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The 3 Wishes Project quickly gained traction at St. Joseph's Healthcare Hamilton as we showed how it helps to honour dying patients, comfort families, and strengthen interpersonal connections among patients, family members, and clinicians. In the original setting, it became an important part of the high quality care offered to all dying patients, and word spread. We received inquiries from all over the world about how it worked, and whether it could be incorporated into practice elsewhere. Could it scale? Would it spread?

With funding from The Greenwall Foundation, we studied the initiation of the 3 Wishes Project in 3 new ICUs in Canada and the United States. We wanted to understand whether the program could be implemented in these new settings, and whether the family members, clinicians, family members, and institutions would experience the same value of the program that we had experienced in Hamilton. While the 3 Wishes Project had been underway for 4 years at St. Joseph's Healthcare, we also wanted to determine whether it was both affordable and sustainable in the new locations.

Accordingly, we conducted a formative program evaluation - a methodological technique used to assess the development and implementation of a program early in its life cycle. This mixed-methods study occurred in ICUs in three new sites beyond the original site at St Joseph’s Healthcare in Hamilton, Ontario: St. Michael’s Hospital in Toronto, Ontario; Ronald Reagan UCLA Medical Center in Los Angeles, California; and Vancouver General Hospital in Vancouver, British Columbia.

The overall goal of the multicenter project was to evaluate whether it could be implemented in centers beyond the original setting. Our objectives were to examine its 1) Value: as experienced by family members, frontline clinicians, intensive care unit (ICU) managers and hospital administrators; 2) Transferability: successful implementation beyond the original single-center ICU by a different mix of clinicians; 3) Affordability: cost of wishes being less than $50/patient; 4) Sustainability: project continuation beyond the first year of evaluation.

We concluded that the 3 Wishes Project was transferrable as it was established successfully in all sites. We cared for 730 dying patients and implemented 3325 wishes in 4 academic ICUs. Given our intent to empower frontline staff to adapt the 3 Wishes Project to their own practice, we did not protocolize any single approach to personalizing end of life care. Implementation was assisted by support from the original center, the 3WP Start Up Guide, toolkits, retreats, reverse site visits, and institutional collaboration to create training materials for frontline clinicians.

Qualitative data through interviews and focus groups were gathered from 74 family members, 72 clinicians, and 20 managers or hospital administrators. Families valued the opportunity to implement wishes, share stories with clinicians, and reminisce about the patient's life. The 3 Wishes Project fostered more intentional comforting of families by clinicians as they honoured patients' legacies. Staff participation evolved from passive support to professional agency, fuelling diverse and largely simple acts of compassion. Program initiation required minimal investment for re-useable materials; thereafter, the mean cost was $5 per wish; 76% of the wishes were at no cost to the program. Community donations and volunteer assistance also helped to minimize expenditures. Sustainability was demonstrated by continuation of the 3 Wishes Project at each site following study completion.

While some similarities existed across centers, local adaptations of the 3 Wishes Project encouraged each group to take ownership of the program to suit their interests, needs, and resources for end of life care. Key factors promoting success included family appreciation and a collaborative ICU culture committed to individualized, dignity-conserving end of life care.  The 3 Wishes Project is a transferrable, affordable and sustainable program which provides value to dying patients, their family members, clinicians, and institutions when local clinicians seek to champion and sustain implementation.