The 3 Wishes Project is an initiative focused on compassionate end-of-life care for critically ill patients and their families.1 This article reviews some of the challenges to optimal end-of-life care in the setting of the intensive care unit (ICU), shares reflections on spirituality at the end of life, and considers the potential for compassion in practice.

The modern world of critical care medicine is fast-paced, complex, and so replete with technology that it is sometimes hard to recognize the patient in the bed. However, the patient is at the center of everything we do. As we know from Francis Peabody, “One of the essential qualities of the clinician is an interest in humanity, for the secret of the care of the patient is indeed in caring for the patient.”2 The patient and their family are the reason we are here.

As we know, individuals in the community are surrounded by people, and often various groups of people—family, friends, and community members in places such as the gym or places of faith (Figure 1). However, when people are taken out of their community and admitted to the hospital, especially if they come into the ICU, they become patients. As such, our patients’ supportive communities are labelled as “visitors.” There is an array of health care providers caring for each patient in the ICU, many of them listed here, including, of course, the spiritual care clinician (Figure 2).

Figure 1. The view of a person in the community

Figure 2. The view of a patient in the hospital

Spiritual care in the hospital setting focuses on matters far beyond the physical, attending holistically to the body, mind, and soul. Spiritual concepts include hope, support, peace, comfort, and connections. It is well documented that the ICU setting is stressful for patients and their family members; however, it can also be stressful for clinicians. Spiritual distress is everywhere. Serious illness, as we know, triggers numerous existential questions about the purpose of the illness, maybe even the purpose of life, and what it means to be critically ill. It also initiates questions about relationships. It is often a time when people reflect on special relationships as well as relationships forgone, broken, or those in need of renewal. Serious illness also triggers questions about death—when and how it will occur. Even for those of us who do not think of ourselves as spiritual care providers, when working with individuals at the end of life, we often encounter and recognize spiritual distress in our patients and their families, but also in our colleagues and ourselves. How can we better attend to spiritual distress in the face of death in the ICU? How can we move toward more spiritual care in the ICU, even if we are not spiritual care experts?

In the faith-based organization of St. Joseph’s Healthcare Hamilton in Ontario, Canada, a group of critical care, palliative care, and spiritual care clinicians developed the 3 Wishes Project. The overall goal was to try to improve the quality of the dying experience for patients and families. We had 3 specific objectives: 1) for patients, we wanted to honor their inherent dignity; 2) for family members, we wished to humanize the dying process and better support them in grief, and 3) for clinicians, we wanted to inspire a deeper sense of vocation. The premise of the 3 Wishes Project is that by understanding the patients beyond their critical illness, then eliciting or asking about preferences, requests, or wishes, and finally fulfilling these wishes, we could help bring comfort in the final hours or days. This dialogue is a scaffolding, prompting questions that clinicians can ask, such as Can you tell us more about your sister? What did your father like to do? What should we know about you to best help you right now? It is through questions such as these that wishes are identified.

Wishes can be expressed by many different individuals. There is variation in terms of who elicits each wish, whose wish it is, and who implements the wish. If able, the patient may express wishes for the end of their life. Often, families or friends reflect on what patients would say if they could speak for themselves. Many wishes represent spontaneous acts of compassion from clinicians. A touchstone phrase is Surround the patient with the people and things they love. This can include a visit from a pet as an important family member. We encourage family members to bring items to the hospital from home to help humanize the environment, such as Grandpa’s special sweater or Nana’s cozy slippers. Music is a common wish—calming instrumentals, tunes of a favorite artist, or a live performance by a family member or a volunteer. Sometimes the patients request to be outside in the sunshine and inhale some fresh air one last time. Wishes may be explicitly celebratory, such as an early birthday or Christmas celebration. Clinician wishes are often related to family care, including simple gestures, such as making a cup of tea or coffee, or buying snacks for family members who are too preoccupied to eat. Local community groups have made and donated crocheted or knitted blankets, which are more colorful and personal than traditional hospital blankets. Organ donation, when medically possible and following careful discussions, aligns well with the 3 Wishes Project as a legacy wish.3 Keepsakes are very popular, such as locks of hair in a glass vial, framed electrocardiography strips, thumbprint key chains, handprints, love letters, and word clouds.4 These have been cherished mementos that families take home in memory of their loved one.5 During the COVID-19 pandemic, we have offered them in person, or mailed or delivered them to families who could not be present at the bedside.

Wishes may be overtly spiritual, such as readings and rituals for the patient and family or bringing religious objects into the room in accordance with faith traditions. In a community hospital that serves a large Indigenous population, these spiritual wishes have included smudge ceremonies and a cedar bath.6 Readings that range from religious to secular are common, culturally aligned, and may be personalized for each patient or family. These may be viewed as more classical spiritual wishes, but many of the other foregoing wishes reflect support, comfort, and connections. One of the definitions of spirituality is “the aspect of humanity that refers to the way individuals seek and express meaning and purpose, and the way they experience their connectedness.”7 In this sense, the 3 Wishes Project offers connections—sometimes to the moment, to self, to others, to nature, or to the significant or the sacred in the eyes of those dying and those attendant to that death.

Dying is generally considered a spiritual event. Spirituality is an integral part of the life narrative of the patient before, during, and after death. Experiences and expressions of spirituality for dying patients, their families, and their clinicians can be supported by eliciting and implementing wishes in several ways. Eliciting wishes stimulates conversation for people of diverse spiritual orientations to respond to death in personally meaningful ways that can create connections and ease emotional trauma. Soliciting wishes identifies positive aspirations, which provide comfort in the face of death. The act of soliciting wishes brings clinician humanity to the fore. Through the process of wishing, individual spiritual preferences and practices become more accessible. Wishes may be grounded in spiritual goals, such as peace, comfort, connections, and tributes; they may seek a spiritually-enhanced environment, or represent specific spiritual interventions. The 3 Wishes Project has demonstrated how spirituality is an important dimension of end-of-life care, inviting and supporting the expression of myriad forms of spirituality during the dying process, concordant with patient and family preferences, traditions, or beliefs.3,8

Another study demonstrating the 3 Wishes Project as a spiritual care intervention was conducted in a University of California Los Angeles–affiliated institution at the Ronald Reagan Hospital. The investigators invited families of ICU decedents, 3 months after the death, to complete a modified Bereaved Family Survey (BFS), a validated tool for measuring the quality of end-of-life care. They compared patients whose care involved the 3 Wishes Project with those who did not using 3 measures from this tool: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care). Of the 314 completed surveys, 117 concerned patients whose care included the 3 Wishes Project, and the rest were from other families. While the Respectful Care and Communication factor and BFS-PM were not different between the groups, bereaved the families of patients who were cared for as aligned with the 3 Wishes Project rated the Emotional and Spiritual Support factor significantly higher than the families that did not experience this type of care.9

As the program has gained momentum, it has spread beyond the original sites and beyond the clinical context of the ICU. Current 3 Wishes Project expansion involves other wards and additional settings, such as community hospitals and hospice centers. We have created guidebooks and other materials to help new centers get started with this simple, inexpensive, and often spiritual intervention that has been shown to honor the dignity of dying patients and foster humanistic connections at the end of life.