What is a digital nomad? Definition and taxonomy in the era of mainstream remote work. (Special Issue: Leisure, knowledge work and the digital nomadism.)

Digital nomadism gradually expanded during the 2010s. Since the COVID-19 pandemic, remote work (a prerequisite to digital nomadism), suddenly became mainstream. In this new context the term digital nomadism is increasingly used in ways that are broader or different to its original conception. This paper reviews scientific literature and draws on the author's ethnographic fieldwork to create an updated classification of contemporary digital nomadism that acknowledges the broad spectrum of individuals, groups, communities, identities, and imaginaries labelled with the term digital nomad. The paper updates the definition of digital nomadism and provides a new taxonomy which subdivides the digital nomad model into five distinct types: freelance digital nomads;digital nomad business owners;salaried digital nomads;experimental digital nomads and armchair digital nomads. It also proposes that six key variable themes should be applied to these classifications. These are: autonomy over mobility;homebase practices;domestic vs. transnational travel;legal legitimacy;work-life balance and coworking space usage. The taxonomy and the variable themes are proposed as a roadmap for future research and as a tool so researchers and policymakers can more accurately evaluate real-world examples of digital nomad context, motivation, practice, and impact.

Remote Work, Work Measurement and the State of Work Research in Human-Centred Computing

Over the past few decades, a small but growing group of people have worked remotely from their homes. With the arrival of the coronavirus pandemic, millions of people found themselves joining this group overnight. In this position paper, we examine the kinds of work that 'went remote' in response to the pandemic, and consider the ways in which this transition was influenced by (and in turn came to influence) contemporary trends in digital workplace measurement and evaluation. We see that employers appeared reluctant to let certain classes of employee work remotely. When the pandemic forced staff home, employers compensated by turning to digital surveillance tools, even though, as we argue, these tools seem unable to overcome the significant conceptual barriers to understanding how people are working. We also observed that, in the United Kingdom context, the pandemic didn't mean remote work for a significant proportion of the population. We assert that, to maximize its impact, 'future of work' research in human-centred computing must be more inclusive and representative of work, rather than focusing on the experiences of knowledge workers and those involved in new forms of work.

What is a digital nomad? Definition and taxonomy in the era of mainstream remote work

Digital nomadism gradually expanded during the 2010s. Since the COVID-19 pandemic, remote work (a prerequisite to digital nomadism), suddenly became mainstream. In this new context the term digital nomadism is increasingly used in ways that are broader or different to its original conception. This paper reviews scientific literature and draws on the author's ethnographic fieldwork to create an updated classification of contemporary digital nomadism that acknowledges the broad spectrum of individuals, groups, communities, identities, and imaginaries labelled with the term digital nomad. The paper updates the definition of digital nomadism and provides a new taxonomy which subdivides the digital nomad model into five distinct types: freelance digital nomads;digital nomad business owners;salaried digital nomads;experimental digital nomads and armchair digital nomads. It also proposes that six key variable themes should be applied to these classifications. These are: autonomy over mobility;homebase practices;domestic vs. transnational travel;legal legitimacy;work-life balance and coworking space usage. The taxonomy and the variable themes are proposed as a roadmap for future research and as a tool so researchers and policymakers can more accurately evaluate real-world examples of digital nomad context, motivation, practice, and impact. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Awake Prone Positioning for COVID-19 Hypoxemic Respiratory Failure: A Systematic Review and MetaAnalysis of Randomized Trials

Background and Rationale: The benefits of awake prone positioning (APP) in patients with hypoxemic respiratory failure due to Coronavirus disease 2019 (COVID-19) remain uncertain. This systematic review and meta-analysis aimed to determine the efficacy and safety of APP versus usual care in non-intubated adults with COVID-19 hypoxemic respiratory failure. Method(s): We searched MEDLINE, Embase and CENTRAL for randomized trials on APP for hypoxemic respiratory failure. The primary outcome was endotracheal intubation. Secondary outcomes were mortality, ventilator-free days, intensive care unit and hospital length of stay, escalation of oxygen modality, change in oxygenation and respiratory rate, and adverse events. Random-effects meta-analysis was performed for the primary and secondary outcomes. Bayesian meta-analysis was performed for endotracheal intubation and mortality outcomes. Result(s): Seventeen trials (2931 patients) met eligibility criteria. APP, versus usual care, reduced the risk of intubation (24.2% vs 29.8%, relative risk [RR] 0.83, 95% Confidence Interval [CI] 0.73-0.94;I =0%, high certainty). APP did not significantly affect mortality or other secondary outcomes. Bayesian meta-analysis using non-informative priors found a high probability of benefit with APP for intubation (mean RR of 0.84, 95% Credible Interval [CrI] 0.72 to 0.97;posterior probability for RR <1 of 0.99) but not for mortality (mean RR of 0.94, 95% CrI 0.78 to 1.14: posterior probability for RR <1 of 0.75). Conclusion(s): APP reduces the risk of intubation versus usual care in patients with COVID-19 but did not improve mortality or other secondary outcomes.

Awake Prone Positioning in Acute Hypoxemic Respiratory Failure from COVID-19: A Randomized Clinical Trial

Background: The efficacy and safety of awake prone positioning (APP) in hypoxemic patients with coronavirus disease 2019 (COVID-19) is unclear. Aim(s): To evaluate the efficacy and safety of APP in non-intubated adults with COVID-19. Method(s): We performed a pragmatic, international, randomized trial at 21 centers in Canada, Saudi Arabia, Kuwait, and the United States between May 19, 2020, and May 18, 2021. Eligible patients were hospitalized adults with COVID-19 requiring >40% oxygen. Patients were randomized to APP (n=205) or usual care (n=195). The primary outcome was intubation by day 30. Secondary outcomes included mortality at 60 days, ventilation-free days at 30 days, intensive care unit (ICU) and hospital-free days at 60 days, adverse events, and serious adverse events. Result(s): Patients in the APP group proned for a median of 4.8 hours per day (IQR 1.8 to 8.0) in the first 4 days. By day 30, 70/205 patients (34.1%) in the APP group and 79/195 (40.5%) in the control group were intubated (hazard ratio [HR] 0.81;95% confidence interval [CI] 0.59 to 1.12). APP did not reduce mortality at 60 days (HR 0.93;95% CI 0.62 to 1.40) and had no effect on days alive invasively or noninvasively ventilated at 30 days, or days out of ICU or hospital at 60 days. There were no serious adverse events in either group. A prespecified subgroup analysis suggested that APP reduced intubation among patients with SpO2:FiO2 >150 (HR of 0.44, 95% CI 0.23 to 0.87) but not among patients with SpO2:FiO2 <150 (HR 1.02;95% CI 0.70 to 1.48;P-interaction= 0.03). Conclusion(s): APP did not significantly reduce intubation at 30 days or mortality at 60 days overall, but may be effective in patients with SpO2:FiO2 >150.

COVID-19 and Well-Being in Remote Coastal Communities—A Case Study from Iceland

This study utilizes a recently developed framework for the well-being economy to evaluate the impacts of COVID-19 in the sparsely populated Westfjords region of northwestern Iceland. A total of 42 semi-structured interviews were conducted with a broad spectrum of local community members, nearly all undertaken in October 2021. Local impacts to human and social capital were very evident, whilst economic consequences to individuals and business were largely mitigated through national economic packages. The remoteness of the Westfjords and pre-existing challenges, such as exposure to nature disasters, a harsh climate, and limited infrastructure, provided a bedrock of resilience with which to tackle the pandemic. This underpinned the sustainability of the communities, and flexible approaches to work and education constrained some of the worst potential effects of social distancing and isolation. Nevertheless, some socio-demographic groups remained harder hit than others, including the elderly in nursing homes and non-Icelandic speaking foreigners, who were marginalized via isolation and lack of information provision in the early, most severe outbreaks of COVID-19. The study demonstrated the coping mechanisms and solutions that were adopted to sustain subjective and community well-being, whilst reinforcing the importance of utilizing local community strengths in tackling the many challenges induced by a pandemic crisis. © 2022 by the authors.

CKD and Rapid Kidney Function Decline During the COVID-19 Pandemic

The impact of COVID-19 infection and the indirect effects of the pandemic on the trajectory of CKD is unknown. We performed a retrospective study using de-identified administrative claims data for Medicare Advantage enrollees with CKD Stages G3-4 in 2018-2021. Rapid kidney function decline (RFKD) was defined as a decrease in eGFR of >5ml/min/1.73m2 per year. RFKD was compared for the overall cohort during the pre-pandemic period (Jan 1, 2018 to Feb 29, 2020) to RFKD for the pandemic period (March 1, 2020 to August 31, 2021), and comparatively between enrollees with and without a diagnosed COVID-19 infection. We also evaluated factors independently associated with RKFD. Of 90,734 enrollees with available data, mean age was 75 years, 59% were males, 70% were White;62%, 30%, 8% had CKD G3a, 3b, and 4, respectively. RKFD was observed in 20.4% of enrollees in the pre-pandemic period and in 26.8% during the pandemic. Overall, COVID infection was diagnosed in 8.7% of enrollees. RKFD was observed in 28.2% of those with a COVID-19 diagnosis and 25.1% of those without (p value < 0.05). Factors associated with increased odds of RKFD in the pandemic included Black or Hispanic race/ethnicity, RKFD in the pre-pandemic period, and documented COVID infection;advancing CKD stage was inversely associated with RRFD (Figure). The COVID-19 pandemic resulted in more than a quarter of the population experiencing rapid kidney function decline for individuals with CKD, irrespective of COVID-19 infection. The downstream impact of pandemic-related eGFR decline on health outcomes, such as cardiovascular disease, kidney failure or mortality, requires further study. (Figure Presented)

The 3 Wishes Program Improves Families' Experience of Emotional and Spiritual Support at the End-Of-Life

RATIONALE Dying in the intensive care unit (ICU) can be a source of trauma for both patients and their families. By fulfilling small wishes, the 3 Wishes Program (3WP) aims to provide personalized, humanizing experiences at the end of life (EOL) in the ICU. Prior qualitative studies using semi-structured interviews have shown that the intervention positively impacts families' experience of EOL care, but objective comparison was lacking. We assessed families' ratings of EOL care for patients whose care involved the 3WP and those that did not. METHODS A modified version of the Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was delivered by mail or telephone approximately three months after death to the next-of-kin (NOK) of patients who died in the ICUs of a two-hospital healthcare system. Clinical and demographic data regarding patients were obtained from the medical record. We compared three BFS-derived measures for patients whose care did or did not include the 3WP: Respectful Care and Communication (5 questions, alpha = 0.82), Emotional and Spiritual Support (3 questions, alpha = 0.77), and the BFS-Performance Measure (BFS-PM, a single item global measure of overall experience of care). We used multivariable regression to adjust for characteristics including age, sex, race/ethnicity, presence of palliative care consultation, and clinical complexity on ICU admission as measured by SOFA. RESULTS Of 1029 patients who died in the ICUs during the study period, 314 (30.7%) NOK completed the modified BFS. Of the 314 surveys completed, 117 were from NOK of patients whose EOL care involved the 3WP. Among those for whom surveys were received, decedents whose care involved the 3WP were younger (69 vs 70, p=0.024), less often male (45% vs 58%, p=.031), less often non-Hispanic white (38% vs 60%, p < 0.001), had a longer LOS (14 vs 7 days, p<0.001), and were more likely to have died during a COVID-related hospitalization (27% vs. 6%, p<0.001). Bereaved families of patients whose care involved the 3WP rated Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p=0.003, adjusted p=0.001) than those whose did not. There was no significant difference in the Respectful Care and Communication factor (14.0 vs 14.0, p=0.225, adjusted 0.052) or the BFS-PM (67.5% vs 60.4% excellent, p=0.207, adjusted p=0.002). CONCLUSIONS The 3WP enhanced patient's families' experience of the emotional and spiritual support they received during and after EOL care in the ICU.

Helmet Non-Invasive Ventilation for Acute Respiratory Failure: A Case Series

Rationale: The helmet is a novel interface for delivering non-invasive ventilation (NIV) to hospitalized patients with respiratory failure. Its purported benefits compared to traditional oronasal interface includes better tolerance, lower intubation rates, improved survival, increased ventilator free days and decreased ICU length of stay. However, to date, only small randomized control trials (RCTs) have been conducted on this topic. Given this, we conducted an observational study describing single-centre institutional and patient experience with this device in both COVID and non-COVID patients. Methods: With REB approval, we enrolled all patients with respiratory failure admitted to the Juravinski Hospital ICU in Hamilton, Canada who used the helmet interface (Intersurgical StarMed) for delivery of NIV between November 1, 2020 and June 30, 2021. We collected patient demographics, past medical history, reason for respiratory failure, NIV settings and patient outcomes. We also recorded any complications ascribed to the device and conducted informal interviews with clinicians regarding issues with helmet use. We present results descriptively without statistical comparisons.Results: We included 13 patients in this observational cohort study. The mean age was 66.3 ± (standard deviation) 10.3 years and 39.4% of the patients were female. The most common etiology for respiratory failure was pneumonia (76.9%). The mean duration of NIV during the ICU admission was 127.9 ± 198.8 minutes, with a mean maximum inspiratory positive air pressure (IPAP) of 16.2 ± 3.2 cm H2O and a mean maximum expiratory positive airway pressure (EPAP) of 8.5 cm H20 ± 1.7. Three patients (23%) did not tolerate the helmet. Seven (53.8%) patients ultimately required intubation, and 5 (38.5%) patients died while in the ICU. The most common reason for intubation was worsening hypoxia (30.8%). The mean length of stay in ICU was 30.8 ± 29.9 days. 1 (8%) patient had an aspiration event with helmet use, but no other complications were recorded. Clinician interviews revealed that the most common issues with the helmet were patient agitation , oronasal mucosal dryness due to lack of humidity and skin breakdown at the armpits. Conclusion: This observational cohort study reports our institutional experience with the helmet interface for delivery of NIV. In our 8-month experience, we found that the helmet was well tolerated in the majority of patients and just over half ultimately required intubation. Issues regarding lack of humidity, skin breakdown around the armpits and agitation will need to be addressed as we continue to gain expertise with this interface. (Table Presented).

DID THE COVID-19 PANDEMIC AFFECT PSYCHOLOGICAL READINESS TO RETURN-TOSPORT IN YOUNG ATHLETES UNDERGOING ACL RECONSTRUCTION?

Background: Return-to-sport (RTS) following anterior cruciate ligament reconstruction (ACLR) is influenced by multiple physical and psychological variables. Psychological readiness has been associated with improved patient reported outcomes as well as RTS rates in young athletes. The COVID-19 pandemic may have altered the typical recovery process for patients undergoing ACLR. Hypothesis/Purpose: To compare 6-month postoperative levels of psychological readiness to RTS in ACLR patients before and during the pandemic. Methods: Patients were prospectively enrolled 6 months after primary ACLR at a single academic sports medicine practice, from December 2018 until May 2021. Patients were categorized into pre-COVID (enrollment prior to March 13, 2020) and COVID groups (March 13, 2020 - May 26, 2021). Demographic information, outcomes scores including the ACL-Return to Sport after Injury Scale (RSI) and PROMIS Psychological Stress Experiences (PROMIS-PSE), and physician RTS clearance were obtained and compared for both groups. Comparisons were performed utilizing Chi-square, Student's t-tests and linear regression. A matched analysis was conducted between groups controlling for age, sex, and graft type. Results: 231 patients were included in the present study (89 males, 142 females;mean age 16.9 years), with 76% (176/231) in the pre-COVID group and 24% (55/231) in the COVID group. There were no significant differences in age and sex between the two population cohorts. There was a significant difference in time from surgery to enrollment in the COVID group compared to the pre- COVID group (7.1 vs 6.2 months, p<0.001). In the matched cohort (n=126, 37/126 COVID group), the COVID group was cleared earlier by their physician to RTS compared to the pre-COVID group (6.9 months vs 8.5 months, p<0.001). While there was no significant difference between groups in 6 month ACL-RSI scores (63.8 pre-COVID vs 66.6 COVID, p=0.48), both groups yielded globally low scores. There were no significant associations between matched groups in PROMIS-PSE (p=0.71), IKDC (p=0.55), Pedi-IKDC (p=0.15), and Pedi-FABS (p=0.77) scores (Table 1). Conclusion: Young athletes demonstrated similar levels of psychological readiness to RTS at 6 months following ACLR prior to and during the COVID-19 pandemic. Patient-reported outcome scores were similar in pre-COVID and COVID ACLR patients, suggesting that the pandemic may not have played a detrimental role in perceptions of recovery. Psychological readiness may not be fully optimized at 6 months post-ACLR and young athletes may benefit from additional time and training for progressive confidence, muscle strength, and performance.

The end of the active work break? Remote work, sedentariness and the role of technology in creating active break-taking norms

Excessive sedentariness can impair workers' health and productivity. The move to working from home as a result of the Covid-19 pandemic eliminated many workday opportunities for physical activity. This, coupled with a blurring of boundaries between work and non-work periods, put many at risk of overwork and musculoskeletal issues. We examined how the sudden transition to working from home influenced people's ability to take physically active work breaks. We found that the absence of social norms associated with the presence of colleagues in the work environment left workers uncertain about whether and when it is appropriate to take breaks. The pressure to demonstrate productivity while working asynchronously led to increased sedentariness and decreased break-taking. We propose that online tools that promote flexible social norms around break-taking could empower remote workers to incorporate regular physical activity into their days, without compromising the beneficial aspects of asynchronous working. © 2022 ACM.

Bringing research to the intensive care setting

Dr. Deborah J. Cook's contributions in the field of critical care have not only impacted the intensive care unit (ICU) patients she treats and countless others worldwide but have also helped establish research programs and clinical trials as integral components of improving care and outcomes for the most seriously ill. Lara Szewczak spoke with Dr. Cook, recipient of the 2022 Canada Gairdner Wightman award, about critical care research, her reflections on the COVID-19 pandemic, and her views on mentorship. An edited version of this conversation is presented below.

Incidence, characteristics, and outcomes of patients presenting to an urban academic institution with stsegment elevation myocardial infarction during the covid-19 pandemic

Introduction: ST-segment elevation myocardial infarction (STEMI) is an emergency presentation of an acutely occluded coronary artery. Following the announcement of the COVID-19 pandemic (March 11, 2020), a global decrease in STEMI incidence has been observed. Incidence, characteristics, and outcomes for STEMI activation patients were investigated in the 5 years prior (“reference period”) to and 1 year into the pandemic (“pandemic period”). We assessed the hypothesis that pandemic period STEMI activations will have more severe infarction (elevated troponin I), a higher percentage of true STEMI, and worse outcomes (higher case fatality rate). Methods: STEMI activation incidence was obtained from an institutional database (reference period n = 430;pandemic period n = 31). Patient characteristics and outcomes were obtained retrospectively from electronic health records (EHRs). True STEMI was adjudicated based on chest pain, EKG, troponins, and angiogram. Results: Monthly STEMI activations declined significantly in the first year of the pandemic (2.50 ± .68 vs. 7.17 ± .41, P = <.001). No significant difference in demographic characteristics (age, BMI,and male-to-female ratio) were observed. True STEMI percentage was higher during the pandemic (80.65% vs. 70.93%), but not statistically significant. Peak troponin levels for true STEMI were significantly higher during the pandemic (98.83 ± 25.82 vs. 51.44 ± 4.11, P = .003). There was no significant difference in 30-day and 90-day case fatality rates. Conclusions: STEMI activation incidence declined significantly during the pandemic;interestingly, the proportion of these which were true STEMIs remained consistent. True STEMIs during the pandemic had higher troponin levels suggesting larger infarct, but there was no significant difference in case fatality. In conclusion, fewer patients presented with STEMI while case fatality remained unchanged despite more severe infarct occurrence during the pandemic.

The impact of the COVID-19 pandemic on nighttime room entries and sleep disruptions for pediatric patients

Introduction: Sleep is critical to children's health and recovery, but pediatric inpatient sleep is often disrupted by nonessential overnight interruptions. The COVID-19 pandemic necessitated social distancing policies which minimized contact with low-risk patients. These policies have the potential to decrease overnight disruptions and improve sleep for hospitalized patients. Methods: This cohort study compared sleep disruptions for pediatric inpatients admitted prior to (Sep 2018 - Feb 2020) and during (Apr 2020 - Aug 2020) the COVID-19 pandemic at a single site, urban academic medical center. Objective disruptions were measured as room entries detected by hand hygiene sensors for occupied rooms pre-pandemic (n-average=56) and during the pandemic (n-average=48) for 69 and 154 nights, respectively. Subjective reports of overnight disruptions, sleep quantity, and caregiver mood were measured by surveys adopted from validated tools: the Karolinska Sleep Log, Potential Hospital Sleep Disruptions and Noises Questionnaire, and Visual Analog Mood Scale. Caregivers of a convenience sample of pediatric general medicine inpatients completed surveys. Caregivers pre-pandemic were surveyed in person, and during the pandemic, surveys were conducted over the phone. Results: 293 pre-pandemic (age-patients=4.1±4.4 years) and 154 pandemic (age-patients=8.7±5.6 years) surveys were collected from caregivers. The majority (71% pre-pandemic and 52% pandemic) of the study population identified as Black/African American. Nighttime room entries initially decreased 36% (95% CI: 30%, 42%, p<0.001), then returned towards pre-pandemic levels as the COVID-19 hospital caseload decreased. Despite this, caregivers reported more disrupted patient sleep (p<0.001) due to tests (21% vs. 38%) as well as stress (30% vs. 49%), anxiety (23% vs. 41%), and pain (23% vs. 48%). Caregivers also reported children slept 61 minutes less (95% CI: 12 min, 110 min, p<0.001) and had more awakenings. Caregivers self-reported feeling more sad and weary, less calm, and worse overall (p<0.001 for all). Conclusion: Despite fewer objective room entries, caregivers reported increased sleep disruptions and an hour less nighttime sleep with more awakenings during the pandemic for pediatric patients. Caregivers also self-reported worse mood. This highlights the importance of addressing subjective perceptions and experiences of hospitalized children and their caregivers during hospitalization.

Dying during the COVID-19 pandemic: impact of infection control measures at the bedside

INTRODUCTION: Infection control measures introduced during the COVID-19 pandemic present myriad challenges to end-of-life (EOL) care beyond restricted hospital visiting hours. The objective of this analysis was to understand the effect of infection control measures on bedside care for dying patients in a study embedded in an evaluation of the 3 Wishes Project. We hypothesized diverse effects from clinicians' perspectives. METHODS: Using a mixed-methods design, we enrolled patients with a ≥95% probability of dying in hospital, or plans were to withdraw life support on 3 hospital wards. Clinicians who cared for these patients were purposively sampled 2-10 weeks postmortem for an audio-recorded interview;data were analyzed by conventional content analysis. RESULTS: In total, 45 patients were enrolled in the ICU (n=34);COVID-19 ward (n=7), or medical step-down unit (n=4) from March 16-July 1, 2020. Of 236 terminal wishes elicited, 99% were implemented. During their hospital stay, 32 (71%) patients had ≥1 family member visit in the patient's room, outside the room, or at the outdoor window. At the time of death, 20 (44%) patients had family members at the bedside (none had COVID-19). Perspectives from 45 clinicians (16 nurses, 10 physicians, 8 residents, and others) highlighted several changes to physical aspects of EOL care during the pandemic. Patients with COVID-19 are cohort and/or isolated. Care for patients with and without COVID-19 is clustered to preserve personal protective equipment (PPE), thereby modifying the number and nature of bedside conversations, and physical aspects of care by some healthcare professionals. PPE, including gowns, masks, face shields, and gloves hinder visual and tactile aspects of care, precluding lip reading, covering facial expressions, interfering with natural tactile manifestations of concern. Many wishes were targeted at reducing patient isolation. Beyond task-oriented aspects of care, infection control strategies affect both verbal and non-verbal communication, including expressing and detecting emotion. CONCLUSIONS: Care for patients with and without COVID-19 is affected by infection control measures necessary during the pandemic, which modify many aspects of end-of-life care.

Pandemic visiting restrictions at the end of life: Clinicians' experiences with the 3 wishes project

INTRODUCTION: Restricted visiting hours during the COVID-19 pandemic are common. We hypothesized that clinicians would be distressed caring for patients at the end of life (EOL) related to visiting restrictions, as assessed in our pandemic-specific study to evaluate whether the 3 Wishes Project is feasible and valuable for dying patients. METHODS: In an embedded mixed-methods study from March16-July 1, 2020, we enrolled patients with a ≥95% probability of death or plans to withdraw life support. Clinicians and families elicited and implemented ≥3 final wishes/patient. We recorded patient characteristics and clinician demographics. We purposively sampled clinicians who cared for these patients for interviews 2-10 weeks postmortem;transcripts were analyzed using a qualitative descriptive approach. RESULTS: For 45 enrolled patients, 236 wishes were elicited. Overall, 5.2 (2.1) [mean (SD)] wishes/patient were implemented;50 (21%) by families. Most patients (32, 71%) had family visits during their hospital stay (in the patient's room, outside the room, or at the outdoor window). At the time of death, a family member was present with 20 (44%) patients. We interviewed 45 diverse clinicians with 13.7 (11.5) years of experience. Clinicians discussed operationally challenging dimensions of visiting restrictions related to the timing, duration, number, and purpose of visitors;different policies across units;variable implementation of the same policy;and policies shifting during the pandemic. Clinicians experienced moral distress caused by limited family companionship for patients. Emotions evoked included heartbreak, concern, devastation, frustration, and helplessness. This prompted professional coping strategies such as peer support;story-telling;informal debriefing;family advocacy;initiating research on this issue;and more intentional acts of compassion by creating meaningful wishes to personalize EOL care without family presence. CONCLUSIONS: Clinicians experienced both first-hand and vicarious distress when caring for dying patients during the pandemic related to visiting restrictions. The 3 Wishes Project provided a framework for empowering clinicians to provide humanistic EOL care for patients who were separated from their families.