Hospital environments are typically not well prepared to deal with death. When it has been established that a severely ill person will no longer benefit from major medical interventions, palliative end-of-life care may be proposed. Along with this shift in treatment, it may also be appropriate to shift to a physical environment that is sensitive to the circumstances of the patient's suffering and respectful of the patient's impending transition away from the clinical setting.

Such an environment has been created at the Palliative Care Center at the Georg-August University Hospital in Göttingen, Germany. This ward, designed by Michael Timm of the Göttingen office of bmp Architekten, opened in January 2007. Its design is making a significant contribution to the discussion about what the architecture of palliative care units (perhaps even healthcare architecture) should be.

As is true for all palliative centers that have opened in many German hospitals since the mid-1980s, patients on this ward are extremely ill, often close to death, and typically suffering from extreme physical pain often due to cancer in advanced stages. The goal of palliative medicine is to reduce human suffering and to stabilize and possibly improve the quality of life for patients and their relatives during the last weeks and days of life. Pain reduction and symptom control are achieved through a holistic care model that includes medical, psychological, social, and spiritual dimensions.

Can architecture assist in achieving these important objectives? It would appear that at the Palliative Care Center in Göttingen, the answer is a resounding yes. Soothing the psyche, coming to terms with death, assuaging the fear of pain, reducing the horror of not being able to take the next breath, mending strained family relationships, and other positive outcomes are possible through design of the environment.

Guided by this vision, the ward's psychologist, a team of nurses and several consultants (most notably a color physiologist) worked closely with the architect to make sure that the architecture supported the care model. Together they created an architectural environment in which seriously ill patients are immersed in a variety of beautiful multisensory and calming atmospheres that allow them to perceive life as worth living for the remaining days and weeks of their lives (figure 1).

Thus, even before entering the ward, one wonders about one's whereabouts. The view of the hospital's institutional-appearing upper level faéade is hidden by trellised climbers. Taking its clue from the word pallium, which is Latin for coat, it seems as if the plants provide an evergreen protective cover for the palliative ward (figures 2 and 3). A noninstitutional, rose-colored marker tells the visitor that he or she is in the right place and invites entry into the gently lit foyer (figure 4).

Inside and out, materials and colors generate a sense of subtle warmth and create an ambiance offering a variety of activities and moods: outward views and inner reflection, stimulation and relaxation, calmness and movement, communication and silence, activity and withdrawal. The psychosocial and spiritual aspects of life are moved into the foreground, enhanced by the spatial organization of the ward and emphasized through innovative and thoughtful details. The Room of Sound and the Bathing Room were given particular attention in this regard, as was the psychically demanding work environment for the staff.

Given the location of the new ward on the remodeled ground floor of a typical 1970s multistory university hospital building, the architect had to work within the constraints of the existing structural system.

The ward provides both inpatient and outpatient care. The inpatient ward can accommodate up to 10 patients (eight in single rooms and two in a double room). The rooms are generously dimensioned and include an ensuite, barrier-free bathroom (figure 5). As in other realms of the ward, furnishings are carefully selected with regard to materiality and color in order to support the patient's physical and psychological well-being. Careful detailing facilitates ease and comfort of use and assists the patient in his or her struggle to adapt to the change in life circumstance. For example, a ventilation window and exterior shades can be individually controlled by the patient.

All patient rooms face east, and each opens generously into an adjacent garden room formed by a steel trellis structure (figures 6 and 7). The rather exposed location of these decks and gardens next to a semipublic hospital access road less than six meters away is ameliorated by the climbing plants that have begun to grow on the trellises. Residential in scale and character, these garden rooms are connected by a wide deck which itself is protected from rain and wind by glazed vertical side panels and a glazed roof above. Exterior plants and water surfaces are illuminated at night, significantly enhancing the possibilities for use throughout the year and blocking the patient's view into black emptiness after dark (figure 8). Some of the built-in furnishings and couches were designed by the architect and fabricated in the hospital workshops.

Special attention was given to interior circulation realms. About half of the main hall is a single-loaded corridor, where the spaces between the structural supports have been purposefully developed into alcoves, allowing either for a temporary retreat from activity or for quiet conversation among members of a small group (figure 9). From here, too, there are views into an exterior green space, this one facing west and feeling like a private courtyard garden.

Located at the quiet end of the ward, the Room of Sound has special meaning for patients, friends and family, as well as staff. Purposefully avoiding the expressed character of a chapel, the space is nonetheless intended as “a world apart” and highly contemplative in nature (figure 10). A narrow band of light separates the acacia wood floor surface from the walls. The walls themselves are made of soft batik-dyed orange fabric and curve gently, in a way perhaps reminiscent of a womb. The suspended ceiling plane is made of jointless stretched film upon which moving clouds and the daylight spectrum of colors can be projected. Several flat loudspeakers hidden behind the wall fabric can create soothing soundscapes, further enhancing the wide range of positive moods. Curved glass panes offer views of a small meditative garden, where the gentle flow of spring water flows from a rock into simple reflective water basin. A small sculpture inside the window invites silent meditation (figure 11).

In the Bathing Room the focus is on feeling and seeing. Conveniently located roughly in the middle of the ward, this space distinguishes itself radically from any other institutional bathroom this author has ever seen before (figure 12). The rectangular volume of the space is softened by an inner curved wall which elegantly hides cabinets and a sink, while providing a glow of indirect lighting for the space. Reminiscent of a wellness spa rather than the ward of a hospital, the bath contains a tub that features water jets and small light sources incorporated into its inner lining, as well as a “rain shower” and infrared lights that offer additional warmth to the bather. On the wall across from the tub is a large-scale screen upon which a variety of soothing videos, typically of water or landscape scenes, can be projected.

To further enhance the experience of this bathing event, the ceiling is dotted with tiny, sparkling, star-like lights, the color of which can be adjusted to the patient's wishes. There is also a stereo to support the mood with appropriate music, as well as provisions for aromatherapy to compensate for the smell of necrotic flesh. Feeling via the skin, for example the flow of water on one's body, is not only a joyful and relaxing sense perception, but a sensation that can be experienced up until the very end.

After visiting the palliative care center at the university hospital in Göttingen, there is only one question left: if it is possible to do so much architecturally to offer a mood of nurturing support here, then why can it not be done in other settings for persons at the end-of-life, and even on other hospital wards? HD

Acknowledgements

The author wishes to thank Dirk Eggebrecht, Dipl. Psych., staff member of the Palliative Care Unit at Universitatsmedizin Göttingen, and Michael Timm, Dipl.Ing., of bmp architekten, both of whom gave generously of their time to share insights into patient and staff needs, as well as considerations about the design of this facility.

Susanne Siepl-Coates is Professor of Architecture at Kansas State University.

For further information, e-mail scoates@ksu.edu.

Suggested Reading

  1. bmp Architekten. Palliativzentrum Universitátsklinikum Göttingen. Brochure on the occasion of the “2007 Tag der Architektur, Niedersachsen.”

Healthcare Design 2009 October;9(10):30-37