 5 patients who survived and 5 who died in the ICU. Transcripts were analysed using qualitative content analysis.ResultsThe Footprints Project facilitated holistic, patient-centred care by setting the stage for patient and family experience, motivating the patient and humanising the patient for clinicians. Through informing clinical encounters, Footprints helped clinicians initiate more personal conversations, foster deeper connections and guide treatment. Professional practice influences included more focused attention on the patient, enhanced interdisciplinary communication and changes in community culture. Initially used in 15.8% of patients (audit A), uptake increased to 51.4% in audit B, and was sustained at 57.8% in audit C.ConclusionsBy sharing valuable personal information about patients before and beyond their illness on individualised whiteboards at each bedside, the Footprints Project fosters humanism in critical care practice.

Purpose The reliability of clinical signs and the physical examination in the evaluation of deep venous thrombosis (DVT) in the critically ill is unknown. The purpose of this study was to determine the diagnostic properties of clinical examination for signs of DVT in a cohort of medical-surgical intensive care unit (ICU) patients using screening compression ultrasonography as a reference standard. Materials and Methods We prospectively included patients older than 18 years with an expected length of ICU stay of more than 72 hours. Patients underwent bilateral lower limb screening compression ultrasound twice weekly and structured physical examination twice weekly by 2 independent trained research coordinators blinded to the ultrasonography results. We classified patients according to 2 methods: method 1, a DVT Risk Stratification System of 3 categories and method 2, a DVT Risk Score, both of which use the history and physical examination to stratify patients for their risk of DVT. Results We included 239 patients in our study, 32 of whom had DVT based on the results of their compression ultrasound. We excluded 7 patients with DVT on ICU admission and 2 who did not undergo any structured examinations. We matched controls with cases (9:1) based on duration of ICU stay. Cases and controls were then allocated to low, moderate, and high risk strata for DVT. Using method 1, the area under the receiver operating characteristic curve (AUC) was 0.57 (95% CI, 0.33-0.78, P = .01). Using method 2, the AUC was 0.59 (95% CI, 0.42-0.75, P = .02). An AUC of 1.0 indicates an ideal test, and AUC of 0.50 indicates a test with no diagnostic utility. Conclusions The history and physical examination for DVT are not useful in detecting lower limb DVT in the ICU.

To understand the perspectives and attitudes of ICU clinicians about use of a daily goals checklist on rounds.Our three data collection methods were as follows: (1) Field observations: two investigators conducted field observations to understand how and by whom the daily goals checklist was used for 80 ICU patient rounds over 6 days. (2) Document analysis: The 72 completed daily goals checklists from observed rounds were analyzed using mixed methods. (3) Interviews: With 56 clinicians, we conducted semistructured individual and focus-group interviews, analyzing transcripts using a qualitative descriptive approach and content analysis. Triangulation was achieved by a multidisciplinary investigative team using two research methods and three data sources.Fifteen bed closed ICU in a tertiary care, university-affiliated hospital.Medical-surgical ICU patients.None.Field observations: The daily goals checklist was completed for 93% of observed rounds, largely by residents (86%). The champion of the verbal review was commonly a resident (83%) or medical student (9%). Document analysis: Domains with high completion rates included ventilation, sedation, central venous access, nutrition, and various prophylactic interventions. Interviews: The daily goals checklist enhanced communication, patient care, and education. Nurses, physicians, and pharmacists endorsed its enhancement of interdisciplinary communication. It facilitated a structured, thorough, and individualized approach to patient care. The daily goals checklist helped to identify new patient care issues and sparked management discussions, especially for sedation, weaning, and medications. Residents were prominent users, finding served as a multipurpose teaching tool.The daily goals checklist was perceived to improve the management of critically ill patients by creating a systematic, comprehensive approach to patient care and by setting individualized daily goals. Reportedly improving interprofessional communication and practice, the daily goals checklist also enhanced patient safety and daily progress, encouraging momentum in recovery from critical illness. Daily goals checklist review prompted teaching opportunities for multidisciplinary learners on morning rounds.

Purpose Intra-abdominal hypertension is frequently underdiagnosed and defined by intra-abdominal pressure (IAP) 12 mm Hg or higher. Increasing IAP may compromise organ viability and culminate in abdominal compartment syndrome. Bladder pressure measurement is a surrogate for IAP, but measurement properties are unknown in the intensive care unit. Our primary objective was to assess the agreement of bladder pressure measurements in critically ill patients. Methods We conducted an observational study examining the correlation of measurement variability of bladder pressure. Four raters (2 nurses and 2 physicians) measured IAP. Patient's age, Acute Physiology and Chronic Health Evaluation II, body mass index, mechanical ventilation parameters, and demographics were collected. Results Fifty-one patients had bladder pressures measured in quadruplicate, producing 204 measurements. Among 51 patients, the mean age was 61.9 years, Acute Physiology and Chronic Health Evaluation II was 23.8, and body mass index was 27.8 kg/m2. The average bladder pressure was 12.4 (SD, ± 6.2) mm Hg. The interrater agreement by intraclass correlation coefficient was 0.745 (95% confidence interval [CI], 0.637-0.825), 0.804 (95% CI, 0.684-0.882), and 0.626 (95% CI, 0.428-0.767) among all raters, physicians, and nurses, respectively. Conclusions Agreement on bladder pressure was high among 4 clinicians and were not significantly different between physicians and nurses. Given that medical/surgical treatments are considered on bladder pressure values, understanding their reliability is essential to monitor critically ill patients.