Palliative, hospice care design comforts patients, families
Trustee talking points
- Health care facilities' design and amenities meet patients' needs and lead to better care.
- Palliative and end-of-life care require spaces that feature holistic designs.
- Homelike elements can reduce stress and help patients cope with their symptoms.
- Such designs will continue to gain importance as palliative care spaces expand.
The physical health care environment is an important part of patient treatment, and it is a key factor in the success of palliative and end-of-life care. Facilities designed for people who are dealing with serious, long-term or terminal illness — in hospitals and off site — are leading the way in the creation of spaces that support patients, families and caregivers across the care continuum.
“Palliative care is patient- and family-centered care that is very holistic. Ideally, the holistic approach should influence our health care facility design,” says Martha L. Twaddle, M.D., senior vice president of medical excellence and innovation for JourneyCare in Barrington, Ill.
Putting the person first
The traditional biomedical model of care begins with a diagnosis, moves on to a treatment plan and only then considers the individual wants and needs of the patient, says Twaddle. Palliative care upends this model by focusing on the patient and family first.
“It looks at who the person is, what’s most important to them, how they make their health care decisions,” she says. “And then in the context of that: What is their illness, what do they know about it, how much do they want to know about it, and what do they want as far as their care?” Palliative care helps people to manage the symptoms of significant, life-altering conditions, along with the side effects of treatment and any related psychological, social or spiritual issues. Hospice is palliative care for people near the end of life. Its aim is the comfort of the patient rather than a cure.
Twaddle says there are certain things that should receive careful attention in the design of facilities for people with serious illness or near death. Healing spaces that are aesthetically designed to help patients and family members cope with the situation are “extremely important,” she says. So are privacy and places to talk with members of the care team. “It can’t be, God forbid, in the hallway,” she says.
Design features that mitigate symptoms and side effects are valuable to palliative care patients. “Whether the issues are cancer, heart disease or lung disease, people may have a lot of symptom burden. So we need spaces that augment our symptom control,” Twaddle explains. “One of the things, interestingly, that can help tremendously is windows.”
She points to architecture and health care design professor Roger Ulrich’s seminal research into the restorative effects of views on surgical patients. Windows also introduce natural light, which can help a person with delirium regulate his or her internal body clock and sleep/wake cycle. Large windows that reach close to the floor allow people in bed to see outdoors and have perspective, so they feel less confined. “It can really, really help with shortness of breath to have a perspective,” says Twaddle. Moving air is another remedy for shortness of breath, so windows that open are especially useful. “That can have a huge impact on symptom burden,” she says. “And watching its effect is really satisfying — turning a bed toward the window and having someone just go, ‘Ahh.’ ”
Reduced walking distances, easy wayfinding, organized clinical space and team work areas for caregivers are among the other design features health care professionals note as critical to delivering effective palliative care.
Homelike environments
Twaddle’s organization operates five inpatient hospice care centers in the Chicago area, all in Illinois. The eight-bed Arlington Heights center and seven-bed Woodstock center are in Northwest Community Hospital and Centegra Specialty Hospital, respectively.
These two centers, created from renovated hospital space, give patients who are unlikely to live to leave the hospital an environment that is quieter and affords more intensive care than a general medical-surgical unit. The Ada F. Addington Hospice CareCenter is a 13-bed unit on the fifth floor of Rush University Medical Center’s Johnston R. Bowman Health Center in Chicago and operates as a partnership between JourneyCare and Rush. The Pepper Family Hospice CareCenter, Barrington, and Marshak Family Hospice CareCenter, Glenview, are both freestanding facilities. Each JourneyCare location is designed to provide a homelike atmosphere for patients and families.
The Barrington facility has what Twaddle describes as a conventional hospice design, with 16 private patient rooms on one floor, each with an outdoor patio. The building affords views toward an adjacent marshland and wooded park.
The Glenview building is a three-floor tower design, with 16 private rooms on the third floor, each with a balcony. Being on an upper floor helps to create a sense of safety and privacy, Twaddle explains. It’s also comforting to those who would feel vulnerable if the doors to their rooms opened directly outside at ground level. Each room has a window that opens to allow fresh air and views.
In addition to patient rooms, the third floor houses a spa, with a hair-washing sink and spa tub. The first floor includes a meditation room, family rooms and other meeting rooms. Outside the building is a healing garden with moving water that can be heard from patient rooms — a more comforting sound than the usual beeps and buzzes of a hospital, Twaddle says. “It’s so interesting to me to watch the impact of this lovely space in Glenview on people and their families, the calming effect and ... how it helps with symptoms, just by its physical construction,” she says.
Charles Rizza, an associate partner in the Portland, Maine, office of E4H Architecture, says, “Architects have the unique opportunity through the built environment to create a place where many of the most nurturing attributes come together to support the patient and the family,” as demonstrated in the design for the Jack Byrne Center for Palliative and Hospice Care, scheduled to open in 2017 at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.
A great room with a fireplace, comfortable furnishings and lots of natural light will welcome people on entry to the facility. An eat-in kitchen designed much like that in a home will be visible to patients and family members as they arrive. “It offers an immediate sense of welcome,” says Rizza.
Other respite areas will include a sunroom, a playroom for young children, a teen lounge and an outdoor garden for patients, family and staff. Spaces for music, massage and art therapy — activities Rizza notes play a vital role in stress relief — also will be available, in addition to an exercise room and showers for family members and staff. The design contains a meditation and reflection room that will have two entrances, one from inside the building and the other from outside, so people can enter the building directly into the room for memorial services.
Each of the facility’s 12 private patient rooms is designed to have woodland views and features its own private, outdoor patio accessible even to bedridden patients. Two decentralized nurse stations will serve six rooms each, with a central work area for care teams to collaborate. A separate area will be dedicated to volunteer activities.
“The environment for palliative care is essential to making everyone caring for the patient feel as though they’re doing the best they can, with all available resources to support the work they’re doing,” says Rizza.
Stress reduction
Kevin Harney, senior design manager at archictecture firm ESa in Nashville, Tenn., notes that a patient who is dealing with a serious illness like cancer “is already experiencing a lot of uncertainty and stress.” Designing for palliative care is “creating an environment that begins to reduce those stressors,” he says.
The firm's AMITA Health Cancer Institute & Outpatient Center in Hinsdale, Ill., utilizes an easy wayfinding scheme that starts as people drive onto the campus and continues into the building itself. The interior design features a “Compass of Meaning” theme developed by the health system. A compass design is incorporated into the flooring of the main lobby to symbolize a patient's journey through the treatment process.
Windows bring daylight into the main lobby, exam rooms, infusion areas and even down into the control area and entrance to the linear accelerator vault. “Obviously, in the vault itself, you’ve got to maintain all the shielding requirements. But as the patient enters the radiation oncology treatment area, they enter through an area that is light-filled from a rooftop clerestory glass,” Harney explains. A garden surrounds the medical oncology area, providing all the infusion spaces with views of nature. Both private infusion rooms and a more communal, open treatment bay area look out over the garden, toward a nearby forest preserve.
The building was created to consolidate cancer care services in a central location to make it easier for patients to manage their care. In addition to lab, pharmacy, chemotherapy and radiation services, the facility includes a clinic that can be used for massage therapy or other alternative therapies for relieving cancer symptoms and the side effects of treatment.
In addition, there are a variety of spaces for patient consultations and caregiver collaboration, to support a holistic approach to care. Patients who come to the center for medical treatment also can meet with a nutritional specialist, for example, to talk about dietary changes to supplement their treatment, or a financial counseling specialist for help in navigating the insurance process. A technologically advanced conference room provides the space and tools for multidisciplinary care teams to work together to develop comprehensive, personalized treatment plans for patients.
Positive change
Twaddle sees an encouraging trend toward the development of facilities that focus on healing and comfort for all patients, including people with difficult medical conditions and those at the end of life.
“We’re not going to be able to cure everyone. But we will always be able to help care for people, and this can facilitate healing,” she says. “I feel like we’re changing, gradually. We’re changing how we create spaces for patients and families in such a very positive way.” T
Amy Eagle is a freelance writer based in Homewood, Ill.
Cancer centers set the bar in palliative care design
Increased survivorship among cancer patients in recent decades has put cancer care ahead of the curve in the design of spaces that support palliative care.
“In the 1970s, only about 49 percent of patients with cancer were living longer than five years,” says Marcia Gruber-Page, R.N., vice president of oncology services at Dignity Health Arizona in Phoenix. “Now, it’s nearly 70 percent of patients. So they want more from us. They want to know how to survive. They want to know how to thrive.”
Cancer care has moved beyond narrowly treating the disease to helping people manage their symptoms, the side effects of treatment and related concerns. “Nausea, vomiting, fatigue, peripheral neuropathy, sleep problems — those are typically what we see and what we treat now, both through education and then intervention,” Gruber-Page says.
As the care model has changed, facilities have progressed to support this type of care. At the University of Arizona Cancer Center at Dignity Health St. Joseph’s Hospital and Medical Center in Phoenix, exam rooms are designed to accommodate consultations with physicians, pain and symptom management professionals, social workers and other members of the care team.
“We spent a lot of time thinking about the design of the exam room, and really making sure it could facilitate a comfortable, positive environment to have a conversation, not just an exam,” says Janet Pangman, associate partner at ZGF Architects LLP in Los Angeles. The approximately 120-square-foot rooms are zoned with separate areas for prep/storage, exams and consultation, with furnishings and technology appropriate for each activity. There are additional consult rooms throughout the facility.
Gruber-Page says that because one of the most frequent and distressing symptoms experienced by cancer patients is fatigue, fatigue management and rehabilitation are important concerns at the center. Space for physical therapy and the treatment of lymphedema — a common side effect of lymph node removal — is one of the largest components of the building’s programming, she notes.
To help combat obesity, a risk factor for some recurring cancers, the facility includes an educational kitchen for cooking and nutrition classes. The kitchen is scaled like a home kitchen. It can be closed off with a movable partition for use in occupational therapy, to determine which exercises or assistive devices might help patients who have been physically compromised by cancer surgery or other treatments when it comes to navigating their own kitchen. In addition, the facility includes other supportive care areas such as a wellness center with space for services like reiki or massage therapy, as well as a healing garden that features native desert plantings.
ZGF was recognized for this project by the American Institute of Architects Academy of Architecture for Health with a 2016 National Healthcare Design award. Of the seven projects awarded the honor last year, three are cancer centers: the UACC facility; the Memorial Sloan Kettering Regional Ambulatory Cancer Center in West Harrison, N.Y.; and the Kaiser Permanente Kraemer Radiation Oncology Center in Anaheim, Calif.
Pangman says the supportive care and wellness features included in the UACC are becoming important in the design of all types of health facilities as comorbidities increase, care becomes more complex and population health management receives greater emphasis.
When it comes to palliative or supportive care, “I think cancer care has kind of set the bar for that, and other groups and organizations are really tapping into that and realizing how it applies more broadly than they imagined,” Pangman says. “Understanding the whole continuum of care — I can’t stress how important that is for us as architects.”