Professional Documents
Culture Documents
( Received in original form June 2, 2016; accepted in final form July 26, 2016 )
This study was peer-review funded by Covenant Health and the Hamilton Academy of Health Sciences, and benefited from donations from the Canadian
Intensive Care Foundation, Canadian Tire Foundation, and several physicians, families, and friends who donated to the Three Wishes Project to help other
dying patients and grieving families.
Author Contributions: Conception or design, M. Swinton, F.T., T.R., T.H.-B., A.B., A.W., R.S., and D.C. Acquisition of data, M. Swinton, F.T., F.C., and D.C.
Analysis and interpretation of data, M. Swinton, M.G., F.T., T.R., T.H.-B., A.B., A.W., and M. Shears. Drafting the work, M. Swinton, M.G., F.T., A.B., A.W.,
R.S., and D.C. Revising for important intellectual content, T.R., T.H.-B., F.C., and M. Shears. Final approval, M. Swinton, M.G., F.T., T.R., T.H.-B., A.B., A.W.,
F.C., M. Shears, R.S., and D.C.
Correspondence and requests for reprints should be addressed to Deborah Cook, M.D., Academic Critical Care Office, St. Josephs Healthcare Hamilton,
50 Charlton Avenue East, Hamilton, ON, LSN 4 A6 Canada. E-mail: debcook@mcmaster.ca
Am J Respir Crit Care Med Vol 195, Iss 2, pp 198204, Jan 15, 2017
Copyright 2017 by the American Thoracic Society
Originally Published in Press as DOI: 10.1164/rccm.201606-1102OC on August 15, 2016
Internet address: www.atsjournals.org
198 American Journal of Respiratory and Critical Care Medicine Volume 195 Number 2 | January 15 2017
ORIGINAL ARTICLE
Table 1. Baseline Patient Characteristics make meaning in life and what they value . . . Table 2. Family Member Characteristics
(n = 70) death seems a sharpened focus on all those
things (chaplain). The bedside is Characteristic Value
Characteristic Value transformed into a spiritual place: In the
room when someones dying, theres . . .
Days from patient death 116 (45210.5)
Age, yr, mean (SD) 67.2 (14.5)
theres a lot of sacred stuff going on . . . to interview, median
Female, n (%) 33 (47.1) theres a lot of spiritual stuff going on . . . (IQR)
Race, n (%) (brother). Interview type, n (%)
White 63 (90.0) In this sacred space some people are Face-to-face 36 (56.3)
Nonwhite 7 (10.0) E-mail 1 (1.6)
compelled to fulll religious duties. For Telephone 27 (42.2)
APACHE II score, mean (SD) 29.3 (9.2)
ICU admitting diagnosis, others, dying evokes unfamiliar thoughts Relationship to patient,
n (%) about the meaning of life and death, need n (%)
Cardiovascular/vascular 25 (35.7) for closure, or how to honor the dying. Spouse 15 (19.7)
Respiratory 22 (31.4) Partner 3 (3.9)
Eliciting wishes provides a vehicle for their Friend 7 (9.2)
Gastrointestinal 8 (11.4)
Neurologic 4 (5.7) questions: Now, as you see the end of your Sibling 10 (13.2)
Sepsis 9 (12.9) life approaching, what are you thinking Parent 7 (9.2)
Renal 2 (2.9) about? What does that mean for you? What Child 27 (35.5)
Spiritual or religious Other 7 (9.2)
are you struggling with? What are you Age, yr, mean (SD) 55.7 (12.1)
afliation, n (%)
Agnostic 12 (17.1) scared about? What do you hope for? All of Sex, n (%)
Anglican 5 (7.1) that. I cant see getting at that without Female 46 (60.5)
Baptist 4 (5.7) allowing space and time and permission for Male 30 (39.5)
Catholic 25 (35.7) Spiritual or religious
clinicians to . . . ask very simple questions afliation, n (%)
Christian 1 (1.4)
Lutheran 1 (1.4) about who this person is before them Agnostic 10 (13.2)
Muslim 2 (2.9) (nurse). Anglican 2 (2.6)
Presbyterian 1 (1.4) A dying persons story reaches into the Baptist 3 (3.9)
Protestant 3 (4.3) past, through to the present, and beyond Catholic 19 (25.0)
United 1 (1.4) Christian 6 (7.9)
Unknown 6 (8.6)
the death: and they had mentioned that, Muslim 2 (2.6)
None 9 (12.9) you know, once their father passes away, he Protestant 1 (1.3)
Hospital course could be reunited with their mother in Spiritual 2 (2.6)
Advanced life supports heaven (resident); and celebrat[ing] this United 1 (1.3)
administered at any None 5 (6.6)
transition from this life to the next Unspecied 25 (32.9)
time in ICU, n (%)
Mechanical ventilation 69 (98.6) (chaplain). Concern for future narratives
Inotropes 46 (65.7) included planning the disposition of the Definition of abbreviation: IQR = interquartile
Dialysis 24 (34.3) range.
body, understanding the spirits destiny,
Advanced life supports N = 64 interviews with 76 family members.
and anticipating bereavement for loved
withdrawn just before
death, n (%) ones. [My Uncle] wasnt religious. He
Mechanical ventilation 43 (61.4) didnt, you know, go to church. When we ask about the meaning of life and they ask
Inotropes 11 (15.7) were lling out the paperwork for his questions about closure and things undone,
Dialysis 4 (5.7) surgery here and it says religion, he said to things unsaid, life after death for some
Spiritual care consult in 51 (72.9)
ICU, n (%) me, No thanks. . . . But when he was in the people, regret and hope . . . It calls all of
Palliative care consult in 19 (27.1) ICU . . . and I was having to make decisions that forth (physician).
ICU, n (%) regarding life support and all kinds of stuff,
Hospital admission to 0 (08) the hospital chaplain was there. One of the
ICU admission, Spiritual Experiences in Wish
median (IQR), d wishes was that she would be at the funeral. Solicitation
ICU admission to death, 6.5 (417) She was there for us. . . . She didnt know Participants characterize spirituality as
median (IQR), d him through life but she knew him through what matters most at the end of life.
Hospital admission 9 (429) the stories and through the Three Wishes
to death, median
Because a wish is a positive aspiration,
(IQR), d and coming and talking to me every day requesting wishes generates hope and
ICU admission to Three 5 (211) (niece). afrmation when people suffer despair and
Wishes Project Soliciting and fullling wishes helps to despondence. Asking about wishes sets a
enrollment, median create healing moments in the story of each stage for spirituality. Soliciting wishes
(IQR), d
Three Wishes Project 1 (02)
dying person. Clinicians identify these acts acknowledges imminent death, shifting
enrollment to death, as spiritual in quality, highlighting two focus from what is the matter with the
median (IQR), d mechanisms: easing emotional trauma and patient? to what matters to the patient?
achieving closure. Through engaging (13): The medical sideit becomes less
Definition of abbreviations: APACHE = Acute
Physiology and Chronic Health Evaluation;
spiritual questions, many grieving people relevant and something like the Three
ICU = intensive care unit; IQR = interquartile move toward accepting death as a part of Wishes program helps you reect and
range. life: They ask questions about why, and makes you think more about the spiritual
200 American Journal of Respiratory and Critical Care Medicine Volume 195 Number 2 | January 15 2017
ORIGINAL ARTICLE
VOICING
POSITIVE
Days from patient death 13 (525) DYING
ASPIRATIONS
to interview, median
(IQR)
Interview type, n (%) ILLNESS SOLICITING
Face-to-face 148 (98.7) TRAJECTORY WISHES EASING
E-mail 1 (0.7) EMOTIONAL
TRAUMA
Telephone 1 (0.7)
Profession, n (%) DEATH
Physician 71 (47.3)
Nurse 46 (30.7)
Spiritual care clinician 9 (6.0) ACHIEVING
CLOSURE
Three Wishes staff 4 (2.7) LIFE
Physiotherapist 2 (1.3) AFTER
DEATH
Dietician 1 (0.7)
Social worker 1 (0.7) SPIRITUAL
Respiratory therapist 6 (4.0) GOALS
Other 10 (6.7)
Years working in critical 3 (0.412)
care, median (IQR)
Age, mean (SD) 37.0 (12.1) FULFILLING
COMFORT WISHES
Sex, n (%) AND
SPIRITUAL
RITUALS AND
Female 91 (60.7) PEACE
PRACTICES
Male 59 (39.3)
Spiritual or religious
afliation, n (%) CONNECTIONS PERSONAL
AND
Agnostic 16 (10.7) RECONNECTIONS
TRIBUTES
Anglican 8 (5.3)
Baptist 2 (1.3)
Catholic 35 (23.3) Figure 2. This figure illustrates the integration of death into the patients life narrative through the
Christian 27 (18.0)
practice of soliciting and fulfilling wishes. ICU = intensive care unit.
Jewish 3 (2.0)
Muslim 15 (10.0)
Presbyterian 1 (0.7)
Protestant 1 (0.7)
Spiritual 12 (8.0) there (chaplain). Soliciting wishes makes dying persons mother recounted: People
United 3 (2.0) some spiritual practices more accessible. that have that social network in the church
Unknown 1 (0.7) Many cultures involve spiritual practices for and have a priest or a minister or somebody
None indicated 12 (8.0) death; repressing these can exacerbate that they can go to for help in these times
Other 14 (9.3)
suffering. For the religiously afliated, may turn to that for support. . . . We didnt
Definition of abbreviation: IQR = interquartile wishes clarify compulsory faith-based have that. We dont have that. So this [Three
range. observances. One family requested bedside Wishes] was kind of like that, right? Kind
recital of Quran verses, turning the patient of like a way of helping us to cope and get
toward the east, and direct transferal of the through it (mother).
side of things and the patients wishes body before burial to the mosque. A Religious or not, many people feel
(resident). Clinicians [just] see the person Muslim fellow noted that granting these bewildered by the dying experience and
as a person . . . thats where the spirituality wishes that are very relevant to the Muslim yearn for someone to help make sense of it
piece comes in (nurse). A physician more faith will have a great inuence in the all: Cause at that time, when things like
graphically described how soliciting wishes short- and long-term . . . for the family that happen, you know, we think of other
reclaimed personhood: So youre in this members (fellow). things. We think of God and we think of
situation . . . with gear and gadgets and Many persons without an active faith heaven and stuff. I think we should have
wires and tubes in a very impersonal community desire spiritual connection at someone who may be able to answer those
environment and [Three Wishes] brings this time, When youre in and around questions for us. Tough questions that they
dignity and respect back into the death and dying, all of a sudden these may be (brother).
environment. Or, it ensures that it . . . that beliefs that they didnt have forlike For people with strong nonreligious
its got a place in the room, because I think 30 yearsare back, because theyre so identity (e.g., religion is nonsense) or
often . . . often, it might not (physician). scared (nurse). Expressing wishes helps to personal beliefs (e.g., characterizing a
The act of asking, in itself, invites locate that missing support. One family fathers spirituality as being nature),
people to voice their spiritual values, goals, declined a chaplains visit when it was soliciting wishes invites expressions of
and concerns: Its just simply by asking the offered as usual, but later requested her spirituality. A resident explained, When
question . . . To me, that just does it right presence as one of their wishes. Another you offer things that are
Table 4. Categories and Examples of Realized Wishes Experienced and Expressed as discerning needs, then access spiritual
Spiritual by Family Members or Clinicians resources. A chaplain explained: [The
project] . . . gives an opportunity to talk
about spiritually signicant parts of a
Comfort and peace patients experience without ladening
Personal items at the bedside (e.g., healing stones, rosary)
Decorating patients room for special occasions (e.g., Easter, Valentines day) clinicians with a whole scope of practice that
Trip outside to hospital garden is maybe intimidating . . . I often hear from
Moment of silence after failed resuscitation of homeless person other clinicians that they just dont have
Connections and reconnections time to do all that. So that this gives them
Retelling family travel tales
Father to make amends with his son a way into that without having to feel
Patient to see long-standing colleague one last time responsible for the whole . . . scope of their
Final photograph of family and friends taken around patients deathbed spiritual care (chaplain).
Personal tributes By contrast, other clinicians draw on
Creating keepsake for remembrance (e.g., locket of husbands hair for his wife) their own spirituality for strength to respond
Gift of ICU team for the family (e.g., Fathers Day cake postmortem)
Life lessons from patient (e.g., partner sharing secrets of her long marriage before she to grief they encounter daily. Fullling wishes
died) gives clinicians vehicles for compassion, a
Family gift to staff (e.g., wifes needlepoint given by her husband to bedside nurse) central value across many belief systems.
Spiritual rituals and practices Prayer helps others: I did really, honestly
Bedside chanting by family
Staff offering of smudge stick to patients sons pray that they would nd some peace. So for
Bedside prayers or sacraments (e.g., last rites) me, I denitely found, just personally, a bit of
Spiritual care for wife after her husband died solace in my own spirituality (nurse). Being
present is another commonly valued
Definition of abbreviation: ICU = intensive care unit.
spiritual practice: you know, we were there
and, and just sitting with them and talking to
nondenominational, that have some of the I was really quite breath-taken . . . The them . . . I feel kind of awkward because Im
elements of spirituality but . . . are a bit humanity of [the physician] (chaplain). not so sure what the difference is in, between,
more secular . . . I think its just easier for Some clinicians view spirituality as not spirituality and, and just being there and
families to get involved with the program, their business, or only territory for being connected with the person (nurse).
and approach it (resident). clinicians with spiritual afnities. Regardless of differences, clinicians
By initiating wish solicitation, [Spirituality has] almost been trained out own spirituality helps to recognize spiritual
clinicians step outside the conventional of me . . . Im in the very early stages of my needs in others: The patient had been
professional role with a new-found intention career still and you see kind of like, a divide very spiritual throughout her lifenot
for deeper human connection: It has to be between people [who] retained that . . . necessarily following a specic religion but
a human encounter. Like, it cant be . . . spiritual side in their practice; and then the just very spiritual in nature . . . I feel as
technical . . . it cant be a checklist of ones that are almost a little too clinical and though her belief in whatever it was . . . was
questions that I ask you (nurse). This a little too rational (resident). I mean, we important to me because I respected the
human-to-human stance can be deeply ask all these very private questions about fact that my religion was quite important to
moving. Some identify this act as profoundly patients. Like, we know their eating habits, me, so I could understand the basis of her
spiritual. The humility and compassion of their sexual habits, their drug habits and all spirituality (respiratory therapist).
the gesture, and the egalitarian exchange this information and we have no problems Clinicians self-identifying as spiritual
acknowledging shared humanity and with asking it but then when . . . when it or religious consider it important not to
vulnerability, brings solace. A resident comes to faith and spirituality, I think theres inuence others: What I would call my faith
described: Its a want to do more. Its a this barrier for us. We feel uncomfortable tradition gives me an attentiveness to spiritual
want to try to reach out to something thats asking them questions (resident). matters and spiritual care. So I value it and
beyond just something that could be seen . . . Clinicians feeling ill equipped often Im highly attuned to it. I think its just how
its a form of love . . . agape love or its kind perceive spiritual care as outside the scope of Im programmed to be. I struggle with
of a very unconditional . . . youre just kind their practice (14): Sometimes when you language so Ive always struggled, as a
of exuding a type of . . . a love into . . . this have difcult discussions about end of life nurse . . . because Im so aware of not
person and the family and I think thats the and the families are very religious, for me, it imposing my beliefs on anyone (nurse).
sense of spirituality that I get and can bring can be hard because I dont know enough Soliciting wishes helps families become
forth . . . asking for the wishes (resident). about their beliefs . . . Like, when someone aware of their needs during the stress and
An observer of the clinicianfamily does pass away . . . what does that mean for exhaustion of a fatal illness. Soliciting wishes
interaction described being moved: And them? So when families say stuff like, But can comfort and heal those grieving. One
then [the physician] moved into . . . a God wouldnt want this, I dont really daughter described it as lifting the gloom.
conversation with them about the Three know . . . how am I supposed to explain A chaplain explained, there was sort of a
Wishes and I was like, Whoa. Wow. I was what God wants because Im not someone lightness brought into the dark (chaplain).
quite breath-taken and in fact . . . for most who knows, if that makes sense (resident). Finally, soliciting wishes addresses
of the time that I was in the room . . . I put Soliciting wishes offers a pragmatic way tremendous spiritual diversity. In my own
my hand up to my chest, up to my heart . . . for clinicians to minimize discomfort, practice, its all about trying to understand
202 American Journal of Respiratory and Critical Care Medicine Volume 195 Number 2 | January 15 2017
ORIGINAL ARTICLE
what does spirituality mean for this reminiscing: One of the things your [Three are for a spiritually enhanced environment.
person . . . this patient or this family thats Wishes] program had done was to provide Others are for religious rituals. Soliciting
in front of me? And then just honor that, in very personalized prayer cards . . . very wishes helps families revive lapsed spiritual
whatever way (nurse). Wishes educate personalized to her, with prayers and her supports, while respecting preferences of
clinicians about varied spiritual approaches name . . . What I was expecting to be a very those avowedly nonreligious or holding
to death and bereavement: I think cold [experience] ended up to be almost private views.
spirituality is different for everyone and oddly beautiful. We all sat around and held The limitations of this study include no
every family, and they all will express it in hands and that little paper that you made, quantitative metrics of dying processes,
their three wishes in many different ways . . . I still keep . . . I keep it with her other bereavement, or posttraumatic stress (21).
we might not think its spirituality, but to possessions and its like any of her Although many clinicians may offer basic
them, it is, and you just have to go with it keepsakes; . . . its just as valuable to me spiritual support, we acknowledge that
and respect what they want to do (nurse). as any of the others (son). trained professionals (22) are crucial
A common wish is for reconciliation. to assist with spiritual distress (3), yet
Spiritual Dimensions of the Wishes Wishes can help to restore family consultation is often deferred to end of life.
Themselves communication and to dissipate tensions. The spiritual needs of dying patients
Some wishes for soft lighting, silence, or A requested ICU wedding, for example, and families seem to be poorly recognized
soothing sounds nurture spiritual feelings cleared the air: I mentioned the family and addressed in a venue where physiology,
(15): I think singing was very spiritual for arguing . . . everything that needed to be technology, and efciency are emphasized
them; I think that was a big part of their said, I believe was looked after. And in (23, 24). However, the ICU is potentially
spirituality. The music was always on when the end, the day before the wedding . . . a powerful setting for reecting on
I was there, for two days, always (nurse). there was a sense of calm (nurse). experiences and expressions of spirituality.
Some wishes are religious (e.g., inviting a Longing for forgiveness motivated a As aligned with the European Association
patients own rabbi) or assisting with rituals mothers wish for reconnecting with her of Palliative Care Taskforce (25), we
(e.g., smudging ceremony). Postmortem estranged son. One womans gracious developed an interdisciplinary strategy to
wishes can cultivate the patients spiritual wish on behalf of her ex-husband was to ask about, and address, the human spirit in
mission. A wish for one man was a tell his rst wife years after their divorce this setting.
donation to a conservation area: Is there how proud he was of the children they We offer an approach to explore and
something thats important to Mr. C.? had raised. respond to spiritual diversity (26, 27).
and it was like, Oh, nature. Thats his Actions may speak louder than words in
spirituality . . . it really supported . . . the this context. Soliciting and realizing wishes
family engaging a lot of the spirit that they Discussion fosters spiritual care by prompting myriad
had seen within their father (chaplain). interventions that are directly or indirectly
Wishes often concern values common Across belief systems, death is experienced interpreted as spiritual (28). Many people,
across belief systems, such as peace and as a spiritual event. Families strive to whether self-reportedly spiritual, religious,
comfort. Where there is strife and despair, integrate death into a patients narrative. By both, or neither, regardless of remote or
wishes cultivate peace. Some wishes comfort soliciting and honoring wishes, clinicians recent afnity, call forth a spiritual response
the dying, such as the familiarity of watching can acknowledge and sustain the patients when bearing witness to death. The Three
the sports channel around the clock, life story, helping with closure for loved Wishes Project helps to realize the
[sports is] what gave him joy in life and it ones. Soliciting wishes envisions hopeful spectrum and impact of spirituality for
was nice that thats the way he parted as measures that can be taken during the those dying, living, and working in the
well as that he had what gave him comfort dying process, and brings clinicians ICU. n
(medical student) The bereaved seemed humanity to the fore. Clinicians endorse
comforted through wishes, as in the death expression of common spiritual
Author disclosures are available with the text
of a young person: it seemed tragic, and practices, such as compassion (16, 17) of this article at www.atsjournals.org.
the response that the family had to his and presencing (18), even posthumously
impending death was really tragic, too, (19), in their roles. For clinicians without
because they were so desperate and so a spiritual orientation, soliciting wishes Acknowledgment: The authors thank all the
patients, families, and clinicians who participated
angry. And I really saw a change in their offers strategies to broach an unfamiliar in the Three Wishes Project. They are grateful for
demeanor; I saw a change in them ghting subject (20). Although a clinicians own the nursing, physician, chaplain, social work, and
to give up on him to just, just accepting that spirituality may help to recognize spiritual respiratory therapy staff in the St. Josephs
he might die and letting go. And I think needs in others, refraining from imposing Healthcare Hamilton ICU, and Lois Saunders,
that all happened when we introduced personal beliefs is a stance underscored by Nicole Zytaruk, Neala Hoad, and Shelley Anderson-
White for helping with the realization of several
Three Wishes. There was sort of a peace the patient-centered ethos of the Three wishes. They appreciate the quantitative analysis
about them (nurse). Wishes Project. by Diane Heels-Ansdell, and the transcription
Many wishes are individualized Common wishes pursue spiritual goals, assistance by Diana Clancy and Laurel Grainger.
keepsakes in the form of a locket of hair, such as peace, comfort, and love. They thank Drs. Daren Heyland, Graeme Rocker,
Wes Ely, and Randy Curtis for encouragement with
a nal family photograph during a life Reconnection is an especially powerful, this project, and anonymous peer-reviewers for their
celebration in the patients room, or a poignant wish of persons separated by excellent suggestions. This work was inspired by
commemorative framed word cloud for distance or discord. Frequent secular wishes the work of the Sisters of St. Joseph in Hamilton.
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