The Production of Hospice Space

Conceptualising the Space of Caring and Dying

Sarah McGann

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781317018933
• Topic: Architecture
• Subtopic: Architecture General

Challenging the widely held notion of a hospice as a building or a place, this book argues that it should instead be a philosophy of care. It proposes that the positive and negative impact that space can have in the pursuit of an ideal such as hospice care has previously been underestimated. Whether it be a purpose-built hospice, part of a hospital, a nursing home or within the home, a hospice is anchored by space and spatial practices, and these spatial practices are critical for a holistic approach to dying with dignity. Such spatial practices are understood as part of a broad architectural, social, conceptual and theoretical process. By linking health, social and architectural theory and establishing conceptual principles, this book defines 'hospice' as a philosophy that is underpinned by space and spatial practice. In putting forward the notion of 'hospice space', removed from the bounds of a specific building type, it suggests that hospice philosophy could and should be available within any setting of choice where the spatial practices support that philosophy, be it home, nursing home, hospice or 'hospice-friendly-hospitals'.

1
Situating the Problem of Hospice Space

My wallpaper and I are fighting a duel to the death. One or other of us has to go.

I open this book with Oscar Wilde’s famously misquoted last words. While perhaps these words are mere folklore, interpreting Wilde-style wit, the fact remains that they made famous by the implication that the space of dying matters.

The initial architectural brief to design St Francis Hospice, Dublin, in 1989, appeared to be a relatively simple task – design a small intimately-scaled building for people; people who happened to be dying. Initially, drawing on hospitality architecture, I set about positioning myself within the imagined building and asked myself how I would like the spaces to look and feel if I were dying in this new building?

That beginning was complicated, however, in the first design meeting with the clients, the Daughters of Charity, when they explained that ‘a hospice is a philosophy of care, not a building.’ The nuns later emphasised the point when they further explained that the downfall of the first firm of architects appointed to this project was that what they had designed was ‘just a building.’ Moreover, the range of requirements listed by the nuns presented a host of dilemmas: the desired accommodation potentially filled the entire site, but there was to be an emphasis on openness and garden space; the accommodation was to be homely, but the building was to be nothing like the size of a home; everything was to be of high quality, but there wasn’t any money (yet). I realised this was not going to be the simple task I initially thought it would be.

By the end of the building project, the influence of the clients, my growing knowledge of hospice care and the success of St Francis Hospice changed how I think and how I design as an architect. Throughout the lengthy design process the nuns’ initial statement stuck in my head, as I tried to design some thing more than ‘just a building.’ This book sets out, through social, architectural and theoretical methods, to investigate just what that statement might mean.

PLACE OF DEATH

The place of death is a significant detail in the summation of a person’s life, featuring in official death certificates, in funeral notices and in television news reports. The place of death, together with the circumstances and the state of mind of the dying, forms a contextual frame for the lasting memories bereaved relatives will have of a person and this picture will often stay with the family members for the duration of their own lives. This suggests how closely place, identity and memory are connected – where we are born, where we live and where we die form key descriptors of a person’s life.

Where we die has become a topic of current debate in contemporary western society. Surveys (such as Weafer 2004) suggest that the preferred place of death is now the home. It is interesting to note that despite the current preference to die at home it is not matched by the actual place of death, with the majority of deaths still occurring in hospital buildings. The place of death has constantly changed over time – from home to hospital, then later from hospital to hospice, and more recently from hospice to home again. In reality all three building types – hospital, hospice and home – continue today to accommodate death and dying, yet only the hospice is actually designed to envision that part of life, for, though, the hospital and the home both frequently accommodate death and dying, it is largely regarded as an unfortunate event, requiring rearrangement and compromise.

At the outset of this study I set out to question the meaning of hospice – is it a building that, as an architect, I was asked to design, or is it a philosophy, as my clients stated in our opening meeting? The central proposition is that hospice is a philosophy, a philosophy that is underpinned by space and spatial practices. The approach is to study the attributes of hospice design through the use of selected critical theorists and architectural analyses in order to establish conceptual principles for the production of ‘hospice space.’ The principles discovered in this way are proposed as ones that can be employed to analyse the design, or redesign, of hospice, hospital, home and, especially, nursing homes in order to enable death and dying to take place as a normal part of life. Thus, the principles of hospice space can be seen as underpinning the hospice philosophy.

OVERVIEW OF THE BOOK

The book is made up of six chapters that develop the notion of hospice space. The first three chapters discuss the various buildings that commonly accommodate death and dying in contemporary western culture – the hospital, the hospice and the home. In particular, the emergence of the modern hospice movement and allied building type is discussed against the problems associated with dying in hospital. The last three chapters investigate the attributes of successful hospice space. That investigation begins with a chapter in which St Francis Hospice forms a case study and the reflection on the conceptual design of that hospice provides key insights that lead to identifying three such attributes. Throughout, the chapters draw on illustrative materials (photographs, architectural drawing, theoretical diagrams) to develop and illustrate their points.

In particular, photographs, plans and diagrammatic illustrations of St Francis Hospice are presented sequentially throughout the work, not only to illustrate and develop particular points, but also to make the ideas more accessible outside the architectural profession. The images are not intended in any way to present the project as a stand-alone architectural review but rather contribute to the argument. The reader will also notice that epigraphs are used to start each section. The epigraphs demonstrate the trans-disciplinary nature of the topic and provide varied perspectives – from experiential and fictional to poetic and philosophical – on death, health, home and hospice.

Central to understanding the argument is an understanding of the hospice philosophy. A sense of this philosophy is captured by the words of Dame Cicely Saunders, who is considered to be the founder of what is described as the modern hospice movement, and who has published extensively, been widely written about and quoted over many years in relation to hospice care. In Hospice: The Living Idea Saunders (1981: 4) discusses the two meanings of philosophy as ‘all the knowledge belonging to a particular branch of learning’ and ‘the fundamentals that underlie branches of learning – ways of looking at things, how we do things but also why we do them.’ With regard to hospice philosophy, she explains: ‘in the hospice movement we continue to be concerned both with the sophisticated science of our treatments and with the art of our caring, bringing competence alongside compassion’ (Saunders 1981: 4). Saunders’s early approach was to question the way care for the dying was administered within the hospital system. In The Last Stages of Life, Saunders (1983: 5) says ‘the way to find a philosophy that gives confidence and permits a positive approach to death and dying is to look continually at the patients, not at their need but at their courage, not at their dependence but at their dignity.’ In essence, Saunders pioneered the idea of patient-centred care combined with a holistic and open approach to death and dying. However, despite the significance of her writings on the development of hospice movement, she did not consider fully how the philosophy she pioneered is underpinned by spatial practices.

Scope

This study is not intended as a scientific analyses set within environmental psychology realm, nor does it seek to replace existing design guidelines, which provide timely and much needed pragmatic information for architects and health practitioners alike. Of particular note is Innovations in Hospice Architecture by Stephen Verderber and Ben Refuerzo (2006). Also extremely valuable are the various design guidelines published by peak bodies such as the Irish Hospice Foundation. In addition, Ken Worpole’s Modern Hospice Design: The Architecture of Palliative Care (2009) contributes holistically to the architecture debate on hospice. Rather, this book proposes conceptual and theoretical principles for designing, or assessing, spaces where dying takes place, principles that can lead to a fuller understanding and deployment of the pragmatic detail of such guidelines. The study deals with the experience of dying (in hospices) as it occurs in western culture and, in particular, in Ireland and the United Kingdom.1 Additionally, the scope has precluded an analysis of nursing homes as a specific building type – a consideration of nursing homes as a space for the dying would form the basis of a valuable future research project.

Lastly, it is important to emphasise that the focus of the study is on is the failings of space and is not, in any way, a critique of nursing or medical care practices, for which I have the upmost respect and which are a source of a constant amazement despite the often-appalling settings.

Structure of the Argument

The book begins by telling the story of the hospice building – its background, its change over time and the conceptual design and realisation of one exemplar – and moves from there to develop the concept of hospice space through the interrelated analysis of buildings, drawings, guidelines and theory. The approach, situated within the architectural field, necessarily is multidisciplinary, drawing on literature from the fields of health and palliative care, geography, sociology, philosophy and architectural theory. It cites established seminal work, such as that of Cicely Saunders, Jay Appleton, Philippe Aries, Erving Goffman, Henri Lefebvre and Gaston Bachelard, along with recent architectural texts such as those by Stephen Verderber and Thomas A Markus, and it reflects on current guidelines and research in palliative healthcare design.

Chapter 2, ‘The Question of the Hospital,’ examines the transfer of death from the home to the hospital and the changing attitudes to death that emerged from the hospital institution. The premise, as proposed by Markus and Cameron (2002), that buildings are ‘answers’ to ‘questions’ asked in preceding architectural texts is used here as a paradigm to inform the analysis of hospital planning guides and resultant hospital buildings from the point of view of their dealings with death. The architectural instructions within the planning texts reached far beyond room arrangements and spatial adjacencies. Attitudes toward patients, toward health and, in particular, toward death were explicitly expressed both in words and in the space of the resultant buildings. The research is thus expanded to include the idea that buildings are also texts that embody cultural and social meanings.

This chapter proposes that hospital buildings and their implied mandate reinforce the notion of the hidden death and the view that death in hospital is perceived as a failure of medicine. It further proposes that the denial of death in the spaces of the hospital resulted in the alienation of the dying patient, with lack of privacy, total segregation, loss of personal autonomy and pervasive medical intervention emerging as central issues. The general dissatisfaction with the answer the hospital building provided to the question of death led to the development of the hospice movement.

Chapter 3, ‘The Question of the Hospice,’ focuses on the early hospice and on the development of the modern hospice movement. This chapter discusses the emergence of the purpose-built hospice as a new building type, and also how that building type has been challenged as the emphasis has shifted from place to care practices, and from hospice building to home hospice. The notion of the hospice as a homely place emerges as a key idea associated with hospice both as a place and as a philosophy of care. However, the societal emphasis on the idea of home as hospice and family as carer presents many complex spatial issues, in particular, the home often has to change so drastically to accommodate hospice care that it starts to feel more like a hospital. This creates a spatial paradox for both patient and family. According to Brown (2003: 833) there is a blurring of the public–private boundaries of the home hospice through four spatial paradoxes – ‘a normative paradox of home being a good and bad place to die, a territorial paradox of control itself changing the home, a constitutive paradox between heart and welfare politics, and a relational paradox between autonomy and dependency.’ The questioning of the spatial and emotional implications of home/hospice and family/carer leads to the need to examine the cultural and social meanings behind hospice space. Similarly, Milligan (2005: 2118) establishes a link between emotions, care and place and discusses how the emotional experience of caregiving is ‘intimately bound up with the place of care and the transitions in the place of care.’

The discussion of the early development of the hospice movement and hospice building argues that movement and buildings were a response to the question of death in the hospital, and explores the notion of the hospice as both philosophy and place. The argument of this chapter develops in two parallel directions: that hospice can be located in multiple settings – hospital, hospice, nursing home or home; and that the success of hospice care depends on an understanding of setting as a key factor in the care. Part of that argument is a discussion of the hospice in terms of the hospice building, the hospice community and the home-care hospice – what emerges from that discussion is the notion of hospice space. In separating the idea of hospice space from the hospice building, all settings – the hospital, the hospice, the nursing home and the home – can be imagined as suitable spaces for dying. Thus the chapter proposes that hospice space and spatial practices underpin hospice ideology and are ever more important as home, family and community change.

Chapter 4, ‘An Irish Hospice,’ employs a case-study method to isolate design ideas that relate to the notion of hospice space. A purpose-built hospice, whose design performance brief is specific to death and dying, is selected to demonstrate the link between palliative care and palliative architecture. The story of St Francis Hospice in Dublin is told from my first-hand knowledge as the architect of the first two of its three stages of building. The clients, the evolution of the brief and the design response are all fundamental characters in that story. The hospice brief is discussed in detail and demonstrated visually through the architectural drawings presented to the clients for approval. Brief and building form a link between the theory and practice of hospice care. The final outcome, or building, is demonstrated through photographs and reviews of the completed project. The analysis of the conceptual design helps establish conceptual themes and ideals that can then be applied to the notion of appropriated hospice space within any setting.

Thus this chapter discusses the conceptual principles underpinning a contemporary purpose-built hospice in Ireland. The discussion is divided into three main sections, with each exploring the project from the differing perspectives of place, purpose and proposition. The section on place focuses on Ireland’s familiarity with death and dying, a connection that enables the wide acceptance of the hospice philosophy within the community. The section on purpose explores the building brief from the point of view of its pragmatic needs and from the underlying meaning behind those needs. The analysis of the brief shows how the contemporary hospice has evolved into a complex hybrid building, symbolic of the holistic principles of hospice practice. The section on proposition interprets the combination of the place, purpose and philosophy of the hospice and conceptualises the hospice as an inside-out building. This conceptualisation is presented in conjunction with an analysis of the building brief, which considers the hospice as a building of parts: part home/part community centre, part hotel/part hospital and part home/part garden. In turn this reveals three major thematic pairs: privacy/community, front/back and prospect/refuge. The purpose of this chapter is to identify these recurring themes so that they can be used to propose principles for the conceptualisation of hospice space. These principles illustrate the importance of linking hospice space with hospice philosophy.

Chapter 5, ‘The Production of Hospice Space,’ further examines the conceptual themes from the case study through an array of spatial theories in order to develop principles that enable deeper understandings of hospice space. Henri Lefebvre’s theoretical framework provides the background theory and each element of his spatial triad is explored through a lens provided by the seminal work of other theorists – Erving Goffman, Jay Appleton and Irwin Altman. This chapter interprets the three dual themes, identified in the previous chapter – front/back, prospect/refuge, and privacy/community – through Lefevbre’s (1991) conceptual triad of perceived, conceived and lived space. Each dual theme is individually explored in terms of Lefebvre’s theoretical framework, elaborated through key theorists, and then tested against recent design guidelines for relevance to contemporary hospice practice.

Running in parallel to this exploration is a visual diagramming of each spatial attribute of hospice space. Each attribute is explored through diagramming the architectural drawings of the case study to provide a new framework to read the building as text. This framework supports and illustrates the proposal to establish the deeper understanding and principles of hospice space and its embodied meanings. The drawings, diagrams and photographs employ the case study as a background in order to elaborate the variable qualities of each element of the triad. This visual analysis provides different readings of hospice space illustrating the use of the principles in practice. By developing principles for the production of hospice space this study contests the notion that hospice is a philosophy and not a building or place, and proposes that hospice is a philosophy anchored by space and spatial practices.

Chapter 6, ‘The Unbounded Hospice,’ summarises the study, draws a range of conclusions, and reflects on them. The chapter discusses the implications of hospice philosophy in contemporary society and suggests critical areas for future consideration to enable a wider adoption of the concept of hospice space.

In concluding this chapter, I return to my clients and re-interpret their words. A hospice is not just a building; it is a philosophy enabled by a meaningful, thoughtful and enabling space. Hospice space has the power to inspire peace and calm, to make possible and frame forever the most intimate moments before a loved one dies. The understanding of the symbiotic relationship between philosophy and space is critical if hospice care is to be available in the multiple settings of hospice, hospital, nursing home and home.

NOTES

1 The original precedent studies visited prior to the design project were, at the time, limited to these countries and so this later study uses the same focus area.

2
The Question of the Hospital

[Q]uestions are considered more powerful moves than answers, because the question always constrains the answer … . In the domain of architecture, the ‘question’ is in the text(s) that preceded a building; the building is an ‘answer’ to that question. But since many people use buildings, whereas few read architectural briefs, we are usually in the position of judging the answer without really knowing what the question was. (Markus and Cameron 2002: 78)

Much architectural writing is centred on the notion that architecture is the embodiment of an idea and that ‘buildings or planned environments become statements’ (Hirst 1993: 53). Markus and Cameron claim that statements embodied by buildings are answers to questions asked within prior texts. So, while the texts that preceded past buildings may now be discar...

Table of contents

• Cover
• Half Title
• Dedication
• Title Page
• Copyright Page
• Table of Contents
• List of Figures
• Acknowledgements
• Introduction
• 1 Situating the Problem of Hospice Space
• 2 The Question of the Hospital
• 3 The Question of the Hospice
• 4 An Irish Hospice
• 5 The Production of Hospice Space
• 6 The Unbounded Hospice
• Bibliography
• Index