Hospice design essentials from Rick Rowbotham, landscape architect at St Wilfrid’s Hospice.

Macmillan Cancer Care, Hereford. © Fira Landscape Architects

Jane Findlay responds to some of the issues raised in the Modern Hospice Design book and looks at what they mean for landscape practitioners.

Death is an unusual topic of conversation for a landscape architect. We usually discuss the benefits of landscape for improving our health and wellbeing. The way we design our urban and rural landscapes to promote a healthy population and even the design of hospitals, where the landscape can aid the healing process, is a concept pioneered by Professor Roger Ulrich. But while death is something that we don’t talk about much publicly, or perhaps think about on a day-to-day level, it’s a feature in all of our lives.

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

How do we make sure the place where we do die is the best it can be for supporting a ‘good death’?

Answering that question is Ken Worpole in his book Modern Hospice Design: The Architecture of Palliative and Social Care, in which he assesses the needs of people living with a terminal illness and looks at the places that support them, both today and in the past. He advocates care settings that, in the words of Maggie Keswick Jencks, ‘rise to the occasion’.

Historically, humans used to place a great deal of importance on death and the rituals associated with it. However, in contemporary society there has been a distinct shift. Instead of embracing it as a natural part of life, there is a tendency to conceal and distance death within unremarkable, sterile institutions. A hundred years ago, we were likely to die of infectious diseases like pneumonia; ill health would be short. We tended to die at home, in our own beds, looked after by family. The 20th century saw a revolution in healthcare. We developed new medicines like penicillin to treat infectious diseases, for example, and new medical technologies were invented. Because they were so big and expensive, they were housed in large, centralised buildings, shaping our modern hospitals. Post-war universal healthcare systems, like the NHS, allowed everyone easy access to the treatment they needed. The result was that lifespans extended from about 45 at the start of the century to almost double that today.

We now overwhelmingly die of degenerative diseases, like cancer and heart disease. It means that people tend to have a long period of chronic illness at the end of their lives in which they will spend a significant amount of time in hospitals, hospices, and care homes. These buildings are widely regarded as being awful places to be, not just because people are there for a negative reason, but also because the buildings and their surroundings tend to be institutional and often uninspiring, with miles of long corridors, no natural daylight, and a feeling of loss of control for the patient.

Dying well, or what constitutes a ‘good’ death will mean different things to us all. Most people express a wish to die at home, but often care for the chronically ill can be too complex for families. Can we make the end of life as meaningful and enriching as the beginning, not just for the patient but for families too? Worpole suggests that a careful blend between a homely and supportive environment with architectural and landscape interest that is imaginative and bespoke can be achieved in the new generation of supportive facilities, developed in response to the increasing anxieties about ageing by patients and their families. They are also an essential part of the care system to relieve the pressure on our hospitals.

Worpole uses the example of Maggie’s Cancer Care Centres as exemplar projects. Although not hospices, they are a hybrid of beautiful, imaginative and homely facilities with gardens and nature at their heart; to support the person and family during their most difficult time.

For decades my practice, Fira, has been designing healthcare environments, from large acute hospitals which are highly technical to small, homely hospice and care units. The concept that contact with nature can positively contribute to patient recovery is accepted by the medical profession and is essential for palliative care. By combining a consultative approach to form a detailed understanding of the needs of patients, staff, family and visitors, we place people at the heart of the project. The design brief, as Worpole states, is essential to a successful scheme.

The feedback and post-occupancy evaluation bears this out. We are continually surprised and moved by the letters of thanks from patients, families, and staff on our hospice and Macmillan Cancer Care projects.

They appreciate the care and attention to detail, such as access to beautiful gardens, the sounds of nature, the smells, uplifting colours, allowing choice at a time when there is little control over their medical needs.

The learnings from these small schemes continue to influence our approach to large healthcare projects, but they also influence the way we design healthy and beautiful places where people live, work, learn and play. Most importantly it raises the important question of how we design so that we might grow older in our own homes, within supportive communities.

Jane Findlay is past president of the Landscape Institute and founding director of Fira Landscape Architects.

Jane Findlay