HISTORY

Indian context:
India, the land of cultures and different religions has its own history and stories. The
different languages and its religions define every individual from others yet they are
same when they come under certain situations where they had to accept the fact of
their lives.

The kumbh mela's in India still shows how people stick to their roots and their rituals.
They are known as the world's largest religious gathering space. People from
different corner of the world come to these places for their mental peace. Not only
Hindus, but also people from other religions come and spend their time for their
spiritual knowledge also known as PARA VIDHYA.

These activities, where a lot in olden days with many ashrams in India .The country
was known for the style in which people lived in olden days .The orders, and ashrams
that they stayed in, had everything that people needed. In olden days people used to
visit or even stay in ashrams to achieve certain motives in their life. Young kids
studied for a certain period of time in an ashram called as GURUKUL.

In the same way, people who were interested in sports and wars had a different
ashrams and people interested in dance and music learnt in NATYASHASTRA
ashram. Out of many other ashrams such as GRAHASTH ASHRAM,
BRAHMACHARI ASHRAM, AKHADADALI ASHRAM, etc.,
VANAPRASTH ASHRAM was one such ashram where people use to go in their
last days. These people were either old or suffering from some non-curable disease.
What is Vanaprastha?
Vanaprastha means ''retiring into a forest’’.

Vanaprastha is part of the ancient Indian concept

called Chaturashrama, which identified four
stages of a human life, with distinct differences
based on natural human needs and drives. The
first stage of life was Brahmacharya (bachelor
student) lasting through about 20 years of life, the
second stage was Grihastha (married
householder) and lasted for till 50 years of
age. Vanaprastha represented the third stage and typically marked with birth of
grandchildren, gradual transition of householder responsibilities to the next
generation, increasingly hermit-like lifestyle, and greater emphasis on community
services and spiritual pursuit. The Vanaprastha stage ultimately transitioned
into Sanyasa, a stage of complete renunciation and dedication to spiritual questions.

Nugteren states that Vanaprastha was, in practice, a metaphor and guideline. It

encouraged gradual transition of social responsibility, economic roles, personal
focus towards spirituality, from being center of the action to a more advisory
peripheral role, without actually requiring someone to move into a forest with or
without one's partner. While some literally gave up their property and possessions
to move into distant lands, most stayed with their families and communities but
assumed a transitioning role and gracefully accept an evolving role with
age. Dhavamony identifies Vanaprastha stage as one of the "detachment and
increasing seclusion" but usually serving as a counselor, peace-maker, judge, teacher
to young and advisor to the middle aged.

These ashrams are certainly not restricted to one type of religion but also can now
be used by any user groups of any religion and age or both. Not only in India, but
also other countries like the US, the UK etc. have such ashrams with other names.
These ashrams helped human beings of those ages to keep their spirits alive and
organized because originally Indian Yogis considered human life to have a span of
100 years and it was divided into 4 stages.

The first 25 years of age were spent in Bramhacharyashram, the next 25 to 50 years
of age in Grihasthashram, followed by 50 to 75 years of age
in Vanaprasthashram, where you start delegating and preparing yourself for further
journey and the final 75 to 100 years of age were enjoyed in Sanyasashram, where
you are not bound by your normal duties. Sanyasashram is the last stage after you
have completed the normal duties, when you are totally free because other people
have taken over and you start walking the path of spirituality.

What vanaprasthashram is in today’s context?

As the time changed, the way of living also changed. The Gurukuls were now
replaced with the modern schools and colleges. We as human beings have evolved
in every state of manner and so our way of living did.

We are now even more modernized and so well developed that the concept of going
to vanaprasthashram has vanished. Still the concept of vanaprasthashram is been
seen in a very different manner.

There are the places where people suffering from terminal illness like cancer,
tumors, etc. and people who are abandoned stay during their last stages of their lives
so that they can spend their last days in peace.

These spaces are now called as 'HOSPICE'.

VANAPRASTHASHRAM HOSPICE?

Hospice is a modern name for vanaprasthashram. During olden days people used to
go to vanaprasthashram when they almost completed their marital life or when they
were done with their happy life as they want spiritual peace during their last days.

In the modern world full of competition, we are all stressed and our life is filled with
complications and at the end the day all that one need is a peaceful life.

Hence people in their last days search for a peaceful and calm life. On the other hand
people suffering from few chronic disease and know that their life is going to end
soon search for a peaceful and happy life so that they can spend their last days in
peace hence we can easily say that in today's world the term hospice is related to the
olden word vanaprasthashram.
In short, hospice is a modernized name for vanaprasthashram in today's context.

What is the difference between both the terms?

Hospice has more contemporary design which contains modernized equipment’s and
materials. Unlike vanaprasthashram, hospice is designed.

History in worldwide context:-

 500 A.D -
- Community as a group responded because death often posed direct threat to
the entire community.
- In some cases, ill person would be excluded from the group and left to die
on their own.
- The places where these patients were kept were supposedly the first hospice.

 6th Century -
- Monasteries started to take in sick and those disabled or unable to support
themselves.
- Wealthy women and widows started working in these monasteries as their
first nurses.

 11th Century -
- When rise of crusading movement saw ill and incurable, they were permitted
into places dedicated to treatment by Crusaders.

 14th Century -
- The order of Knights Hospitaller of St. John of Jerusalem opened first
hospice in Rhodes, meant to provide refuge for travelers and care for ill
and dying.
 Middle Ages -
- Hospices flourished in the Middle Ages, but languished as religious orders
became dispersed.

 17th Century –
- France revived hospice by the Daughters of Charity of Saint Vincent de
Paul and until 1900, six hospices were formed and served.

 Mid-19th Century-

- The U.K - Attention was drawn with Lancet and the British Medical
Journal publishing articles, four more hospices were established in London by
1905

- Australia - Active hospice development, with notable hospices including

*Home for Incurables in Adelaide (1879)
*The Home of Peace (1902)
*The Anglican House of Peace for the Dying in Sydney (1907)

- Ireland- Early developers of hospice including Irish Religious Sisters of

Charity opened the Lady's Hospice in Harold's Cross at Dublin in 1879.

 In 1950’s –
- Cicely Saunders developed many of the foundational principles of modern
hospice care.
About Dame Cicely Mary Saunders

- Dame Cicely Mary Saunders (22 June 1918 -14 July'05), was an English
Anglican nurse, social worker, physician and writer, involved with many
International universities.

-She is best known for her role in the birth of the hospice movement, emphasizing
the importance of palliative care in modern medicine.

-Ms. Saunders introduced the idea of "total pain", which included physical,
emotional, social, and spiritual distress.

-In 1967, St Christopher's Hospice, the world's first purpose-built hospice, was
established.

-The hospice was founded on the principles of combining teaching and clinical
research, expert pain and symptom relief with holistic care to meet the physical,
social, psychological and spiritual needs of its patients and those of their family
and friends.

- It was a place where patients could garden, write, talk and get their hair done.
- Death marks the end of a transition phase – the time approaching death becomes
the transition period, where one is preparing for the transition.

- This time period, like incubation period, should be spent in a comfortable, caring
and dignified environment.
LITERATURE
STUDY
Hospice Care

Considered to be the model for quality and compassionate care for people facing a
life-limiting illness or injury. Hospice care involves a team-oriented approach to
expert medical care, pain management, and emotional and spiritual support
expressly tailored to the patient's needs and wishes. Support is provided to the
patient's loved ones as well. At the center of hospice and palliative care is the belief
that each of us has the right to die pain-free and with dignity, and that their families
will receive the necessary support to do so.

What is hospice care?

Hospice is specialized type of care for those facing a life-limiting illness, their
families and their caregivers.

 The word hospice is derived from Latin word 'hospitium' a place where a guest
receives hospitality.
 The words 'hospital' ,'hotel' & 'hostel' all derive from same Latin root, and
suggest places of comfort, support and care.
 Hospice care addresses the patient’s physical, emotional, social and spiritual
needs.
 Hospice care also helps the patient’s family caregivers.
 Hospice care takes place in the patient’s home or in a home-like setting.
 Hospice care concentrates on managing a patient’s pain and other symptoms so
that the patient may live as comfortable as possible and make the most of the
time that remains.

‘Hospice care believes the quality of life to be as important as length of life.’

PURPOSE

 To provide LTC (Long Term Care) facilities with an overview and guidelines for
partnering with Medicare-certified hospice to benefit terminally ill residents and
their families and review responsibilities of the facility as well as the hospice to
provide palliative care.
 The core issues of developing palliative care in Indian setting keeping in mind
the ethical, spiritual and legal issues.
OBJECTIVES

 To describe the proposed project and associated works together with the
requirements for carrying out the proposed development.
 To identify and describe the elements of the community and environment likely
to be affected by the proposed developments.
 To establish the baseline environmental and social scenario of the project site and
its surroundings.
 To identify and quantify emission sources and determine the significance of
impacts on sensitive receptors.
 To identify, predict and evaluate environmental and social impacts during the
construction and usage of the project in relation to the sensitive receptors.
 To develop an Environmental Management Plan that identifies the negative
impacts and develops mitigation measures so as to minimize pollution,
environmental disturbance and nuisance during construction and operations of
the development.
 To design and specify the monitoring and audit requirements necessary to ensure
the implementation and the effectiveness of the mitigation measures adopted.

Members of the Hospice Team

Challenges in providing hospice care
 providers must cooperate with each other

 providers must communicate with each other

 providers must establish and agree upon coordinated services

 providers must be responsive to the unique needs of the resident and his/her
desires

 providers must be both knowledgeable and attentive to the regulations of the

other

HOSPICE SERVICES

The hospice scope of care includes

 Skilled nursing
 Medical social services
 Personal care
 Spiritual care
 Volunteer support
 Physician services
BENEFITS OF HOSPICE
 By selecting hospice, resident has clearly asked that his/her care be focused
on palliation
 Added attention to pain management and other symptoms related to life-
ending illness
 One-on-one emotional support for the resident and the family
 May have financial relief due to hospice paying for medication ,supplies, and
equipment related to terminal illness
 Volunteers visit residents and provide interaction with the resident and/or
family.

General criteria for hospice eligibility, the patient must be

 Diagnosed with a terminal or life ending illness
 Have a life expectancy of 6-8 months or less as determined by the physician
and the hospice interdisciplinary team
 seeking palliative (pain and symptom relief) rather than curative treatment
 patient, family and physician must understand that artificial life-prolonging
procedures are not consistent with hospice care
 Admission to hospice services is approved by the attending physician and the
hospice medical director
Current guidelines for the eligibility in hospice
 Lung disease
 Heart disease
 Kidney failure
 HIV
 Stroke and coma
 Dementia
 Liver failure
 ALS, Lung Cancer
 Prostate Cancer
 Breast Cancer
 Decline in health status

Core services that must be provided by hospice

 Physician services
 Nursing services
 Medical social services
 Spiritual counseling
 Bereavement counseling
 Dietary counseling
 Volunteering services
Core services

 Collaboration is essential for both providers.

 Hospice provides core services 24-hour/day, 7 days a week ,on call system
The interdisciplinary hospice team and its resources are available not only to the
patient and family but also to facility staff.

 Level of care for patients:-

1- Routine Home Care.

2- General Inpatient Care. (24 hour nurse for short-term stay)
3- Respite Care for Caregiver Stress.
4- Continuous Care (expanded level of skilled nursing)
Hospice and Palliative Care

Symptom Control

Informed System
consent Efficiency

Medication
Communication
Prioritization

Ethical Issues within the Hospice System

The core values of medical ethics:

(1) Autonomy- patient has the right to choose or refuse the treatment
(2) Beneficence- a doctor should act in the best interest of the patient
(3) Non-maleficence- first, do no harm
(4) Justice- it concerns the distribution of health resources equitably
(5) Dignity- the patient and the persons treating the patient have the right to dignity
(6) Truthfulness and honesty- the concept of informed consent and truth telling
The Western model of palliative care which has evolved around these values of
medical ethics may be at times difficult to adhere to looking at the current framework
of palliative care available in India.
Modern methods of pain control are available, accessible and effective. It is
estimated that less than 3% of India's cancer patients have access to adequate pain
relief. Improper pain relief leads to violation of the principle of beneficence.
In India, Narcotic Drugs and Psychotropic Substances Act regulates the medicinal
use of opioids such as morphine. To dispense morphine to patients the hospitals must
be registered with the government and adhere to a set procedure.
Thus, opioid accessibility continues to remain a constant problem for the providers
of palliative care in India. The ethical dilemma faced when analgesics are used is
that doses of analgesics sufficient to relieve some form of chronic pain might hasten
death.
The doctor is protected against litigation if acting in the best interest of the patient.
For the same purpose, the Indian Society of Critical Care Medicine has developed
directives to deal with such issues in India. The document essentially deals with
physician's attitude towards the severely ill patients in ICU.
It also refers to physician's objective and subjective assessment, honest and accurate
disclosure of prognosis, early option of palliative care in poor prognosis, ensure
consistency among the care giver team, It also gives a checklist as when to put the
patient on EOL care (i.e., withdrawal of life supports within the bounds of law.

Terminal Agitation
Terminal agitation often surprises many family members and caregivers alike. The
loved one who is usually calm, suddenly and unexpectedly becomes agitated and
restless. The patients near the end of a terminal illness may experience profound
mood changes. Therefore, terminal agitation is often accompanied by mood swings
or personality changes which leave caregivers feeling helpless and bewildered. The
sudden onset of behavior changes differentiates terminal agitation from the
personality changes of dementia which are usually gradual.

User Groups
With the time, the concept of olden design has changed to new ones with a better
space. Now the old vanaprasthashram is been replaced by hospices in this modern
times and so the type of people coming to this place has been changing. Unlike the
olden days, now even the young people and kids suffering from terminal illness and
many other serious problems, can now register themselves and stay there to spend
their last days of life.
Not only people suffering from serious illness, but also people who want to stay
away from the competitive world, and want to spend some time in peace and serenity
to gain spiritual knowledge and increase it, can also come and stay for few days.

It also contains spaces for the local people where people can come there during the
evenings after their office hours and spend some quality time, as it can turn out to be
a good recreational place for the city as well.

Hence the user groups coming to such spaces are

 older people with terminal illness
 older people with disabilities and left abandon
 younger people with such diseases
 local people looking out for recreational spaces

Related Behaviors
 Restlessness Verbalizations

Not able to rest, relax or be still  Singing/humming

 Confused speech
 Repetitive movement
 Calling out
 Constant moving or motion  Crying
 Inability to be still  Rhythmic
 Movement vocalizations
 Unable to rest
 Constantly changing positions
 Movement of limbs
 Increased movement
 Non-purposeful motor activity
 Hyperactivity
 Tossing and turning
 Busyness
 Climbing out of bed
 Grabbing people
 Head rolling
 Thrashing/flailing

Mental State Sleep Issues

 Hallucination
 Confusion Inability to sleep Impaired
 Incoherence sleep
 Paranoia Wakefulness/insomnia Sleep
 Disorientation disturbance
 Difficulty focusing
 Inability to concentration

Agitation Anxiety Distress

Extreme emotional State of uneasiness Anxiety or
disturbance and apprehension mental
suffering
Anger Nervousness Behaviours
listed under
both agitation
and anxiety
included here
Despair Tearfulness
Combativeness Tension
Irritability Fear
Striking out Anguish
Grimacing Furrowed brow
No eye contact
Wild eyed

It is important to eliminate other causes:

 Does the patient have an infection?

 Is pain under control?
 Is the patient having any psychosocial or emotional issues?
 When was the last bowel movement?
 Does the patient have a fever?
 Does the patient have any breathing difficulty?
 Is the patient’s bladder full?
 Has the patient received any new medication?
 Is anything physically interfering with the patient’s comfort (ex: wrinkled
sheets, room temperature)?
Spiritual Care Services
Spiritual pain has been defined as “pain caused by extinction of the being and
meaning of the self. Palliative care patients use spiritual and religious coping
methods naturally when other coping methods do not provide solace.
Talking about various religions, Hinduism, which is the main religion of India, it
sees death as a transition to another life by reincarnation, life in heaven with god or
absorption into Brahma (ultimate reality). There is a notion of good death, how to
die and a bad death is greatly feared. Good karma leads to good rebirth and bad
karma to bad rebirth. Suffering can be explained in terms of past karma.
In the Sanyasashram, people detach themselves from material and emotional
concerns and prepare for death through prayer, scripture reading and meditation. A
dying person can refuse medications to die with a clear and unclouded mind and
view pain as expurgating sin. There is a distinction between the willed death of a
spiritually advanced person and someone in pain wishing to end an intolerable life.
Suicide for a selfish reason is morally wrong and leads to hell. Hindu good death
provides a model for how death can be approached positively without apprehension.
Buddhism believes in after-life. The ultimate goal is to reach nirvana, freedom from
the cycle of suffering and rebirth. Taking medications that may alter one's state of
mind like narcotics is discouraged as they believe it can affect one's life transition
and rebirth.
Christianity believes that death is a consequence of sin and is temporary separation
of a body and a soul. Christian patients may view their illness and death as
punishment and may experience associated feelings of guilt. They believe that the
soul of deceased goes on to the after-life, ultimately to heaven or hell after being
judged by the Christ. Death anxiety is present as no one knows for sure whether
he/she will go to heaven. The dying person is prayed over, and the body is anointed
with holy oils, he confesses his/her sins and the priest absolves the person of any
guilt. The dying person receives a holy water representing the body and blood of
Christ. The ritual concludes with a prayer.
The Islamic religion, considers submission to suffering as a submission to god. It
affirms the use of narcotic analgesics for the management of severely pain in
terminally ill patients. However, the religion does not allow use of narcotics to
hasten death. Pain and symptom management has to be balanced against the patient's
ability to participate in prayers and rituals in the final moments of life.
In Jainism, there is a concept of self-willed death to obtain freedom by sacrificing
self. Assessment of spiritual needs involves attention to three factors: Sense of
meaning and purpose, means of forgiveness and source of love and relationship.
There is a concept of Mahaprasthana or Santhara seen as willful death.
However, assumptions or conclusions about spiritual needs on the basis of patient's
religious status should be suspended. Decisions about approach and treatment should
be taken on the basis of the actual customs, opinions, values and attitudes of the
individual patient, and not on the basis of a predetermined simplistic construction
Hospice recognizes that many human beings, and especially those at the end of life,
have a spiritual dimension that may need to be addressed. This may be true for those
who consider themselves to be religious as well as those who do not. At this time,
you may feel a need for someone to provide additional support.

This is the reason that a hospice should do this by exploring with people their unique
sources of faith and hope, helping them to recognize their own spiritual nature and
individual practice of faith, or by just being there.

Spiritual Care represents the concern for an individual as a whole person – a unity
of body, mind, and spirit. All individuals are unique and of value. It is our hope that,
through the Spiritual Care staff, the meaning of life’s journey can be understood and
interpreted. Spiritual Care is available without regard for gender, race, national
origin or religious affiliation, or previous enrolment in hospice.

Functionalities of a Hospice
  Contacts the patient and/or family member to discuss needs so that spiritual
care can be provided in a manner respectful of their faith.
 Provides a compassionate listening presence, allowing patients and families to
share feelings and concerns.
 Provides support for families in their grief process as they anticipate the loss
of their loved one.
 Contacts patient’s clergy at patient/family request.
 Helps provide religious practices and rituals including: prayer, scripture
reading, sacraments of baptism, worship, communion and anointing, plus other
spiritual resources as needs arise.
 Makes routine and emergency visits with patient and/ or family when they
desire support during loved one’s terminal illness.
 Provides consultation in ethical decision making
 Helps with mediation of stressful situations.
 Provides Spiritual Care in homes, long term care facilities, hospitals or
inpatient settings.

Tube Feeding

As the person get older or have health problems, they may not be able to swallow
normally or take in enough food or water. If they want food and water, they can
choose to receive them by tubes. This fact sheet can help them decide if they want
to try tube feeding. The time to make this choice is when they feel well and have the
facts they need. They can ask questions and talk with their doctor and others. They
can also think about what being alive means to them. Tube feeding may or may not
work for all. There may be side effects. The doctor who knows the patient best can
help them make their decision.

Tube feeding methods include:

• A tube put through their nose into the stomach (or)
• A tube put through the skin into the stomach.
Food and water are slowly and gently pumped through these tubes. Does a tube
feeding work? Tube feeding may or may not work for all.
Pet Peace of Mind
Pet Peace of Mind is a ground-breaking national program that allows hospice
patients to keep their pets at home with them throughout their end-of-life journey.
They do this by supplying in-home pet care, food, cat litter, routine veterinary care,
preventive medications, temporary boarding and assist with helping the patients find
a home for their pet when needed.

Memories & Music

M&M is a therapeutic use of music (not music therapy) for patients with early
Alzheimer’s disease or other forms of dementia. It is designed for patients where
music has been an important part of their lives and they are alert enough to enjoy.
Patients will listen to music with a volunteer on iPods with a customized playlist
based on input from them, or their family.

Relaxation Therapies

Guided imagery, yoga, breathing exercises and meditation are examples of

techniques that can be used with patients to facilitate relaxation and reduce stress,
pain and anxiety. These techniques also promote a sense of calm and a peaceful state
of mind. Simple, yet effective, many of these techniques can be learned by patients
and families for ongoing self-care.

Music Therapy
Music therapy is a recognized health profession proven to manage physical
symptoms, enhance mood and stimulate memory recall. The board certified music
therapist (MTBC) uses live music to provide pain management and offer emotional
support for patients while also supporting their families. Music therapy is a patient-
centered and non-invasive approach to end-of-life care.

Need of Hospice in India

India has one million new cancer cases every year. 75% of them are diagnosed at
the terminal stage, when it is too late to cure or even treat the patient. To make
matters worse ,there are very few cancer facilities in India and therefore little time
or space in over burden hospitals for the terminally ill .In plain words ,this means
that every year in India, tens of thousands of cancer patients die agonizing and
undignified death without medicine, help and support.

Among the 40 countries ranked, for end of life care services they provide to their
citizens, the UK was at the top of the chart followed by AUSTRALIA and NEW
ZEALAND. Sadly INDIA was at the bottom behind UGANDA.

"We have patients who have huge wounds or swellings. Some with oesophageal
cancer are fed through a tube, there are some who have little tissue left on their
faces. But we never think for a moment that euthanasia is an answer," said one of
the volunteers at the 100-bedded hospice.

Anaesthesiology at Gujarat Cancer and Research Institute (GCandRI), a Regional

Cancer Centre in Western India, is one of the important steps in the history of
palliative care development in India. It also began from here; forming of Indian
Association of Palliative Care (IAPC). In 1986, Professor D’Souza opened the
first hospice, Shanti Avedna Ashram, in Mumbai, Maharashtra, Central India. At
a similar time, pain clinics were established at the Regional Cancer Centre,
Trivandrum, Kerala, with the assistance of a WHO subsidy, and at Kidwai
Memorial Institute of Oncology, Bangalore, Karnataka. From the 1990’s onwards,
there was a significant increase in the momentum of development of hospice and
palliative care provision.

Less than 1% of India’s 1.3 billion population has access to palliative care. The
efforts by pioneers over the last quarter of a century have resulted in progress,
some of which may hold lessons for the rest of the developing world. In recent
years, a few of the major barriers have begun to be overcome. The South Indian
state of Kerala, which has 3% of India’s population, stands out in terms of
achieving coverage of palliative care. This has been achieved initially by non-
government charitable activity, which catalyzed the creation of a government
palliative care policy.

The nongovernment action, by involving the community, serves to strive for

quality of care as the government system improves coverage. On the national
 level, recent years saw several improvements, including the creation of a National
Program for Palliative Care (NPPC) by the government of India in 2012. The year
2014 saw the landmark action by the Indian Parliament, which amended India’s
infamous Narcotic Drugs and Psychotropic Substances Act, thus overcoming
many of the legal barriers to opioid access. Education of professionals and public
awareness are now seen to be the greatest needs for improving access to palliative
care in India.

Design Objectives

The following are the main design objectives for my design

 The Hospice can be divided into three parts

1) The first part is recreational space - This space consists of local people and people
in a better stage say in a starting stage. these spaces will mostly have open spaces
and activity spaces such as:

 gathering spaces
 sitting area
 informal spaces
 halls
 meditation rooms
 open spaces for meditation
 open air theatre

2) In the second part of the design, the space will consist of the informal activity
spaces which will act as a bridge between the 1st and the 3rd part it allows the
minimum local crowd to enter and contains most of the informal spaces.

3) The third part will contain the major part of hospice where people during their end
days can stay live with their parents or stay in a community.

 Providing a barrier free environment for people coming

 Providing residential spaces which are connected to a small P.H.C so that patients
can be shifted for emergency checking.
 Taking consideration of the type of people coming in the space with different
orders and designing spaces which can help those people to overcome these
situations.

Even though certain open spaces should be designed to encourage a certain kind
of user group through designed ‘ownership’, the outdoor environment should cater
for a diverse community and their different accessibility and requirements. The
residential environment should be designed to foster and encourage independence.
Autonomy, independence, and usefulness are fostered by providing
personalization opportunities and control over the design.

Limitations
 Minimum structural details of the design will be given
 More focus in the design will be given on the ethical behavior of the people
coming the major focus of the design will be given for the spiritual care of the
people

Residential environment - both indoors and outdoors

Key factors influencing the design of outdoor residential environments for older
people include:
 Options/variety in types of spaces, their potential uses, location and degree
of shelter afforded
 Proximity to main circulation routes and to common activity spaces
 Contact with visual/aural pleasures of the natural world
 Opportunities for personalization and territorial expansion
 Security and freedom from intrusion and outsiders
 Location within hearing and sight of other tenants
 Accessibility to individual units and dwellings

Accommodations for terminally ill people

We also need to see that the rooms and the wash rooms designed are barrier free and
are provided with sufficient amount of oxygen to it for their health purposes We
being architects should take care of the people coming in the hospice and their
parents there are again people coming with their parents and also people coming
who were left abandon spaces can be designed in such a way that the people staying
in it should feel homely and safe at the same time proper medication and track can
be kept on their health on day to day bases.
 DATA
COLLECTION

Standards
Standards are very important for an architectural design specially for such kind of
spaces where all kind of people come majorly, elderly people. Hence it is important
to provide a barrier free design for people. For a barrier free standard first we need
to understand the type of people coming n their anthropometry.

Adequate space for persons using mobility devices

 Adequate space should be allocated for persons using mobility devices, e.g.
wheelchairs, crutches and walkers, as well as those walking with the
assistance of other persons
 The range of reach (forward and side; with or without obstruction) of a
person in a wheelchair should be taken into consideration
 Attention should be given to dimensions of wheelchairs used locally.
Standard size of wheel chair has been taken as 1050mm x 750mm (as per
ISI).
Range of Reach

Allow a space at least 350 mm deep and 700 mm high under a counter, stand, etc.

* A wheelchair user’s movement pivots around his or her shoulders. Therefore, the
range of reach is limited, approximately 630 mm for an adult male.
* While sitting in a wheelchair, the height of the eyes from the floor is about 1190
mm for an adult male.

Product Shelf Telephone Vending Machine Counter Door Handle Mirror

* A wheelchair has a footplate and leg rest attached in front of the seat. (The footplate
extends about 350 mm in front of the knee).

The footplate may prevent a wheelchair user from getting close enough to an object.

a) Manually operated equipment must be designed to be easily accessible from

a wheelchair.
 b) Make sure that the coin slots of vending machines etc. are located no higher
than 1200 mm.

Allow a space at least 350 mm deep and 700 mm high under a counter, stand, etc.

Semi-Ambulatory Disabilities

People with impaired walking, people who use walking aids such as crutches or
canes, who are amputees, and people who have chest ailments or heart disease fall
in this category. The people in this category include those who cannot walk without
a cane and those who have some trouble in their upper or lower limbs although they
can walk unassisted.

Design requirements

 Width of passage for crutch users (min. 900 mm)

 Finishes of floor surface with non-slip floor material.
 Installation of handrail to support the body weight at the critical places e.g.
staircase, toilet, ramp, passage with a change of level (800-850 mm).
 Extension of handrail on the flat landing at the top and bottom of the stairs
(300 mm).
 To prevent slipping off the cane or crutch from the side of the stairs or ramps
(20 mm high lip on the exposed edge).
Walks and Paths
 Walks should be smooth, hard level surface suitable for walking and
wheeling. Irregular surfaces as cobble stones, coarsely exposed aggregate
concrete, bricks etc. often cause bumpy rides.
 The minimum walk way width would be 1200 mm and for moderate two way
traffic it should be 1650 .mm - 1800 mm.
 Longitudinal walk gradient should be 3 to 5% (30 mm - 50 mm in 1 meter)
 When walks exceed 60 Meter in length it is desirable to provide rest area
adjacent to the walk at convenient intervals with space for bench seats. For
comfort the seat should be between 350 mm - 425 mm high but not over 450
mm.
 Texture change in walk ways adjacent to seating will be desirable for blind
persons.
 Avoid grates and manholes in walks. If grates cannot be avoided then bearing
bar should be perpendicular to the travel path and no opening between bearing
bars greater than 12 mm in width.
Levels and Grooves
(Passing over different levels and grooves)

Sidewalk width

 The casters on a wheelchair are about 180 mm in diameter. Therefore, a

wheelchair can only get over a small level difference.
 Use a method that can reduce the height of the level difference, in addition to
the methods shown here.

Difference in level Shape of level difference

 It can be difficult to move a wheelchair if a caster is caught in a groove.

a) It is desirable that there is no difference in level. (If a difference is

unavoidable, limit it to 20 mm or less.)
b) Round off or bevel the edge.

 To prevent a wheelchair from getting its casters caught in a drainage ditch or

other cover.

a) Install grating with narrow slots in the direction of movement.

b) Treat the grating with a non-slip finish.

 Reduce the gap between an elevator floor and the landing.

Side Walk
Note:

 Walkway should be constructed with a non-slip material & different from rest
of the area.
 The walkway should not cross vehicular traffic.
 The manhole, tree or any other obstructions in the walkway should be avoided.
 Guiding block at the starting of walkway & finishing of the walkway should
be provided.
 Guiding block can be of red chequered tile, smooth rubble finish, prima
regina, Naveen tiles or any other material with a different texture as compared
to the rest of the area.

Parking

 For parking of vehicles of handicapped people the following provisions shall

be made:
 Surface parking for two care spaces shall be provided near entrance for the
physically handicapped persons with maximum travel distance of 30 M from
building entrance.
 The width of parking bay shall be minimum 3.60 Meter.
 The information stating that the space is reserved for wheel chair users shall
be conspicuously displayed.
 Guiding floor materials shall be provided or a device which guides visually
impaired persons with audible signals or other devices which serves the same
purpose shall be provided.
Approaches to Plinth Level

Every building should have at least one entrance accessible to the handicapped and
shall be indicated by proper signage. This entrance shall be approached through a
ramp together with the stepped entry.

Ramped Approach

Ramp shall be finished with non-slip material to enter the building. Minimum width
or ramp shall be 1800 mm. with maximum gradient 1:12, length of ramp shall not
exceed 9.0 M having double handrail at a might of 800 and 900 mm on both sides
extending 300 mm. beyond top and bottom of the ramp. Minimum gap from the
adjacent wall to the hand rail shall be 50 mm.
Cross Section of Ramp

 When climbing a ramp in a wheelchair, the upper limbs must bear the burden
of propelling the body up the ramp.
 When descending a ramp in a wheelchair, especially on steep ramps, there is
a possibility of the wheelchair running out of control because the user must
manually control the speed.
 Prevent the installation of steep ramps.

a) Make sure the grade of a ramp is a moderate rise of 10 mm to each 120

mm of travel.
b) Provide a flat surface 1500 mm or more in length at the top and bottom of
the ramp for a wheelchair to pause and prevent it from going out of control.

Stepped Approach

For stepped approach size of tread shall not be less than 300 mm. and maximum
riser shall be 150 mm. Provision of 900 mm high hand rail on both sides of the
stepped approach similar to the ramped approach.
Detail of a Railing

Entrance Landing

Entrance landing shall be provided adjacent to ramp with the minimum dimension
1800 x 2000 mm. The entrance landing that adjoin the top end of a slope shall be
provided with floor materials to attract the attention of visually impaired persons
(limited to colored floor material whose color and brightness is conspicuously
different from that of the surrounding floor material or the material that emit
different sound to guide visually impaired persons hereinafter referred to as “guiding
floor material”. Finishes shall have a non-slip surface with a texture traversable by
a wheel chair. Curbs wherever provided should blend to a common level .

Corridor connecting the entrance/exit for the handicapped

The corridor connecting the entrance/exit for handicapped leading directly outdoors
to a place where information concerning the overall use of the specified building can
be provided to visually impaired persons either by a person or by signs, shall be
provided as follows:

a) ‘Guiding floor materials’ shall be provided or devices that emit sound to guide
visually impaired persons.
b) The minimum width shall be 1500 mm.
c) In case there is a difference of level slope ways shall be provided with a slope of
1:12.
d) Hand rails shall be provided for ramps/slope ways.
Required Width for Passage of Wheelchair

The wheelchair body itself is about 650 mm wide. Allowing for the use of hands and
arms outside the wheelchair, the passage must be as wide as 900 mm or more.

1) Locations such as entrances and exits can be 900 mm wide. However, a

continuous passage (e.g. a corridor) must at least be 900 mm wide to allow
for slight side-to-side movement of the wheelchair as it travels.
2) Corridors etc. must at least be 900 mm wide. At this width, however, it is
difficult to turn a wheelchair.

Required Width to Turn a Wheelchair

The diagram shows the space required to turn a wheelchair. The required width to
turn a wheelchair. Protruding objects, such as directional signs, tree branches, wires,
guy ropes, public telephone booths, benches and ornamental fixtures should be
installed with consideration of the range of a visually impaired person’s cane.

Exit/Entrance Door and window

Minimum clear opening of the entrance door shall be 900 mm. and it shall not be
provided with a step that obstructs the passage of a wheel chair user. Threshold shall
not be raised more than 12 mm.

 A window should have handles/controls at a height that permits use from

wheelchairs.
 A window should have an unobstructed viewing zone for wheelchair users.
 Curtain or Venetian blind controls/ropes should be accessible for wheelchair
users.
Lifts

Wherever lift is required as per bye-laws, provision of at least one lift shall be made
for the wheel chair user with the following cage dimensions of lift recommended for
passenger lift of 13 persons capacity by Indian Standards.

Clear internal depth: 1100 mm.

Clear internal width: 2000 mm.

Entrance door width: 900 mm.

a) A hand rail not less than 600 mm. long at 800-1000 mm. above floor level shall
be fixed adjacent to the control panel.
b) The lift lobby shall be of an inside measurement of 1800 x 1800 mm. or more.
c) The time of an automatically closing door should or minimum 5 seconds and the
closing speed should not exceed 0.25 M/ Sec.
d) The interior of the cage shall be provided with a device that audibly indicates the
floor the cage has reached and indicates that the door of the cage for entrance/exit
is either open or closed.
TOILETS

One special W.C. in a set of toilet shall be provided for the use of handicapped with
essential provision of wash basin near the entrance for the handicapped.

a) The minimum size shall be 1500 x 1750 mm.

b) Minimum clear opening of the door shall be 900 mm. and the door shall swing
out.
c) Suitable arrangement of vertical/horizontal handrails with 50 mm. clearance
from wall shall be made in the toilet.
d) The W.C. seat shall be 500 mm. from the floor.

Places to Install Guiding Blocks for Persons with Impaired Vision

Immediately in front of a location where there is a vehicular traffic. Immediately in

front of an entrance/exit to and from a staircase or multilevel crossing facility.

 Entrance/exit to and from public transportation terminals, or at boarding

areas.
 Sidewalk section of a guiding or approaching road to the building.
 Path from a public facility which is frequently visited by persons with
impaired vision (e.g. a city hall or library) to the nearest railroad station (to
 be installed at intervals) Other places where installation of a guiding block
for persons with impaired vision is considered effective (e.g. locations
abruptly changing in level or ramp).

Counters

To make a counter easily accessible for a wheel chair user, allow a space about
700mm high and 350mm deep under the counter.
Water Fountains (Drinking)

Allow sufficient space around the water fountain to make it easily accessible for
wheel chair users. Depending on the type of water fountain allow a space about 700
mm high and 350 mm deep under the fountain.

Telephones

Allow a space about 700 mm high and 350 mm deep under the telephone stand. The
telephone receiver must be placed at a height of 1 IO cm or less.

Mailboxes

The mail slot must be located at a height of 1200 mm or less.

Vending Machines

The coin slot must be located at a height of 1200 mm or less.

RESIDENTIAL BUILDING
KITCHEN

 Floor space should allow easy wheelchair movement between worktop, sink
and cooking stove.
 A 1500 mm min. width should be provided for wheelchair turns between
counter and opposite wall.
 Worktops, sinks, and cooking area should be at the same level at a height of
780 mm - 800 mm high from floor.
 A knee room of 700 mm high should be provided under the sink. Base cabinet
storage space with hinged doors and fixed or adjustable shelves should be
avoided.
 Base cabinets are most usable with drawers of various depths. Pullout vertical
units at one or both sides of the work centres are desirable.
 Maximum height of shelves over worktop is 1200 mm. A min. gap of 400
mm. should be provided between the edge of work top and top shelves. Side
reach for low shelf height should be 300 mm.
Living Room & Bed Room

At least 1500 mm turning in space for wheel chair should be kept near all entry
points to the living area.

 A living dining combination is preferable to a kitchen dining combination.

 A wheelchair requires at least 750 mm seating space at the dining table.
 Sleeping- living room combinations are not recommended. Bed rooms for
the wheelchair users need more floor area to provide wheelchair
circulation.
 The bedroom layout should be such that the bed should not be in a corner
of a wall. At least 900 mm should be provided for a wheelchair from the
side of the wall for access and there should be large enough space for
transfer by a wheelchair user, or for a helper to assist in the transfer.’
 The bed should be at a height from the ground that permits wheel chair
turning under the bed.
  A min. 900 mm width should be kept in front of bedroom closet and any
other furniture.
 Clothes hanger rod should be at a height between 1050 mm - 1200 mm.
The max. and min. height of shelf should be 1400 and 300 mm, and the
recommended zone is from 450 mm to 1200 mm.

BATHROOM
 The basin should be installed at a height and position for convenient access
by wheelchair users.
 The basin should have appropriate knee clearance and foot clearance space
for wheelchair users.
 Sufficient clear space for wheelchair users should be provided in front of the
basin. The mirror should be so installed as to permit its use by wheelchair
users.
 Shower cubicles should have seats whose width and height facilitate easy
transfer by wheelchair users.
 Shower cubicles should have grab rails at a height and position that allows for
easy gripping by wheelchair users.
 Shower cubicles should have call buttons or other signals devices at a
height and position easily reached in an emergency.
 Sufficient space should be provided beside shower cubicles for transfer
by wheelchair users.
 Shower doors, locks or catches should be of a type that can be opened
from the outside in an emergency.
 Shower doors should preferably be of a sliding or outward
opening type.
 These recommendations are relevant for communal bathing
facilities for low-income households.
 WC or toilet compartments should have enough floor space for wheelchair
users to enter and exit.
 The toilet bowl should be of a type (e.g. wall-hung) and in such a position as
to permit easy approach by wheelchair users.
 The seat of the toilet bowl should be at the correct height for wheelchair users.
 WC compartments should have support rails at a position and height suitable
for wheelchair users and other persons with physical disabilities. Upward-
folding support bars are recommended to allow lateral transfer from a
wheelchair.
 A toilet paper dispenser should be so installed as to be easily used by a person
with physical impairments sitting on the toilet.
 Fittings, such as soap dispenser, electric hand dryer and mirror, should be low
enough for a wheelchair user to use comfortably.
 The wash basin should be at a height that is easily accessible for wheelchair
users.
  Lever-type taps should be installed to wash basins.
 Floor finishes should be of non-slip material.
 Doors should be either of the sliding or outward-opening type.
 Locks to toilet doors or cubicles should be of a type that can be opened from
outside in case of emergency

HEALTH CARE CENTER

A hospice also requires a health care unit for the patient coming in and staying there
for any emergency and medical help.

Hence it is necessary to provide a good PHC (Primary Health Care unit) in the centre
to provide a good medication and for the people staying over there. A medical unit
must also be provided in the place where they stay.

National Rural Health Mission (NRHM) was launched to strengthen the Rural Public
Health System and has since met many hopes and expectations. The Mission seeks
to provide effective health care to the rural populace throughout the country with
special focus on the States and Union Territories (UTs), which have weak public
health indicators.

Infrastructure

The PHC should have a building of its own. The surroundings should be clean. The
details are as follows: PHC Building

Location

It should be centrally located in an easily accessible area. The area chosen should
have facilities for electricity, all weather road communication, adequate water
supply and telephone. At a place, where a PHC is already located, another health
centre/SC should not be established to avoid the wastage of human resources. PHC
should be away from garbage collection, cattle shed, water logging area, etc. PHC
shall have proper boundary wall and gate.

Area

It should be well planned with the entire necessary infrastructure. It should be well
lit and ventilated with as much use of natural light and ventilation as possible. Indian
Public Health Standards (IPHS) Guidelines for Primary Health Centers 13 The plinth
area would vary from 375 to 450 sq. meters depending on whether an OT facility is
opted for.

Sign-age
The building should have a prominent board displaying the name of the Centre in
the local language at the gate and on the building. PHC should have pictorial,
bilingual directional and layout sign-age of all the departments and public utilities
(toilets, drinking water). Prominent display boards in local language providing
information regarding the services available/user charges/fee and the timings of the
centre. Relevant IEC material shall be displayed at strategic locations. Citizen
charter including patient rights and responsibilities shall be displayed at OPD and
Entrance in local language.

Entrance with Barrier free access

Barrier free access environment for easy access to no ambulant (wheel-chair,

stretcher), semi-ambulant, visually disabled and elderly persons as per guidelines of
GOI. Ramp as per specification, Hand- railing, proper lightning etc. must be
provided in all health facilities and retrofitted in older one which lacks the same. The
doorway leading to the entrance should also have a ramp facilitating easy access for
old and physically challenged patients. Adequate number of wheel chairs, stretchers
etc. should also be provided.

Disaster Prevention

Measures should be taken for all new upcoming facilities in seismic 5 zone or other
disaster prone areas. Building and the internal structure should be made disaster
proof especially earthquake proof, flood proof and equipped with fire protection
measures. Earthquake proof measures - structural and non-structural should be built
in to withstand quake as per geographical/state govt. guidelines. Non-structural
features like fastening the shelves, almirahs, equipment etc. are even more essential
than structural changes in the buildings. Since it is likely to increase the cost
substantially, these measures may especially be taken on priority in known
earthquake prone areas. PHC should not be located in low lying area to prevent
flooding as far as possible.

Firefighting equipment
Fire extinguishers, sand buckets etc. should be available and maintained to be readily
available when needed. Staff should be trained in using firefighting equipment. All
PHCs should have Disaster Management Plan in line with the District Disaster
management Plan. All health staff should be trained and well conversant with
disaster prevention and management aspects. Surprise mock drills should be
conducted at regular intervals.

Waiting Area

a) This should have adequate space and seating arrangements for waiting
clients/patients as per patient load. The walls should carry posters imparting
health education.
b) Booklets/leaflets in local language may be provided in the waiting area for the
same purpose.
c) Toilets with adequate water supply separate for males and females should be
available. Waiting area should have adequate number of fans, coolers,
benches or chairs.
d) Safe Drinking water should be available in the patient’s waiting area. There
should be proper notice displaying departments of the centre, available
services, name of the doctors, users’ fee details and list of members of the
Rogi Kalyan Samiti/Hospital Management Committee. A locked
complaint/suggestion box should be provided and it should be ensured that
the complaints/suggestions are looked into at regular intervals and addressed.
The surroundings should be kept clean with no water logging and vector
breeding places in and around the centre.
DESKTOP CASE
STUDY
STUDY 1- North London Hospice / Allford Hall Monaghan Morris

Architects: Alford Hall Monaghan Morris

 Location: North London Hospice, 71 Chase Side, London N14 5BQ, UK

 Area: 8000.0 ft2

 Project Year: 2012

 Main Contractor: Pave hall PLC

 Structural Engineers: Elliott Wood Associates

 Services Engineers: Atelier Ten

 Landscape Architects: BBUK

For the architect, designed to be ‘a big version of someone’s house’ to install a

domestic sense of well-being, North London Hospice offers specialist palliative care
to patients with life-limiting illnesses. Set on a prominent corner in a quiet residential
area of north London, the massing
of this brick building is broken down
into two north facing gables with
circulation interleaved between.

A single-storey, multi-pitched
extension at the rear completes the
L-shaped plan and frames a south-
facing private courtyard for the
enjoyment of patients. Conceived
from both the inside-out and the
outside-in, the expansive windows
set around a simple palette of brick
and timber, ensure a series of light
and airy spaces that are well-connected both physically and visually with their
external environment.
CASE STUDY……………………………………SHANTI AVEDNA ASHRAM
LIVE CASE STUDY
CASE STUDY-1 …………………………………KARUNASHRAYA

KARNATAKA
Z