Can buildings improve the way we die?


Matt Bowskill asks how can hospice design give people a more comfortable, cared-for end of life experience? 

Where do you want to be when you die?

Where would you want your loved ones to be — your spouse, children, parents, or close friends?

Chances are a hospital isn’t top of your list. Hectic places, stressful, with stark fluorescent lighting, hardly any privacy. Few of us (less than one in ten, in fact) say we’d prefer to die in hospital. No wonder around two-thirds of us would like to be where we live, with the people with love, at the end of life. But, for a whole host of reasons, that isn’t always possible.

For people who can’t, or don’t want to, die at home, how do we make sure the place where they do die the best it can be for supporting a ‘good death’? Answering that question involves looking at the places that support people living with a terminal illness today — and in the past.

Where we die has changed a lot over the years.

Buildings designed to support the sick or dying date as far back as ancient Greece. During the Crusades in the 12th Century, ‘hospices’ existed across the Mediterranean (although the term had more to do with providing rest to religious travellers). In medieval times, if you were sick, frail or elderly, you were more likely to end up in a monastery run by a religious order.

Then, in the 1600s, there was a Europe-wide shift to establish institutions such as prisons, asylums and hospitals. On the surface, the motives were well meaning. The aim was to improve effectiveness and efficiency through architecture and institutional processes. But as the work of French philosopher Michel Foucault made clear, they were also a means of social control — of managing society’s outcasts, whether they were ‘mad’, poor, old, or dying. Control was designed into the fabric of the buildings. Architecture made surveillance and order possible.

Imagine somewhere people might end up when they’re sick or dying today. For many of us, some kind of demoralising brutalist building springs to mind. A forbidding place with unforgiving architecture, interiors made up of imposing, impossible-to-navigate corridors decked out in depressing grey linoleum. Not the most comforting space to spend the final weeks or months of your life.

In her recent TED talk There’s a better way to die, and architecture can helparchitect Allison Killing argues that “hospital architecture has earned its bad reputation”, but that it wasn’t always like this. Killing cites the ambitious L’Ospedale degli Innocenti in Florence, built way back in 1419 by Brunelleschi, as evidence that good design in care settings actually has a very long history. Constructed around a beautiful central courtyard, the hospital’s rooms all had lots of natural light and fresh air. Everything about it said ‘compassion’. It was a place you might actually want to spend some time. To this day, people visit from far and wide to marvel at Brunelleschi’s vision.

 L’Ospedale degli Innocenti, Florence. Photo by Warburg
L’Ospedale degli Innocenti, Florence. Photo by Warburg

There’s certainly been a shift over the last few decades. It might be on a far less grandiose scale, but the design of modern hospice buildings demonstrates that some of those principles are being revived. In a way, you can trace the shift in thinking back to the foundation in 1967 of the Hospice Movement. After befriending a dying patient, its founder Dame Cicily Saunders, resolved to give people more comfortable, compassionate, and caring places to be at the end of life.

Now, nearly 50 years later, hospices are being designed that truly fulfil that vision. Usually more compact and smaller in scale than your average hospital, making it easier to put peace and tranquility first, today’s hospices prioritise the well-being of patients, visitors and staff. Research-led design is at the forefront of creating these ‘hospices that care’.

A view from a window

Professor Roger Ulrich is widely regarded as the father of research into how certain buildings might make us happier and healthier. One of his first papersA View from a Window… published way back in 1984, is something of a classic. Ulrich looked at the recovery of patients who, after gall bladder surgery, had been assigned to rooms on a long ward in a US hospital. He took advantage of the building’s layout: by chance, patients found themselves either in a room overlooking a featureless brick wall or one with a more naturalistic view of trees. The most interesting part? Patients with a view of trees had shorter stays, recovered quicker and needed fewer painkillers than their wall-staring counterparts.

This work was the starting point for wider research that has identified the psychological and health benefits of a range of design features, such as natural lighting, access to nature, openness, creative features such as art and sculpture, and opportunities for both privacy and being sociable, to name but a few.

The research has looked at healthcare settings generally, but more and more is being used to inform how hospices are designed — or at least those that take seriously the Hospice Movement’s philosophy of providing holistic care and support for people living with a terminal illness (i.e. care beyond just pain relief).

Outside at the Marie Curie Hospice, West Midlands ©Sally Ann Norman Photography
Outside at the Marie Curie Hospice, West Midlands ©Sally Ann Norman Photography

Architecture and dying

For nearly two decades, Mura Mullan has been helping to create better spaces for people to die. Mura is an architect at JDDK, the Newcastle-based firm renowned for its hospice design work. She says they start each project by ‘putting themselves in the patient’s bed’ and seeing things from their perspective. She worked on the Marie Curie Hospice, West Midlands, which recently obtained a Care Quality Commission rating of ‘outstanding’.

When we talk, she speaks passionately about putting research-led ideas of ‘good’ hospice design into bricks-and-mortar practice, to give people a more caring and comfortable place to be at the end of life.

“People can be coming in with a lot of stress and a lot of worry,” she says. “When I’ve gone back to see hospices that use that approach, people have said it’s like a magic dust seems to settle on people’s shoulders when they come in — like the place is putting people at ease and helping them deal with the process.”

Putting people at ease. It’s a phrase Mura comes back to repeatedly during our chat. But how do you go about doing that from a design perspective? Clearly, getting away from the clinical, institutional feel of bad hospital design is crucial.

“So for one it’s about the scale of the building and helping people to find their way around, with lots of prompts,” she says. “People need to be able to see outside, to know where they are, without long corridors and no views outside”.

But how do you know if the bricks-and-mortar application of these ideas works for the people who matter? In a word: research. Mura is currently working on an ambitious project at JDDK, in collaboration with Northumbria University, tracking the development of hospice design over the past 30 years. They’re visiting 12 of their most significant hospice projects and looking at how well the buildings have promoted well-being. The findings will then feed back into how hospices are designed in future.

Inside the Marie Curie Hospice, West Midlands. ©Sally Ann Norman Photography
Inside the Marie Curie Hospice, West Midlands. ©Sally Ann Norman Photography

Peace and tranquility in the West Midlands

Walk around the Marie Curie Hospice, West Midlands and the first thing to strike you is the light. Big, open windows. Daylight beating down wherever you turn. Wander outside. Take in the grounds and gardens. Hundreds of trees. Large, neatly cut lawns. Beautiful flower beds. If you pause for a moment, you might hear the sound of birds chirping, or the trickle of the central water feature. It’s calmer and greener than you might expect of a hospice just five minutes outside Solihull town centre.

Started in 2011, and completed in November 2012, the hospice goes to great lengths to really re-connect people with their natural environment. That’s because the hospice’s greenfield site was made a central part of its design.

Each of the hospice’s 24 bedrooms faces south, following an almost horseshoe shape that ensures lots of natural light. Glass bedroom doors look out onto a central courtyard and beautiful gardens maintained by enthusiastic local volunteers. Mura tells me they’ve designed the doors so they’re wide enough for staff to push beds outside if patients aren’t well enough to move around. There’s even an entertainment system that lets patients watch the outside if they’re bed bound.

A patient enjoys time outside his room with family. ©Sally Ann Norman Photography
A patient enjoys time outside his room with family. ©Sally Ann Norman Photography

“Even if you’re not well enough to have your bed taken outside, just having the doors open so you can feel the breeze on your face can give great reassurance,” says Mura. “I think there’s a desire to be part of something that’s much bigger than yourself, really. To not feel isolated”.

The contrast with Marie Curie’s previous West Midlands hospice couldn’t be greater. Located just half a mile down the road, it was basically two Victorian houses joined together. The ground floor comprised a few offices and a day services area. It was a single room. Patient bedrooms were located on the first floor, making it difficult for patients to get outside. They were incredibly cramped and I’ve heard stories about nurses having to move furniture if they needed to hoist patients.

From the start, West Midlands Hospice Manager Liz Cottier was determined that the new hospice should give people a sense of openness, and make people feel part of the world — rather than hemmed in and alone.

“You don’t live your life in bed. I didn’t want it to be a place where people didn’t feel like they could leave their rooms,” says Liz. “It needed areas people could drift into.”

So, getting the brief right was crucial. Liz reckons that getting staff, patients and families involved and working collaboratively with the architects helped make sure that the building balanced their various needs.

“We literally had a pencil and a rubber, taking down as many internal walls as possible,” says Liz. “For all its faults, one thing people loved about the old hospice was its homely central reception area.”

That was translated into a huge reception area, engulfed by natural light, the size of which hits visitors and day patients as soon as they walk through the doors. Just off it is a fancy coffee shop that acts as a bit of a central hub, where patients, families, staff and volunteers can mingle and enjoy a nice latte together.

Feelings of isolation can be a big issue for people at the end of life. Single en-suite bedrooms can exacerbate the problem, especially if people are too ill to get out of bed and move around. On the other hand, single bedrooms give patients privacy and help protect their dignity. It can be tricky to achieve the right balance.

A cramped single bedroom in Marie Curie’s old West Midlands hospice.
A cramped single bedroom in Marie Curie’s old West Midlands hospice

Refusing to compromise, ‘sociability’ was designed into patient bedrooms. Yes, they’re open plan, with social seating areas to give visitors a space to hang out. But they also feature an internal window with remote controlled blinds — so patients can open up the world of the hospice outside their room whenever they choose.

Connection. It strikes me whilst in talking Liz that a big part of getting hospice design right is about making people feel connected — whether to nature, people, or the wider world. And that’s supported by some of the anecdotes I hear about in-patients gathering near the entrances. People want to see all the activity, the hustle and bustle, the goings on. They want to feel connected. And, just possibly, like they have some control over things — at a time when so much can feel uncontrollable.

Buildings for everyone

When I ask her how you go about designing buildings for people at the end the end of life, her answer surprises me at first — but makes sense when you think about it. In a way, she says, it’s about not thinking of people living with terminal illness as different and completely unlike the rest of us.

“It’s about designing places that are nice for people to be in regardless of what they’re going through,” says Mura. “Having somewhere you’re comfortable is obviously really important. But it’s important all of us, you know? Regardless of your age or what your health is like.”

“People sometimes think there’s some kind of secret approach, but there really isn’t,” she says. “Really, people like the same things: to see outside, to see daylight — to see a bit of sunshine.”

So, how do you design buildings for people at the end of life? The trick, Mura says smiling, is not to.

Find out more about how Marie Curie hospices offer care and support at the end of life.



Tags: palliative care Marie Curie end of life planning

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