Providing a serene, comfortable environment where the terminally ill can spend their final days, hospice is a slowly but steadily growing market sector.

Originally integrated into hospitals, hospice care began breaking out into standalone facilities in the early 1990s. They started out small with just a handful of beds, but once industry pioneers figured out that it would take an average of 7 beds running at an 85 percent occupancy rate to break even, facility size slowly increased.

With an average of 83.4 percent of patients in hospice and palliative care centers over the age of 65 combined with the massive baby boomer population moving into this age group, the market is likely to swell.

“Now we hardly ever build a facility that’s less than 12 beds and have completed a couple that are in the 32- and 48-bed range,” reports Tom Mullinax, president, Hospice Design Resource (Bent Mountain, Va.), who’s designed dozens of hospice facilities all across the country.

Although the majority of terminally ill patients receive hospice care in their own homes in the U.S. (around 1.5 million), the percentage of those utilizing hospice care facilities is gradually increasing. According to market research firm IBIS World (New York), there were 4,264 U.S. hospice centers in 2005; that number has more than doubled, standing at 8,802 today.

The comfort of home
With new standalone facilities no longer restricted by design guidelines for acute care spaces, hospice design has evolved into a mix of hospitality and residential styles with plenty of room and amenities for both patients and their families.

Granted, hospice still requires medical resources like patient beds, gas hook-ups, and nurse call systems; however, creative strategies can mask an institutional look, when possible. For example, moveable artwork or casework can conceal medical gases, and beds with moveable foot ends can enhance patient comfort and mobility and enable loved ones to sit at the foot of the bed, explains Kelley Hoffman, project manager/senior designer, Spellman Brady & Co. (St. Louis).

Likewise, Mullinax says he frequently replaces nurses' stations with standalone desks that are visible to the public, while the medical staff is based in an out-of-sight workroom. At the same time, nurses must keep patients within sight, but this can be accomplished through view windows, which also enhances patient privacy and interruption by limiting the need for staff to enter the room.

“Designing a hospice room is a sacred assignment,” explains Douglas W. Whitney, president, WBRC Architects and Engineers (Lakewood Ranch, Fla.). “A hospice room is not only a place to keep a terminal patient comfortable, it's also a place where patients and their families will visit, reminisce, comfort each other, and, ultimately, say goodbye.”

“Today, there's less focus on the clinical aspects of hospice care and greater understanding of the need to create a peaceful, nurturing environment for patients and families,” adds Whitney’s colleague Richard Borrelli, healthcare studio director, WBRC (Portland, Maine). “This trend is encouraging small, well-appointed centers that focus on living, not the ending of living.”

In order to execute this approach, today’s hospice facilities feature private outdoor patios, walking trails, pianos, fireplaces, dining rooms, lounges, and personal shelving space for pictures, cards, and flowers.

“Some plans go as far as designing patient rooms with direct access to a courtyard, allowing the bed to be rolled outside should the patient wish to do so,” Hoffman says.

Soft, indirect lighting is common, along with natural materials such as stone and wood paneling, casework, and trim. Ceilings are sometimes higher, or even vaulted, in smaller, one-story facilities, with ceiling fans and operable windows adding to the residential feel, explains Jeni Wright, principal, Kahler Slater (Madison, Wis.).

Mullinax says that while the use of carpeting or wood flooring can further enhance the feeling of home, maintenance issues have made faux-wood vinyl with a foam backing a more common choice.

In terms of the building’s exterior, more and more designs are mimicking the architectural form of a residence with design features such as sloped roof lines. “Most of the designs we've seen use Craftsman-style elements such as long eave and soffit overhangs supported by ornamental knee bracing,” says Kevin Kitchens, project manager, Perkins & Williamson Architecture (Hattiesburg, Miss.). “Tapered columns are often featured in these designs along with materials such as stone, brick, and lap/shingle siding.”

For the family
Family needs are a high priority in hospice. As such, a pull-out bed in patient rooms, where at least one family member can spend the night, has practically become a design standard. For example, at Agrace HospiceCare’s new inpatient hospice facility in Janesville, Wis., Kahler Slater designed a small, discrete area within each patient room that can be used as a living room by day, and a family sleeping area at night.

“Access to an Internet connection, refreshments, and meal preparation areas are now three must-haves that weren’t necessarily incorporated just a few years ago,” WBRC’s Whitney says. Additional in-room amenities include ample furniture, space for family members’ personal belongings, shower access, laundry facilities, in-room refrigerators, microwaves, a coffee pot, and sometimes even a second TV set with pillow speakers.

“Unlike a hospital room where the patient moves as quickly as possible, a hospice room offers encouragement to spread out and to linger,” says Ila Burdette, principal, Make3 Architecture (Atlanta).

Outside of the patient room, other building features can be added to enhance the family’s experience, such as exercise rooms, a library, sunrooms, meditation areas, private alcoves, and comfortable family room and living room-type seating. “We're seeing the use of more and more therapy areas, mostly manned by volunteers, that could be used for hair care, massage, or acupuncture,” Mullinax says.

Although much attention is centered on the family’s privacy, facility designs also aim to create spaces, such as a larger dining area, where people will naturally cross paths. “This serves as a ‘melting pot,’ allowing families to come close and share counter space, providing a launching pad for conversation and friendships,” Mullinax says.

Hospice care also needs to meet the needs of visiting children and teenagers, who are likely to become bored or restless after spending extended periods of time in the building. Experimenting with different solutions, Mullinax has found children’s playrooms to be quite effective. For example, his team designed one for a hospice facility in Bloomington, Ind., with access through a 4-foot-high door so that the children would feel like it was “their” space.

As for the teenagers, Mullinax says spaces with access to computers and recliners with attached DVD players and headphones have been the most successful. “This gives them a place to go off by themselves, do homework or watch a movie, and not be a distracted by the serious activities that are constantly going on in these facilities,” he says.

Dealing with
the inevitable

An inherent function of hospice facilities is to care for patients until death and after, requiring careful planning for on-stage/off-stage areas to transport deceased patients discreetly. This can be challenging in smaller facilities, but it is possible. For example, in designing the OSF Richard L. Owens Hospice Home in Peoria, Ill., Spellman Brady added extra exits to each residential wing in order to provide back-of-house egress paths.

In other cases, facilities can transport deceased patients through the chapel, through staff support areas, or through an exterior door directly connected to a patient’s room.

“However, many hospices embrace the celebration of the lives of their patients by providing a quiet processional ceremony that moves the deceased patient and their family through a front door or a secondary door into a garden space,” Wright says. “The philosophy here is that patients should leave the facility with the same respect and dignity in which they entered.” Ultimately, this is a very sensitive decision made by individual facilities, and designers can ease the process by providing end users with a range of egress options.

For the staff
As much as hospice is all about patients and their families, another core group that must be considered is the staff that runs these facilities. Providing care to the terminally ill is difficult, and staff members will often develop personal relationships with their patients and families. As a result, Whitney says, they may endure quite an emotional hit from the continued loss of their charges. “Space to escape from the stress and have a private conversation is critical to maintain emotional equilibrium,” she explains.

This might be provided through a private, back-of-the-house area; a staff lounge; or an outdoor patio/garden area. “We’ve started recommending small exercise rooms where staff can get on a treadmill and work out some of their emotions,” Mullinax says.

Burdette has also received requests to create staff areas where both the inpatient caregivers and home care staff can interact and help reinforce a sense of shared mission.

Key role
Although hospice centers are relatively small in scale compared to other healthcare projects, they're considered an important piece in the full continuum of care.

As a result, a continued growth and prioritization of hospice care is expected for years to come. While the proportion of over-65 seniors, as compared to the U.S. population, is projected to grow at an annualized rate of 3.1 percent over the next five years, IBIS World projects that the number of hospice establishments will hit 9,440 by the year 2019.

Barbara Horwitz-Bennett is a contributing editor for Healthcare Design. She can be reached at