"Palliative care and architecture: from hospital to people." Nils Degremont, architect, in European Journal of Palliative Care, vol 5 number 4, july / august 1998.
In 1987, the Paris welfare services launched a competition entitled "places where people die". It was while studying the result of this competition that I became aware of the changes taking place, both in the conception of hospitals, and in patient management, and I became passionate about the subject. Can an architect help improve patient management, particulary in the field of palliative care? This question, one that I had asked myself throughout my architecture studies, led to a degree project on the site of the Laennec Hospital, Paris, in september 1995.
Making palliative care units better places
Since the advent of palliative care, the importance of the environment in which it is provided has become apparent. These new units are special parts of the hospital by virtue of the many qualities they offer. In the centres, everything has evolved to deal with the distress of the patients and those around them. Palliative care has the potential to reform the whole hospital because it changes the traditional concept of a curative institution.
Bringing home and society to the palliative care unit
The knowledge acquired in palliative care units should be used by the hospital at the time of death, which in most cases takes palce outside the home. In our civilisation, a death outside the home can be likened to a death outside society - because, in a hospital environment and despite the existence of palliative care units, death is still something of which to be ashamed. Dying patients must therefore find an image of society and an idea of the home, which has now become inaccessible, in the place where they are accomodated.
The hospital has to make up for the lack of structural and sentimental warmth by recreating a homely feel. Of course, I am not referring to the everyday view of the home but to a hint of the basic elements of which it is composed. Physically enlarging the doorway, for example, preserves privacy while establishing a hierarchical relationship between the inside of the room and the inside of the hospital.
A room with a view
The ability to perceive the world outside the hospital is also vital and preferably two alternatives should be offered: a view of nature, such as a landscape, and another view of urban activity, of life going on. The problem with this perception of the outside world is that it conflicts with the act of dying, which society condemns as almost obscene and would prefer to hide. The superficial values extolled by our society are incompatible with dying, pain, distress and death.
Providing the missing link
If we respect the patient, it is impossible to put him or her into direct contact with a society which refuses to listen. This is why it appears important to transcend society and to bring it into the patient's world in a different way. Inside the palliative care unit, it is the voluntary workers, the family and the medical staff who represent society, an evolved society that is capable of moving closer to the patient.
In my opinion, a place inside the palliative care unit for walking and gathering, which would take on the function of an urban street, could provide the missing link between the patient and society. Recreating outside life by means of a 'street' or a succession of small 'squares' and having the patient's room communicate with it through a window or door, substantially improves life in the palliative care unit.
Creating a 'home'
The room, whether open or closed, assumes the status of a home, belonging to a particular individual. In it, the other people represent society and the internal 'street represents outside life. The room reflects the patient's individuality and provides privacy in his or her 'home'.
Looking ahead
As far as palliative care as palliative care unit planning is concerned, there is a quite large degre of similarity between the various projects carried out, which, on their own scale, offer the families and the carer space. The palliative care unit is a semi-cloistered environment, often shut off from the rest of the world, which in the long-term causes the emotional exhaustion or "burn out" suffered by palliative care workers. Faced with distress and death every day, the medical staff and voluntary workers have to relearn how to care for patients on a daily basis. However, this non-forward-looking relearning seems doomed to result in exhaustion and to become routine.
Research and education centres
A future orientated project that would mark out a vindicate the carer's work in a different way should be considered in palliative care units or hospitals. A clinical, ethical and rigorously even architectural or craft-based research and educational project can enhance the work of the medical staff in a lasting way. Transcending death with the objective of constantly improving care can give the medical staff and voluntary workers a feeling of success and translate directly into quality of care for the patients. For this, suitable research and educational centres are nacessary within the hospital. In terms of planning, this could take the form of lecture and conference rooms, and a library specializing in ethics, medecine and architecture.
Documentation facilities
Lastly, it seems that a documentation centre, like the one at St Christopher's Hospice in London, which would centralise all the architectural data on the places where people die, could provide accurate information on the current situation. Palliative care unit projects carried out abroad could be stored there in the form of drawings, photos, videos, and an Internet site, facilitating the exchange of architectural knowledge to potential future designers. Moreover, the lack of consideration given to design and to the furniture intended for hospital environments also shows the need for progress. Designers, creators and craftsmen must be able to work directly with the users of the places where people die and be given the workplaces to do so.
Conclusion
Finally, the question of time must be considered. Hospital buildings are changing, particulary as far as technology and high-technology services are concerned. From now on, the patient accomodation area should reflect the ways in which attitudes and society are evolving, in terms of care. Evidence of this evolution is provided in palliative care units by the inclusion of spare beds in rooms, as well as lounges and kitchens for the carers, but this often presents problems of implementation when it comes to renovating existing buildings. Part of the palliative care unit must be able to allow spatially for the unkown quantity that is the future, in order to be able to adapt to the new requirements of tomorrow's patients.
Nils Degremont, Architect, Paris, France. March 1998.
Acknowledgements: This study would not have been possible without the assistance of many people involved in palliative care in France and abroad, particulary Dr Henri Delbecque and the architect Robert Prost, whom I thank.
This study and the project of the author can be seen on this site