Evidence-Based Design Practices for the Palliative Care Environment

As human beings, we cannot always control the timing and severity of illnesses, but as healthcare designers, we do have some control over the environment in which chronically or terminally ill patients spend their days. Palliative care strives to make patients comfortable as they are receiving treatment for a severe illness. It is an important part of end-of-life or hospice care, but, as this New York Times article points out, palliative care can also play an integral role in speeding recovery and preventing chronic illness. As hospitals seek to avoid Affordable Care Act penalties for poor patient satisfaction, many expect the palliative care field to grow quickly. Even before the ACA, the number of palliative care programs among American hospitals with 50 or more beds increased by approximately 125% from 2000 to 2008. The number of people dying in such facilities is also rising; though 70-90% of people say that they would prefer to die at home, approximately 75% die in hospitals or nursing homes. More attention is being paid to the design of palliative care facilities, and a growing body of evidence is supporting the development of proven design strategies to address the four areas of pain experienced by severely ill patients- physical pain, psychological pain, social pain and spiritual pain.

Create a Homelike Space

When patients move into a palliative care facility, they surrender much of the control that they are used to in their homes and enter a medicalized environment that some perceive negatively. Changing this perception could require a shift in viewpoint for hospital administrators, staff and patients. As one essay points out, "The idea of a hospital being an honoured place with dying patients as honoured guests opens a new window into our daily reality of working in hospitals" (Donnelly, 2013). In hospitals and in independent palliative care facilities, even small changes- such as the location of the clock or a bedside lamp- can create a less institutional, more homelike environment that empowers patients, relieves stress and improves perceptions of care. Best practices to consider include:

  • Allow patients to control environmental factors such as the temperature of their room and the channels playing on their television.
  • Help patients to mimic homelike activities by including kitchens with spaces for families to prepare meals and eat together and sitting rooms or gardens for groups to gather.
  • Mitigate external noise with strategic layouts and noise absorptive finishes. Studies have shown that, while patients do not always enjoy environments that are "too quiet", they dislike noise disturbances outside of their room or family, such as other patients' televisions or staff conversations. The layout of nursing stations, staff lounges and other heavily trafficked spaces should be designed to concentrate noisy activity in specific areas.
  • Designers should consider that patients have an average of 5.7 objects with them near their bedside when they enter palliative facilities and provide space for keeping these mementos nearby.
  • Provide plenty of natural light and nature views. In interior corridors, feature artwork depicting natural scenes.

Above: Seating, desk and shelving space encourage the presence of family and friends, while high-quality finishes in the patient room and restroom create a less institutional, more-homelike environment.  (Flagler Hospital, St. Augustine, Fla.)

Balance Private and Social Spaces

There is no one formula for patient privacy in the palliative setting- different patients prefer different levels of privacy and social interaction. In one study, the majority of patients expressed a strong preference for multi-bed rooms while they were feeling well enough to interact, and single rooms when they were very ill or dying. In another study, the need for privacy was ranked much higher by family members than by patients themselves, indicating that families need space for confidential discussions and often want to be alone with their loved one. Additionally, studies highlight the importance of chapels and other spaces for private reflection, both for patients and for their families. Taken as a whole, research suggests a need for a mix of multi- and single-bedded rooms, as well as a mix of public lounges with other semi-private and private spaces.

Large windows provide patients with natural light and views at the Community Hospice of Northeast Florida’s Bailey Center. A small chapel offers patients, families and staff a space for quiet reflection.

Staff Support

As important as the physical environment is, staff behavior can make or break the palliative care experience. Providing an environment that supports staff needs will translate to better care for patients, as well as higher staff satisfaction and retention rates. In palliative care facilities, staff complaints often center on layout. Many report having to walk long distances and also express concerns about being able to adequately monitor patients, especially at night. Other worries include small patient rooms inefficient for clinical tasks, lack of family space, and lack of privacy for bereaved families. To alleviate concerns, designers should work with staff early in the planning process to develop a layout that minimizes staff footsteps and provides adequately sized patient, staff and family zones.

With these best practices, designers can create spaces that provide patients with comfort and dignity while still supporting state-of-the-art care. Doing so, they can become an important part of the team and professionals and caregivers that aims, as compassionately as possible, to ease the pain of severe and terminal illness.

Studies consulted:

2002-2010 American Hospital Association Annual Hospital Surveys for FY 2000 to 2008; and Data from the Center to Advance Palliative Care (CAPC) 2009 National Palliative Care Registry.

Brereton, L, Gardiner, C., Gott, M., Ingleton, C., Barnes, S. & Carroll, C. (2011). The hospital environment for end of life care of older adults and their families: An integrative review. Journal of Advanced Nursing. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2011.05900.x/abstract

Cordts, G.A. (2007). Palliative care in the care of patients with cancer. Johns Hopkins Bloomberg School of Public Health. Presentation accessed online on October 23, 2013.  http://ocw.jhsph.edu/courses/fundonc/PDFs/Lecture6.pdf

Donnelly, S. (2013). Patient dying in  hospital: An honored guest in an honoured place?. Q.J. Med, 106:697-700.

Rigby, J., Payne, S. & Froggatt, K. (2010). What evidence is there about the specific environmental needs of older people who are near the end of life and are cared for in hospices or similar institutions? A literature review. Palliative Medicine, 24(3):268-285. http://ocw.jhsph.edu/courses/fundonc/PDFs/Lecture6.pdf

Rowlands, J. (2008). How does the environment impact on the quality of life of advanced cancer patients? A qualitative study with implications for ward design. Palliative Medicine, 22:768-774.  http://pmj.sagepub.com/content/22/6/768.abstract


Comments (5)

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  • December 12, 2013 @ 1:38 PM

    Anita Ryan

    Good Article. Having experienced recently the loss of a loved one in a nursing facility I can see how the design and space makes a huge impact on their comfort in all those areas mentioned above. The design has such an important role in recovery or loss. It is amazing how fast they can go down hill once they are in a nursing home facility when it is not structured or designed for human desires only basic needs.

    • December 13, 2013 @ 2:56 PM

      Sheila Bosch

      I am very sorry for your loss. I whole heartedly agree with you. My own father passed away a couple of years ago peacefully at home, surrounded by his 3 adult children, in his favorite recliner. Although we mourn the loss, I know he was comfortable. I think we are only beginning to understand the relationships between the built environment and the well being of patients nearing the end of life, as well as their loved ones.

  • January 8, 2014 @ 12:44 PM

    Alice Gittler

    It is very encouraging to see discussions about palliative care emerging in the public arena and the medical and design communities. Starting a conversation with patients and family members about palliative care has been identified by some as a critical first step in providing this care - at the end of life, and at any stage of a disease. Likewise, the involvement of many different caregivers is a feature of palliative care. Have some good design practices for enhancing communications and collaboration emerged from your design research and practice in palliative care?

    • January 10, 2014 @ 9:52 AM

      Sheila Bosch

      Thank you for your comment! I certainly agree that communication and collaboration are critical to successful care at every level. With private patient rooms now being required, I believe the patient room is now a place where caregivers can comfortably discuss end-of-life issues with patients and their family members. But, I think we can do a better job of initiating those conversations. Some research has been done on the role of nursing unit design in increasing collaboration among caregivers. One study, published in the Health Environments Research & Design (HERD) Journal, found that multi-hub workspaces, with several opportunities for interaction throughout a given unit, increased nurse-doctor communication. Another option is to focus on providing staff workspaces that are “off-stage”, so that nurses and doctors can discuss cases without violating HIPAA, and to make those spaces both appealing and convenient. Additionally, we conducted a research study at Tampa General Hospital in partnership with Georgia Tech which found that family-centered design helped to increase communication between family members and patients, though we did not have conclusive results demonstrating a statistically significant increase in family-staff communication.

      I hope the coming years will bring much more research on this topic, as I believe it is a very important one. If you would like to look up the HERD study, I have copied the citation for you here:

      Hua, Y., Becker, F., Wurmser, T., Bliss-Holtz, J., & Hedges, C. Effects of nursing unit spatial layout on nursing team communication patterns, quality of care, and patient safety. Health Environments Research & Design Journal, 6(1), 8-38.

      • January 17, 2014 @ 10:16 PM

        Alice Gittler

        Thanks so much for the response and resource. I will definitely take a look. Designing a palliative care/internal medicine inpatient unit was the subject of a studio project I worked on while in the healthcare design program at NYSID. I am interested in continuing to build that knowledge and learning more about palliative care in various settings so I appreciate the suggestions.

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