Environmental Design For End of Life Care

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J Pain Symptom Manage. Author manuscript; available in PMC 2019 March 01.
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Published in final edited form as:

J Pain Symptom Manage. 2018 March ; 55(3): 1018–1034. doi:10.1016/j.jpainsymman.2017.09.011.
Environmental design for end-of-life care: An integrative review

on improving quality of life and managing symptoms for patients
in institutional settings
Rana Sagha Zadeh, PhD, MArch,
Assistant Professor, Design and Environmental Analysis, Cornell University, 1414 Martha Van
Rensselaer Hall, Ithaca, NY, U.S.A 14853-4401, Tel: 607-255-1946, Fax: 607.255-0305,
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rzadeh@cornell.edu
Paul Eshelman, B.S. M.F.A.,

Professor Emeritus, Design and Environmental Analysis, Cornell University, Ithaca, NY, U.S.A
Judith Setla, MD, MPH, FACP,

Associate Professor of Medicine, Voluntary Faculty, Dept of Medicine, SUNY Upstate Medical
University, Syracuse, NY, U.S.A, Medical Director, The Hospice of Central New York, Liverpool,
NY
Laura Kennedy, B.S.,

Design & Environmental Analysis, Cornell University, Portland, OR, U.S.A
Emily Hon, BS, and

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BS, MD Candidate, New York Medical College, Valhalla, NY, U.S.A
Aleksa Basara, BSc

B.A. Candidate, Department of Economics, Cornell University, Ithaca, NY, U.S.A
Abstract
Context—The environment in which end-of-life care is delivered can support or detract from the
physical, psychological, social, and spiritual needs of patients, their families, and their caretakers.
Objectives—This review aims to organize and analyze the existing evidence related to
environmental design factors that improve the quality of life and total well-being of people
involved in end-of-life care and to clarify directions for future research.
Method—This integrated literature review synthesized and summarized research evidence from
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the fields of medicine, environmental psychology, nursing, palliative care, architecture, interior
design, and evidence-based design.
Results—This synthesis analyzed 225 documents, including 9 systematic literature reviews, 40

integrative reviews, 3 randomized controlled trials, 118 empirical research studies, and 55
Correspondence to: Rana Sagha Zadeh.

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Zadeh et al. Page 2
anecdotal evidence. Of the documents, 192 were peer-reviewed, while 33 were not. The key
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environmental factors shown to affect end-of-life care were those that improved 1) social
interaction, 2) positive distractions, 3) privacy, 4) personalization and creation of a home-like
environment, and 5) the ambient environment. Possible design interventions relating to these
topics are discussed. Examples include improvement of visibility and line of sight, view of nature,
hidden medical equipment, and optimization of light and temperature.
Conclusions—Studies indicate several critical components of the physical environment that can
reduce total suffering and improve quality of life for end-of-life patients, their families, and their
caregivers. These factors should be considered when making design decisions for care facilities to
improve physical, psychological, social, and spiritual needs at end of life.
Keywords
end-of-life care; environmental design; interior design; architecture; palliative care; terminal
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illness; hospice
Introduction
Motivated by a desire to understand and better inform the design and operation of hospice
and end-of-life (EOL) care settings, we undertook this integrative literature review.
Palliation, although not specific to EOL care, was employed in this review as an umbrella
term because of the focus it places on relief of debilitating symptoms and suffering.
Access to palliative care, particularly for patients at the EOL, can been viewed ethically is a
global human right (1, 2). Patients who have reached EOL are often at their most vulnerable
state. As physical function declines and disease symptoms impact quality of life, these
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people, as well as their loved ones and care providers, can experience numerous symptoms
such as fatigue, anxiety, fear, anorexia, depression, anger, pruritus, constipation, pain, sleep
disturbance, dyspnea, nausea, and depression (3, 4). EOL care is the array of support and
clinical care given to individuals during final weeks and months of life to relieve these
conditions (5).
The conceptualization of palliative care at EOL has its roots in the thinking and work of
Cicely Saunders, founder of the modern hospice movement (6). Her idea of “total pain”
includes the physical, emotional, social, and spiritual dimensions of distress, which should
all be acknowledged and addressed (6, 7). A prime example involves the physical EOL care
environment and its amenities. Built environment factors can significantly affect quality of
life (8–10) and make important contributions to a multidimensional approach for managing
and minimizing total pain (11). These environmental factors can also influence patients’
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ability to tolerate disease symptoms and assert control of their bodies and emotions and can
enhance caregivers’ abilities to meet the needs and wishes of people who are terminally ill
(12).
Palliative EOL care supports individuals’ goals and acceptance of the inevitable. At times, it
may help to prevent costly repeat visits to emergency rooms and readmissions to hospitals
for care that may be unwanted and often unbeneficial. Yet for palliative EOL care to be
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effective, resources need to be directed carefully. Unfortunately, very few guidelines exist
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about how to direct these funds in designing healthcare facilities or making adaptations to
private residences.
This review summarizes the existing literature in both medical and environmental design
that focuses on physical environments and related policies and procedures that help alleviate
total suffering (physical, emotional, social, and spiritual), manage symptoms, improve
quality of life for EOL patients and family members, and support caregivers in delivering
compassionate care. We report on the aspects of the physical environment that emerged as
significant, explain trends from the literature, and discuss opportunities for future research.
In each section, we report on the related evidence from non-EOL settings (e.g., dementia
patients, acute care patients) that may have the potential to be applied to EOL environments.
Method
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An integrative review provides a comprehensive picture of the existing evidence and

highlights research gaps (13, 14). We look at both peer-reviewed and non-peer-reviewed
qualitative and quantitative research literature, and we present the current state of the topic
and directions for future research.
Search Method
We searched 16 environmental design and clinical databases using key words in various
combinations (Table 1). Searches included literature published between 1965 and 2015 from
all EOL care settings, including terminal care facilities, hospitals (including adult and
pediatric intensive care units, palliative care facilities, and oncology wards), hospices,
homes, critical care units, and nursing facilities. The review was then expanded to include
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non-peer-reviewed written material that is not published commercially or is not generally

accessible, including valuable information regarding the best practices in relevant fields,
conference proceedings, design journals, opinion-based literature, and design guidelines.
The screening of the initial search yielded in 323 articles with relevant titles abstract and key
words. We reviewed these articles’ full content and excluded those not directly relevant to
the physical environment of care or related policies and practices. The remaining 225
documents, including 120 of on EOL populations and 105 on non-EOL populations with
relevance to EOL settings (e.g. individuals which advanced illness, patients in critical care,
dementia patients), were used.
Decoding Themes and Topics

The articles were organized and counted according to their relationship to independent
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variables (design interventions), mediating variables (environmental factors affected by

design intervention), dependent variables (effect on persons within the environment), key
words, populations of interest, applicable settings, and design implications. Articles with
similar independent and outcome variables were clustered; interrelationships within each
cluster were studied; and the emergent topics and subtopics within each cluster were
recorded. We documented the repeatability of each theme by counting the number of studies
for each pair of dependent variables and outcome variables.
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Rigor
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For each study, the sample size, study design, research methodology, and journal title were
recorded. We divided the body of literature into five categories from most to least rigorous:
randomized controlled trials, systematic literature reviews and integrative reviews, empirical
research, and opinion-based literature (Table 1). This clustering system is a method accepted
by experts in the field of evidence-based environmental design and was modified from the
clustering system presented in New York City’s 2010 translational report Active Design
Guidelines (15) , which organized literature on evidence-based design into three categories
— established, emerging, and opinion-based literature—and used these categories to sort the
literature by rigor. The randomized clinical trials (RCTs) that we located were evaluated for
risk of bias using the Cochrane Risk of Bias developed for such trials (16).
Results
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Our critical analysis of the results from 225 scholarly documents revealed several
environmental factors that should be considered in order to improve quality of life and
minimize suffering in EOL settings. The five factors that appeared most frequently in the
literature search and that we recommend be targeted by environmental design interventions
are 1) social interaction, 2) positive distractions, 3) privacy and control, 4) personalization
and a home-like environment, and 5) ambient environment. Other factors discussed include
spirituality, optimization of space and layouts, amenities, and cleanliness. Table 2 displays
the distribution of the studies across settings and geographic locations. The information had
a global distribution and included items from the United States, the United Kingdom,
Canada, Scandinavia, Australia, Western Europe, Asia, and Eastern Europe. The top
environmental factors are summarized by frequency and topic in the following sections. In
terms of rigor, about half of the articles employed empirically sound research designs
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(n=118) or RCTs (n=3). The remaining documents included 9 systematic literature reviews
and 40 integrative reviews and 55 pieces of opinion-based literature.
Quality assessment
Table 3 provides the results of the quality assessment (16) for RCT studies on EOL
populations. In summary, all three RCT studies had low risk of “selective reporting” because
pre-specified outcomes were clearly reported and low risk of “incomplete outcome data”
because of the clarity of reported outcome data and reasons for any exclusion. Regarding
“random sequence generation” and “allocation concealment,” one out of three studies was
unclear due to lack of information. In terms of “blinding of participants and personnel” and
“blinding of outcome assessment,” two out of three studies were categorized as high risk
because they did not provide clear information to indicate whether blinding was maintained
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or whether the absence of blinding may not have affected the outcomes. All three RCTs
included design interventions related to positive distraction, and one also included design
interventions related to ambient environment and privacy.
Factor 1. Facilitated Social Interaction

Table 2 displays the distribution of the studies that stated social interaction was a key factor
in the quality of end-of-life care across populations, settings and geographic locations. An
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appropriately designed care environment supports multiple forms of social interaction

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among various parties (patients, family members, and staff). Therefore, environments need
to be designed to support interaction (16). The findings indicated that environmental design
could enhance the following four types of interactions: patient-to-family interaction,
professional caregiver-to-patient/family interaction, patient-to-patient interaction, and
facility-to-community interaction. Evidence indicates that environmental solutions to
enhance the above forms of interaction—such as unit and room layouts that allow closeness
and proximity to others, visual access to patients, and adequate space—have been associated
with increased ability for family members to advocate for the patient (18), reduced patient
suffering (19), increased caregiver satisfaction (20), decreased patient loneliness (21), and
positive community relations (22).
Patient-Family Interaction—Improved social interaction between patients and their

families in EOL environments can enable family members to better advocate for decisions
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on the patient’s behalf (18). Furthermore, research has indicated that the presence or absence
of loved ones in the last moments of life resulted in disparities in the quality of the EOL
experience (19).
Environmental design factors shown to improve interaction between patients and families
included designs that promoted physical proximity (18) and facilitated physical touch. A
study of 192 dying patients in 10 intensive care units (ICUs) found that the presence of
family members during a patient’s final moments of life reduced patient suffering (which
may have been underestimated by caregivers) as indicated by significantly less analgesic use
compared to patients who had no family members present (19). The researchers concluded
that it was necessary to modify environments to promote the proximity of dying patients to
their families (19). According to another study that included in-depth interviews with 33
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parents after they experienced the death of a child, parents experienced strong desires to be
close to the patients in order to maintain physical touch and involvement in important
decisions (18).
In settings where social interactions were not supported by environmental design, relatives
and family members who desired to be near loved ones suffered because of furniture
limitations and slept uncomfortably in chairs in order to stay next to the patient, according to
one empirical study of interviews with bereaved family members (23). Other family
members who cannot endure such limitations—for example, due to lack of physical strength
—may be unable to stay connected to their loved one during the last moments of life.
Professional Caregiver-Patient/Family Interaction—Caregiver-to-patient/family

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interactions corresponded to high levels of family satisfaction with the EOL experience in a
US study of EOL patients and their family members (24). Such interactions resulted in
significant reductions in the need for aggressive medical treatments (such as ventilation and
resuscitation in cancer patients) and ultimately in an increase in the patients’ quality of life
(25). It also helped patients and families moderate their expectations (26). Failure of the care
team to thoroughly communicate patient-related information was one of the top underlying
causes of families’ dissatisfaction with EOL care, according to one literature review in 2003
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that investigated the advantages of using satisfaction as a measure of palliative care quality
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(27).
Environmental design interventions found to aid in this type of communication included

improving visibility and line of sight from the caregiver to the patient and optimizing the
spatial arrangement of the unit to minimize interruption. One focus group of 24 healthcare
professionals from two hospitals and a hospice explained that one cause of reduced
communication may be absence of visibility: According to an EOL nurse, the absence of a
window in the door made her uncomfortable entering the patient’s room and prevented her
from informing family members that she was there for them (28). Spatial design to
streamline traffic flow also has the potential to safeguard or compromise care-related
communication. In an oncology clinic in Sweden, the location of the reception area in the
middle of the unit was highly regarded by staff, who credited this layout with fewer
interruptions while working, increased privacy with patients during important discussions,
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and increased satisfaction with the ability to welcome patients and family members (20).
Patient-Patient Interaction—In the case of certain terminal illnesses, patient-to-patient

interaction has been shown to improve psychological well-being (9, 29), and keeping
mentally active through social engagement has been established to reduce cognitive
impairment (30, 31).
Environmental design solutions shown to facilitate these types of interaction included the
availability of options for shared rooms and the presence of lounge areas. A 2011 integrative
review of the literature (21) examined hospital EOL environments for older patients and
their families and concluded that feelings of isolation and loneliness may decrease if EOL
patients are housed in shared rooms; however, there is controversy regarding the benefits of
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single-patient rooms in providing privacy (21, 32). Pease and Finlay (29) administered a
questionnaire regarding room type to 50 patients in an oncology ward and 36 of their family
members in the UK and found that 68% of the patients preferred open-bay areas over single
rooms. The main reason patients chose a shared room was to avoid loneliness by building
companionship and engaging in conversations (29). In a study by Rowlands and Noble (9),
12 interviewed cancer patients living in oncology wards in the UK preferred multi-bed
rooms to single rooms because of the social stimulation they experienced by having
roommates. Of the cancer patients in Pease and Finlay’s study, 82% (N=41) stated their wish
to have a lounge as a common space for socialization and that they would make regular use
of such a space if provided (29).
Facility-Community Interaction—Facility-to-community interactions may generate

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increased business (33) and promote a positive image of the facility (22, 34).
Environmental design may help align a facility with local needs and achieve geographical
integration with service providers (33), increase volunteer opportunities (34), and create a
positive image for a facility (22, 33). This concept, however, was only highlighted in best
practices and opinion-based evidence. In particular, an Australian guideline for the planning
and designing of hospices explained the physical proximity of the hospice facilities with a
hospital, care services and amenities would help meet the needs of the dying patients from
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all ages and their families (33). Another example is the UK’s Enhancing the Healing
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Environment Program, which was developed in response to the UK Department of Health’s

statement on the direct impact of the physical environment on the experience of care for
people at EOL and on their caretakers. The program emphasized opportunities to expand
volunteer opportunities through environmental design that focused on fostering facility-to-
community interactions (34). In another example, the directors of a US long-term care
facility tried to maintain a positive image in the community by using a visually appealing
building design and visually separating EOL-related functions (22). The facility, for
example, paid special attention to transportation of the bodies of the recently deceased,
keeping this activity visually separate from nearby community groups.
Factor 2. Positive Distractions

Overall, psychological and physical benefits occurred in response to contact (both visual and
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immersive) with nature (21, 35, 36), visual art (37–39), and music (43–49). Furthermore,
controlling odors and utilizing aromatherapy may minimize anxiety (50). Environmental
design interventions that provide access to nature and to positive audio, visual, and olfactory
sensory stimulation (such as visual art, music, and aromas) were identified as possessing the
potential to positively distract EOL patients.
Nature—Exposure to nature has been shown to reduce patient stress and improve
psychological well-being in hospital environments (21, 32). Furthermore, nature was viewed
as a spiritual healer that enables people to reflect on life (51), making it a valuable element
in fulfilling existential needs.
Environmental design can incorporate nature through visual access or immersion. Visual
access is possible through windows to natural outdoor elements and the presence of indoor
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plants or gardens (21, 43, 53). Immersion is possible through the availability of pleasant
outdoor elements and views such as bird feeders, ponds, water fountains, flowerbeds, and
greenery (54), in addition to an accessible means to transfer the patients to the outdoors,
such as patios with ramps and doors opening to the patient rooms (55, 56). Access to nature
increased the satisfaction of patients and their family members with their experience
relocating to an institutional setting (57). In non-EOL postsurgical patients, views of nature
scenes have also been shown to reduce pain and consumption of pain medication (35).
Nature scenes reduced perceived physical symptoms and improved mental health in older
adults in a long-term health setting (36).
In a qualitative study of interviews with 19 caregivers of 82 deceased patients who

transferred from their homes to an institutional setting, caregivers were asked which factors
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improved patients’ satisfaction with relocation (57). The findings indicated that patient
satisfaction was determined by patients’ relationships with their care providers and by
aspects of the physical environment, including patios with doors looking out to a meadow
and pond. The nurses would wheel the patients into positions allowing access to bird feeders
and exposure to sunlight (57). Another study of interviews with 29 family members of
diseased patients in a hospital environment specifically cited a family member’s statement
that her husband’s death in a private room with a view of sunrise provided a beautiful and
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peaceful environment that justified for the family the decision to move the patient to the ICU
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room when death became imminent (26).
In an empirical research study of 46 postsurgical patients recovering in a US hospital,

patients in rooms with views of a natural setting had decreased use of pain medication,
shorter hospital stays, and fewer negative nurse comments regarding patient condition
compared with patients in other rooms (35).
Furthermore, in a qualitative analysis of structured interviews with 40 elderly patients in 3

separate long-term care facilities in the US, 17.5% of patients claimed that time outdoors
ameliorated their physical ailments, and 22.5% claimed that it improved their mental state
(36).
Positive Sensory Stimulation—When properly employed, positive sensory stimulation

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has been shown to improve patients’ mood (40, 46), reduce anxiety (40, 47, 50), help with
pain management (45, 47, 47, 50), promote tranquility (47, 37), and improve quality of life
(46, 47). In non-EOL settings, positive and distractive sensory stimulants were associated
with reduced agitation (40, 42).
Environmental features that may help provide positive sensory stimulation and distraction
include color, artwork, music, and aromas. No empirical studies were found regarding color
in EOL settings, and very few were found for hospital settings. Yet several studies from
other environments provided common themes and recommendations that matched EOL
experts’ opinions about color usage in these environments.
Many studies have researched the effects of color on human emotions for general
populations. Using an emotional scale, one study quantitatively evaluated the relationship
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between color and feelings of leisure, arousal, and dominance in a group of young adults in
California (38). The findings associated the colors blue, blue-green, green, red-purple,
purple, and purple-blue with pleasant feelings and associated yellow and green-yellow with
less pleasant feelings (38). By examining past empirical research about the effects of color
on humans, the authors of a 2014 literature review confirmed that color can have an
important impact on people’s affect, cognition, and behavior (37). For example, the review
reported that many studies indicate that blue conveys openness and peace and green
promotes calmness and success. In hospital settings, another systematic review identified
numerous studies in which color, along with other environmental interventions, resulted in
positive patient outcomes; however, this review did not find studies that evaluated the
variable in isolation (52).
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For EOL care settings, a qualitative study about Norwegian hospital design collected
viewpoints of experts, who indicated the importance of avoiding vapid and pale colors in
patient rooms and promoted color selections to convey clean, bright, and homey
surroundings (58). Another Norwegian study qualitatively analyzed eight EOL care sites
after the implementation of environmental design improvements funded by the Norway’s
Department of Health; the study named soothing colors as a key characteristic for
therapeutic environments (53). Finally, in a set of recommendations for hospice facility
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interior design, an experienced EOL design practitioner (51) recommended that patient
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rooms feature soft, luminous colors ranging from peach to warm lilac, avoiding yellow
tones, strong color contrasts, or busy patterns that are fatiguing. In common areas, however,
she recommended stimulating and energizing color pallets.
Both displayed art and spaces for creating art have been applied in various healthcare
settings, but empirical evidence supporting the function of art in EOL environments is
lacking. In an interview conducted by Caspari et al. (58), one aesthetic expert noted that
patient room walls were often neglected in decoration schemes. Incorporating bright,
uncomplicated artwork, such as a stained glass window illustrating a tree, to liven the space
is highly recommended anecdotally by patients, family members, and EOL experts (59, 57).
In a study of non-EOL environments, surveys were administered to 210 patients and visitors
in five units within a US hospital. Artwork improved the moods of 84% of patients and
visitors, and participants commented that the artwork reduced their anxiety (40). In a
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separate study, patients exhibited reduced agitation (as measured by medication distribution)
when artwork depicting realistic nature scenes was on display in an acute-care psychiatric
unit (42). An empirical Taiwanese study enrolled 177 terminal cancer patient in a hospice
palliative care unit in art therapy, which consisted of visual artwork appreciation and hands-
on painting (39). The patients expressed improvements of emotional state (70%) and
physical state (53.1%) (41). In opinion-based literature, an expert claimed that creative
spaces that allowed people to create and share art in palliative care facilities could aid the
process of healing, encourage celebration, and provide stability, spirituality, and identity
(39).
Music can also be an important factor. One integrated 1996 review explained that the
engagement of sensory processes through distraction was the underlying mechanism that
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explained a body of evidence on music and pain management (44). A 2005 literature review
of empirical studies examined the relationship between musical therapy in hospice and
palliative care settings and found that musical interventions improved pain management,
anxiety and relaxation, mood, and quality of life (47). In a 2001 US study on hospice
patients, music therapy was found to significantly reduce pain and improve physical comfort
and relaxation (48). A randomized US study found that self-reported quality of life was
higher for 40 terminally ill cancer patients in hospice care who had received music therapy
than for 40 participants who did not receive the intervention and that their quality of life
increased as they received more music therapy sessions (46). A survey of 72 music
therapists and 92 hospice and palliative care nurses revealed that music was used to
effectively distract patients and attend to patient pain (45). In an ethnographic exploratory
study including a series of case studies on EOL patients at a general hospital in Ontario,
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researchers identified a common theme of music improving spiritual well-being and

positively triggering memory (49).
Scent can also provide sensory distraction. In an empirical study in the US that assessed the
responses of 17 in-home cancer hospice patients to humidified lavender oil aromatherapy
(50), researchers found a significant decrease in patient pulse and blood pressure, as well as
lower pain and anxiety scores, compared to the control patients. Literature reviews and
empirical research indicate that about 60% to 86% of EOL patients may face malfunctioning
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of the sense of smell (61). Interventions that nurture the sense of smell are needed, according
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to one EOL environmental design expert (51).
Interventions may also combine sensory experiences. A randomized, controlled trial study of
26 EOL patients in the UK revealed a significant reduction in anxiety for participants who
received an experimental treatment providing access to a multisensory intervention including
color-changing fiber optics, dynamic scenes of shapes and colors, and music (60).
Factor 3. Privacy
In general hospital settings, lack of patient privacy was shown to subject patients to stress
(17, 62), compromise their dignity, and diminish their personhood (13), as well as preventing
family from properly grieving and gaining closure (13), creating strain and frustration for
caregivers as they attempt to provide privacy (63), and even encouraging a sense of apathy
from the caregivers (13). Privacy was identified as one of the most critical topics when it
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comes to meeting the wishes of hospitalized older adults during EOL, as well as the needs of
their family members and care staff, according to a 2012 integrative literature review (21).
When EOL settings were provided with sufficient means to safeguard privacy and
confidentiality (64), patients experienced reductions in sleep problems (65, 66) and stress.
Appropriate environmental privacy provisions in EOL care were also shown to aid in the
communication of sensitive information (18, 64).
The reviewed material covered the use of several privacy provisions in EOL care facilities,
including single-occupancy rooms (65), controlled visual (32) and physical access to rooms
with clear demarcation and signage (67), and designated spaces for family members and
their communication when it comes to facility design and layouts (68).
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In an empirical study of hospice patients in the UK, 8 out of 24 patients who indicated a
preference between single or shared rooms preferred single rooms for privacy reasons (65).
The preference for single rooms increased significantly for patients who were actively dying
or experiencing distressing symptoms such as diarrhea or vomiting. The researchers
explained that a major reason for patient requests for single-occupancy rooms at two UK
hospices was the patient’s ability to better control noise and house visitors. A study that
interviewed 11 care staff and 10 residents in a Swedish assisted-living facility revealed that
the residents’ ability to control access to their own bedrooms was valued and recognized by
both residents and care staff (67). In a Canadian empirical study that investigated the sleep
quality of 13 patients in an ICU single rooms were associated with improving sleep duration
(66). One study interviewed 33 parents of deceased children who had died in a US pediatric
ICU about the participants’ environmental needs during the hospitalization period; the
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researchers found that patients shared more personal information when they were satisfied
with their privacy, such as when they occupied a single-patient room (64).
In addition to single-patient rooms, privacy can be achieved through visual screens, location
of bathrooms, interior windows with adjustable opaqueness, and placement of beds in
hospital settings, according to a 2005 integrative literature review (32). An architectural firm
hired by one US hospice facility used designated private areas and nooks for family
members outside patient rooms to increase privacy by enabling family members to gather,
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converse, and support each other emotionally (68). Clear demarcation of patient bedrooms
and observation of a “certain mode of conduct” by staff can be used to create the feeling that
these areas are patients’ private, personal spaces (67).
Privacy is impossible to maintain in multi-bed patient rooms, where inevitable activity from
the necessary care of roommates has been shown to be disruptive and stressful for EOL
patients in palliative care ICUs (62). Patients in EOL units must deal with factors such as
traumatic sights (69) and sounds (70). In particular, ICUs face many challenges in terms of
privacy of dying patients (19), according to a survey of nurses about 192 deaths in 10
Swedish ICUs (19). A 2009 qualitative interview study of 9 Swedish ICU nurses anecdotally
confirmed previous findings regarding undue amounts of stress faced by patients when
forced to overhear resuscitation attempts and deaths of fellow roommates (62); the problem
arose from a lack of space and sound or visual barriers. A US survey of 198 emergency
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nurses’ perceptions regarding the impact of emergency department design on the EOL
experience highlighted that grief-stricken families suffered considerably from insufficient
levels of privacy due to the design of the layout and spaces (71). “A few of the rooms are
separated by curtains, allowing other patients and families to hear the family or a dying
patient grieve,” stated one emergency nurse in that survey (71).
Factor 4. Personalization and Home-like Environments

The desire to remain at home during EOL is common (16, 57, 72), but transition to an
institutional setting may sometimes be necessary. Home-like EOL settings can increase
patient and family satisfaction (21) and comfort (57, 21), as well as caregiver satisfaction
(73), caregivers’ opinion of the patient (74), and caregivers’ ability to connect to the patient
as an individual (75).
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Hiding medical equipment (76), enabling patients to customize and personalize their
surroundings (17, 75, 77, 78), providing amenities to support family presence (57), and
developing smaller scale care units (in contrast with the large institutionalized settings
provided by many hospitals) (79) are among the factors that mitigate an institutional
atmosphere and contribute to a home-like environment.
A 2012 literature review of environmental design in inpatient healthcare settings noted that
designing for palliative care implies keeping medical equipment hidden from sight to
promote a home-like, rather than medical, atmosphere (76). In a study interviewing
caregivers about deceased hospice patients, one key element that facilitated patients’
satisfaction after the transfer from home to hospice was the quality of the physical
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environment, specifically the home-like atmosphere, including amenities and features that
enable the presence of family members (57). Patients’ attempts to personalize their spaces
with their own belongings have been shown to yield positive psychological effects for both
patients, who reported higher satisfaction with the institution (77), and caregivers, who
reported higher job satisfaction (73) and formed better opinions of the patients (74). In a
study of 51 nursing homes units in the US, residents in units with higher levels of
depersonalization (e.g., lack of books, furniture from home, and magazines) were more
likely than other patients to have lower levels of satisfaction with the facility (77).
Staff members were similarly affected by personalization: Questionnaires completed by 673

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staff members from 42 facilities in the UK revealed that residents’ ability to personalize the
space was positively associated with staff members’ job satisfaction (73). In another study,
44 medical students in the UK viewed an elderly person surrounded by personal belongings
in a more positive manner, compared to the same person in an empty room, suggesting that
personalizing space may improve caregivers’ judgments of patients (74). These more
favorable judgments may involve the staff recognizing patient individuality. A qualitative
study by Kellehear et al. (75) documented and analyzed the bedside objects of 31 hospice
residents. These researchers suggested that caregivers use personal objects as conversational
prompts to better connect with the patients.
EOL facility designers have worked to better align EOL environment designs with patient
wishes. A major characteristic of the “hospice movement” in institutional EOL settings was
the creation of more home-like, smaller scale buildings and settings, in contrast to the
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institutionalized settings provided by many hospitals (79).
Factor 5. Optimization of Ambient Environment

Improving the ambient environment around an EOL patient to support quality of life and
peaceful death involves numerous factors, including sound, temperature, and light. An
optimized ambient environment may decrease disruptive and aggressive behavior among
patients (80–83), improve patient mood and satisfaction (58), and elevate staff functioning
(84). Inadequate ambient environmental components may result in increased patient
behavioral aggression (83), decreased social interaction among patients (83, 85),
deteriorated patient mood (85), adverse physical outcomes (86–88), and lower patient
quality of life (85).
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Acoustics—Sound is a vital component of the ambient EOL environment. Deliberate

sound interventions, such as music, may have positive psychological and behavioral
consequences (80, 82, 83). Meanwhile, unwanted sounds (noises), such as those from
equipment and neighbors, may generate negative physiological and behavioral effects (83,
86–88).
For EOL patients, deliberate positive sound interventions, including white noise (80) and
music (82, 89), may produce an overall calming effect. In a RCT study of hospice patients in
the US, music resulted in reduction of fatigue and anxiety (89). In an experimental study in
England, a 23% reduction in verbal agitation among nine dementia patients was achieved
after a nursing home implemented individualized audio interventions with white noise tapes
(80). In two Belgian nursing homes that housed patients with cognitive impairments,
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significant reductions in total agitated behaviors (63.4%), physically aggressive behaviors

(56.3%), and verbally agitated behaviors (74.5%) were noted when relaxing music was
played during lunch (82).
Conversely, unwanted sounds can be detrimental to quality of life. EOL environments

contain many potential sources of noise, including machines and equipment, residents’
verbal agitation, and staff conversations (80, 69, 90). In general contexts, excess noise has
been linked to adverse physiological and psychological consequences, including elevated
blood pressure (86), sleep loss (88), decreased gastric motility in older subjects (87),
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reduced social interaction (85), and increased aggression and disruptive behavior (83). In 29
in-patient wards in a Korean hospital, 103 patients experienced sleep disturbance (as
measured by the Pittsburgh Sleep Quality Index) that was significantly correlated to noise
level (as measured by noise dosimeters) (88). Separately, in a randomized controlled trial, 21
male subjects between the ages of 22 and 71 underwent three auditory interventions, and
older subjects displayed lower gastric myoelectric activity compared to younger subjects
(87).
In a 2014 systematic literature review of the effect of building design on dementia patients in
long-term care facilities, elevated noise level was associated with increased aggression and
disruptive behavior and decreased social interaction (83). In a Spanish study of 160 nursing
home residents with severe dementia, researchers found that excessive noise levels in the
shared patient lounge were associated with a lower degree of social interaction among
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patients (85). A conceptual framework article on the impacts of the environment on

palliative care patients (9) concluded that EOL patients would feel more in control of their
environment if noises from alarms, voices, other patients, bodily functions, and machines
were reduced. A 2014 systematic literature review indicated that reduction of environmental
noise, such as staff talking and sound from electronic devices, was linked to reduced
behavioral disturbances and violence in dementia patients (83).
Temperature—Few research studies have been conducted that specifically explore the
relationship between ambient temperature and patient perception of comfort in EOL
settings. However, several studies have found a relationship between temperature and health
outcomes in elderly dementia patients, as well as in the general population. One 2014
systemic literature review on the effect of the environment on dementia patients in long-term
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care facilities concluded that a comfortable room temperature resulted in less disruptive
behavior (83). Excessively high temperatures put the elderly population at risk for heat-
related ailments, including heat exhaustion and heat stroke, and elevate risks for individuals
with existing health-related conditions, such as congestive heart failure, diabetes, chronic
obstructive pulmonary disease, decreased mobility, dementia or cognitive impairment, or
obesity, as well as for individuals on certain medications (91). Temperatures above the
average of 78.4 °F in patient bedrooms were associated with a lower quality of life for 160
dementia patients in eight Spanish nursing homes, according to responses from a proxy
informant-based scale (85).
Body temperature of individuals in poor health is more variable than that of healthy
individuals; therefore, providing the individual with more control of the environment, such
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as access to a room-specific thermostat, is beneficial. Irrespective of age, patient morbidity

and dependency on others for daily functions determines sensitivity to heat (92, 93). A
German observational study analyzed 95,808 nursing home residents and found that the
residents who required the highest level of care were also more sensitive to temperature (92).
Similarly, another study on 872 patients in health institutions in Malta (93) identified more
dependent individuals as having an increased risk of hyperthermia.
Light—Lighting is a critical environmental factor in care quality, with documented impact

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in various patient care settings. Light may improve patient satisfaction (58); modify
biological, psychological, and behavioral health (85, 94, 95); and improve vision (and
therefore balance) (96, 97). Natural light may also improve staff performance, mood, and
wellbeing (84, 98).
Lighting is the most important environmental factor that influences the sleep/wake cycle
(97–100) and modulates the hormones melatonin (related to sleepiness and drowsiness) and
cortisol (related to stress and alertness), which are linked to cognitive functioning, alertness,
and sleepiness (101). Exposure to light of sufficient intensity resets the human circadian
pacemaker—decreasing melatonin levels and increasing cortisol levels—and alters the sleep/
wake pattern (102). Therefore, lighting levels have significant effects on patient sleep onset.
In a study of 217 elderly Japanese adults, researchers found that exposure to prolonged
evening light in home settings delayed sleep-onset latency (95).
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Lighting effects extend to mood and behavior. Low lighting was associated with an increase
in bodily signs of negative mood in dementia patients in nursing homes in Spain (85). A US
longitudinal study involving 100 hours of videotaped observation of 7 Alzheimer patients in
two designated day-care rooms (control and experimental conditions) indicated that lighting
interventions resulted in a 41% decrease in disruptive behavior (81).
Control of glare and contrast in lighting and environmental design must be considered for
EOL settings. High lighting levels can actually minimize problems for those patients, such
as hearing-impaired individuals, who need to rely on visual aids, but only when glare, which
causes stress, is carefully minimized (51). Elderly people rely on vision to regulate balance,
so sufficient lighting, particularly at night, reduces the frequency of falls (96, 97). One study
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conducted by Figueiro et al. (97) investigated the postural orientation and stability of 12
elderly subjects under different lighting conditions in an experimental setting; subjects
responded positively to an environment with more lighting. Similarly, postural stability of 33
older women was found to decrease as lighting conditions were dimmed in a British
laboratory study (103). Falls that result in hip fractures and loss of independence can
negatively affect elderly patients (104).
Natural light (as opposed to artificial light) has been identified as desirable for therapeutic
EOL settings (53, 51). According to interviews with 16 nurses, artists, and architects who
were knowledgeable about Norwegian hospitals, design features that make the space bright
and airy and utilize natural daylight improved patient mood and satisfaction significantly
(58). However, patients living in a dark oncology ward in the basement of a building felt
shameful and described their care experience as being in the “waiting room of death” (20).
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Natural daylight has also been associated with decreased absenteeism among caregiving
staff, according to an experimental study comparing two US intensive care units that differed
in sunlight exposure (84).
Discussion
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Access to EOL palliative care is limited, both worldwide (105) and in the United States
(106, 107). Over the next decade, the need for such care is expected to rapidly increase (106)
as the baby-boom generation ages (108). Designing specialized facilities for EOL care
would provide the right infrastructure to support staff in providing safe, timely, and high-
quality care and would support patients in managing symptoms and improving their
experience. This literature review identified five key elements to be strategically targeted for
improving quality of life and supporting care for EOL patients. When appropriately
managed, these elements may improve patients’ psychological, emotional, spiritual, and
physical well-being and overall quality of life. Family members and caregiving staff also
reported that such interventions can grant them psychological and physical relief. Some
examples of specific design interventions related to each environmental factor, as well as
expected outcomes, are provided in Table 4.
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Environmental design for EOL must:
1. Support family presence—Remove barriers and provide features that foster close
and comfortable proximity between patients and families to nurture interaction,
facilitate decision-making, aid in closure, increase peace of mind, and enhance
comfort.
2. Promote privacy—Provide single-occupancy rooms, visual screens, patient

control over physical access with clear signage and demarcations, and a
dedicated space for family members to have private conversations or maintain
dignity while grieving. Privacy improves confidentiality, avoids interruptions to
care-critical conversations and grieving, helps meet the desires of patients and
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family, and ultimately reduces stress and sleep problems.
3. Balance patients’ need for privacy with caregivers’ need to monitor patient
condition—Improve visibility and line of sight from the caregiver to the patient,
while simultaneously optimizing the spatial arrangement to minimize obtrusive
and unrelated foot traffic, thereby protecting privacy and minimizing interruption
during important conversations.
4. Facilitate social engagement—Provide shared spaces and common areas for

activities to facilitate communal presence. Provide the option for shared
bedrooms to those patients who desire multi-bed rooms to reduce feelings of
isolation and loneliness, increase interaction among patients and family
members, and keep patients’ minds active.
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5. Address connections to the community—Enhance the visual appeal of the

building and locate the EOL facility in close proximity to the community. Present
a positive image to the community and foster literal, as well as implied,
interaction between a facility and the surrounding community. Ensure that
patients, families, and care staff have convenient access to social centers,
hospitals, and care services and that volunteer opportunities are convenient to the
community.
6. Provide direct access to nature—Develop pleasant outdoor natural elements,

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such as bird feeders, ponds, water fountains, flowerbeds, and greenery. Ensure
access to such features through patios with doors opening onto nature and
pathways that are easily negotiable by patients in wheelchairs or even beds.
These positive distraction measures can improve patients’ mental state and
reduce their suffering.
7. Provide indirect access to nature—Design interior spaces to not only incorporate

plants but also have ample windows with views of pleasant outdoor elements to
reduce perception of pain, improve satisfaction, and enhance sense of peace.
8. Feed the senses—Incorporate color, artwork, music, and aromas into EOL
environments to feed the senses, reduce anxiety, lessen perception of pain, and
promote tranquility.
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9. Foster a home-like environment—Hide medical equipment, enable patients to

customize their surroundings, and provide in-room amenities for family members
to help prolong family members’ presence. Such measures can facilitate bonding
by providing conversational prompts among patients, staff, and family; increase
caregivers’ perceptions of patient personhood and dignity; and increase patient
and family satisfaction.
10. Control noise—Employ sound-absorbing surfaces and optimize interior layout of

equipment to minimize unwanted noise from equipment, residents’ verbal
agitation, and staff conversations inside patient rooms. Such measures can
improve communication, enhance sleep, and improve health.
11. Provide thermal comfort—Provide patients with adjustable temperature controls

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with a wide range of settings to reduce agitated behavior, improve comfort, and
enhance quality of life.
12. Ensure ample light with a balance of natural and artificial light—Supplement
natural light with artificial light during the day with provisions for glare and
contrast control. Provide night lighting that supports postural orientation and
stability while not disrupting circadian and biological rhythms. Proper lighting
can improve vision, reduce falls, and improve mood, sleep and circadian
rhythms.
A recurring theme throughout this integrative literature review was the patients’ ability to
control or personalize surroundings; this concept was embedded in every identified
environmental factor. It is crucial that spaces be designed for flexibility and personalization
to support the range of patients’ desires.
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The only controversial element found was the use of single-patient versus multi-bed rooms.
A single-occupancy room better protects patient and family privacy, permits better
management of smells and noise, and allows aspects of the patient’s immediate setting (such
as music and temperature) to be customized for each patient. Conversely, multi-bed rooms
encourage positive socialization between roommates, which may combat loneliness and
boredom. Rigby (16) asserts that individual patients will favor the benefits of one setting
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type over the other.
Positive distractive sensory stimulation should be implemented in EOL settings. The effects
of nature, in particular, have been proven to be exceptionally beneficial. Safeguarding patient
privacy through environmental modifications was found to be critical in maintaining patient
dignity and control, in allowing family to grieve freely, and in enabling caregivers to provide
compassionate care. Creating a home-like environment in institutional EOL settings can be
achieved by consciously designing the facility to imitate a home, rather than a hospital, and
by encouraging patients to personalize the space with their belongings.
Finally, the ambient environment must be considered. Minimizing noise and using
interventions such as white noise and music can greatly improve the ambient environment.
Age, morbidity, and dependency may alter temperature preferences, and thermal conditions
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outside comfort levels may compromise quality of life. The benefits of an adequately lit
EOL environment extend to both patients, whose mood improves and who may avoid injury,
and caregivers, who demonstrate heightened work performance and wellbeing.
Limitations and Future Research Directions

This review summarized all possible environmental factors that may influence QOL for EOL
patients and their family members and caregivers across various levels of evidence. We
found that many of the identified factors are not backed by empirically sound evidence in
EOL settings and may be considered common practice or experience-based approaches.
Some design interventions that are rigorously evaluated in other settings (e.g., dementia care
or acute care) on patients with advanced illness, have not been tested in EOL settings
although they may be useful for reducing suffering in EOL patients. A significant gap in the
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research related to physical environments of EOL care—in combination with the increasing
number of patients entering such care—demonstrates an urgent need for evidence-based
solutions to address the spiritual, social, physical, and psychological needs of patients,
family members, and caregivers.
Although a pattern of information emerges from the available peer-reviewed and non-peer-
reviewed literature, there have been few research studies focusing on the key components of
environmental design for institutional EOL settings. One area that shows a particularly large
knowledge gap is the effect of ambient environmental aspects, such as temperature and
ventilation, both of which are critical in maintaining patient comfort and health. The need
for research on ventilation is acute because the risk of a patient contracting an infection from
airborne pathogens is much more likely in the EOL population. The effectiveness of
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aromatherapy also requires more rigorous study to support claims of positive patient
outcomes. And continued research is needed on practical environmental devices that can
reduce delirium, a common EOL condition that often responds poorly to medications.
The use of an EOL facility’s environmental design to foster relationships between the
facility and the surrounding community has been suggested, yet there is little research on the
topic beyond opinion-based pieces nor are there details regarding the execution of such an
endeavor. Similarly, experts recommend having visual artwork within healthcare facilities,
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but the exact effects of visual artwork on patients have been poorly studied. There is also
little research on the best subjects to depict in such artwork.
This review has identified a host of studies indicating that the right physical environment
may enhance the physical, psychological, social, and spiritual well-being of EOL patients.
Future research is necessary to better understand the most appropriate environmental designs
for EOL care and to evaluate environmental effects on care outcomes, as well as on patient,
family, and caregiver experiences. The EOL experience is not a single condition with a
universal response and course of care (109); it varies highly by person, disease, age, race,
context, and culture. Therefore, it requires diverse solutions and responses (109). Future
research is needed to provide specific adaptations to various conditions.
Conclusion
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It is both difficult and costly to provide EOL care within the context of a national and global
healthcare system that is focused on delivering cures and rehabilitation. The use of palliative
EOL care as an alternative model could reduce the societal healthcare costs associated with
the demographic reality of a growing elderly population. Yet providing effective palliative
EOL care is not inexpensive, particularly with regard to care environments. As this
integrative literature review clearly demonstrates, the environment needed for effective
palliative EOL care is highly complex and therefore not without cost. When precious
financial resources are directed at new construction or modification in institutional facilities
or even private residences, guidance is needed to ensure that design decisions are appropriate
and that the greatest possible benefit is realized from the expenditures.
With this systematic review, we aimed to address these issues. We used the theory of total
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well-being to guide a critical analysis and synthesis of the relevant medical research, design
literature, and existing patterns. Five key environmental factors were identified and
discussed: facilitated social interaction, positive distractions, privacy, a home-like and
personalized atmosphere, and ambient environmental features. Moreover, this study offers
direction for future research to fill in the knowledge gaps about design for this uniquely
important setting. The findings generate a resource for all EOL care teams—including
administrators, nurse leaders, nurses, and family caregivers—who seek to provide a suitable
care environment and for design researchers who hope to have a lasting impact on the field.
Acknowledgments
Research reported in this publication was supported by the National Institute on Aging of the National Institutes of
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Health under Award Number P30AG022845. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of Health. The project also received support from
the United States Department of Agriculture National Institute of Food and Agriculture's Federal Capacity Fund
(Smith Lever) for outreach and cooperative extension of research in land grant universities, the Lawrence and
Rebecca Stern Family Foundation through the Translational Research Institute for Pain in Later Life (TRIPLL), an
Edward R. Roybal center (in the Bronfenbrenner Center for Translational Research), Cornell Institute for Healthy
Futures and College of Human Ecology's Building Faculty Connections Program. The authors would like to thank
the following individuals for their valuable contributions to this paper: Amy R. Slutzky of the SUNY Upstate
Medical University and Sheila Danko, Chriss Cherny, Alberto Embriz De Salvatierra, Meg Elizabeth Taylor, Nancy
Jiang, Monika and Marissa Patel, Grace Liu and Laura Bell at Cornell University.
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Table 1
Literature Search Strategy

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Medical Literature (non-pharmacological) Evidence-based Design Literature
Databases Searched • PubMed • JSTOR

• MEDLINE • ScienceDirect
• CINAHL • Wiley InterScience
• Web of Science • Ovid MEDLINE
• Ageline
• Psychinfo
• Sociological Abstracts
• SocINDEX
• Avery Academic Search
• Premier Design and Applied
Arts Index GoogleScholar
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Physical Environment Keywords • Health Facility Environment • Evidence-Based Design

• Environment Design • Environmental Design
• Facility Design and Construction • Built Environment
• Equipment Design • Interior Design
• Environment • Physical Environment
• Controlled • Architecture
• Noise • Environmental Psychology
• Sound
• Acoustic Stimulation
• Music
• Music Therapy
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• Odors
• Lighting
• Built environment
• Interior Design and Furnishings
Setting Keywords • Palliative Care • Palliative Care

• End-of-Life Care • End-of-Life Care
• Nursing Home • Nursing Home
• Terminal Long Disease • Assisted Living
• Terminal
• Heart Disease
• End-Stage
• End-Stage Cancer
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• End-Stage Long Disease
Variable Keywords • Patients: concept of total suffering, • Patients: concept of total

activities of daily living (ADL), improve suffering, activities of daily
quality of life, reduce pain, reduce living (ADL), improve quality
delirium, reduce anxiety, reduce stress of life, reduce pain, reduce
Medical Literature (non-pharmacological) Evidence-based Design Literature

• Caregivers: fatigue, burnout, compassion stress, improve comfort,
fatigue reduce delirium
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• Caregivers: fatigue, burnout,

compassion fatigue
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Author Manuscript
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Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Table 2
Distribution of the literature based on geographic location, setting, study design, and rigor
Home-like
Social Positive Ambient
Zadeh et al.
Characteristic Environmental factor Total Privacy Environment

Interaction Distractions Environment
&Personalization
Population EOL 120 63 51 37 30 22
Other 105 38 27 26 24 53
Australia 11 7 6 3 4 2
Belgium 2 0 1 0 0 0
Canada 19 10 4 7 5 7
China 7 4 0 2 1 4
Czech Republic 1 0 0 0 0 1
Finland 4 1 0 0 1 2
Germany 4 1 2 0 0 3
India 1 0 0 0 0 1
Ireland 1 1 0 0 1 0
Israel 1 0 0 0 0 1
Italy 1 0 0 0 0 0
Location of Study Japan 3 0 0 0 0 3
Korea 1 0 0 0 0 1
Malta 1 0 0 0 0 1
Netherlands 5 3 1 0 2 2
Norway 4 3 2 2 3 2
Scotland 2 0 0 0 0 0
Slovenia 1 1 0 1 1 0
Spain 1 0 0 0 0 1
Sweden 11 8 3 7 4 2
Taiwan 1 0 1 0 0 0
UK 41 16 18 17 15 13
USA 102 45 40 25 17 28
Setting Elderly Living Facility/Nursing Home 57 27 18 19 22 20

Page 26
Home-like
Social Positive Ambient
Characteristic Environmental factor Total Privacy Environment
Interaction Distractions Environment
&Personalization
Home Environment 26 12 8 4 4 7
Hospital Setting (e.g., Intensive Care Unit, Oncology Unit) 116 60 42 37 21 33

Zadeh et al.
Hospice 62 27 34 20 22 13
Other (e.g., Lab) 23 5 3 2 5 14
Systematic Review 9 3 4 2 4 5
Integrative Review 40 21 13 15 13 10
Study Design Randomized Controlled Trial 3 0 3 0 0 0
Empirical Research 118 63 33 34 26 50
Anecdotal Evidence 55 17 25 14 12 11
Peer-reviewed Article 192 92 64 54 46 67

Rigor
Non-peer-reviewed Article 33 9 14 9 8 7
Page 27
Table 3
Cochrane Risk of Bias for RCT Studies for EOL populations
Cochrane Risk of Bias Criteria

Zadeh et al.
Blinding of
Blinding of Incomplete
Author Year Location Environmental Factor Setting Random Outcome Selective
Participants Outcome
Sequence Allocation Concealment Assessment Reporting
and Data (2–6
Generation (All-cause Bias
Personnel weeks)
mortality)
Choi, Y. K 2010 US (Midwest) Positive Distractions Hospice Low Risk Low Risk High Risk High Risk Low Risk Low Risk
Hilliard R. E. 2003 US (Florida) Positive Distractions Hospice Unclear Unclear High Risk High Risk Low Risk Low Risk
Schofield, P. 2003 United Kingdom Positive Distractions, Hospital Low Risk Low Risk Low Risk Low Risk Low Risk Low Risk
Ambient Environment & Setting
Privacy (palliative care
ward)
Page 28
Table 4
Examples of design interventions and expected outcomes

Author Manuscript
Environmental Factors Examples of Design Examples of Outcomes (dependent

(mediators) Interventions (independent variables)
variables)
Facilitation of Social Unit and room layouts that facilitate Ability for family members to advocate for the patient (16),
Interaction closeness and proximity of patient to others, reduced patient suffering (17), caregiver satisfaction (18),
visual access to patients, adequate space patient loneliness (19), and community relations (20) in EOL
patients.
Positive Distractions Nature (visual access or immersion), Patient and family member satisfaction (55); perceived pain,
positive sensory stimulation and distraction pain management and pain medication consumption (43, 45,
such as color, artwork, music, and aromas. 46, 48); perceived physical symptoms, mood, tranquility,
anxiety and overall mental health (34, 44, 45, 48); and quality
of life (44, 45) in EOL patients.
Privacy Single-occupancy rooms, controlled visual Sleep disturbance (6), stress (15, 60), and communication of
and physical access, clear demarcation and sensitive information (16, 62) in EOL patients.
signage, designated spaces for family
members
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Personalization and Home- Hidden medical equipment, customizable Patient and family satisfaction (19) and comfort (55, 19) and
like Environments spaces surrounding patient, amenities caregivers’ ability to connect to the patient as an individual
supporting family presence, small-scale (73) for EOL patients. Caregiver satisfaction and
care units (in contrast with the large improvements in their opinion of the patient for older patients
institutionalized settings provided by many in institutional settings (71, 72).
hospitals)
Optimization of Ambient Sound/acoustics, temperature, and light Mood and satisfaction (56) in EOL patients. Disruptive and
Environment aggressive behavior for patients with dementia or cognitive
impairment (78–81).
Author Manuscript
Author Manuscript

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Published in final edited form as:

Environmental design for end-of-life care: An integrative review

Paul Eshelman, B.S. M.F.A.,

Judith Setla, MD, MPH, FACP,

Laura Kennedy, B.S.,

Emily Hon, BS, and

BS, MD Candidate, New York Medical College, Valhalla, NY, U.S.A

Aleksa Basara, BSc

Results—This synthesis analyzed 225 documents, including 9 systematic literature reviews, 40

Correspondence to: Rana Sagha Zadeh.

An integrative review provides a comprehensive picture of the existing evidence and

non-peer-reviewed written material that is not published commercially or is not generally

Decoding Themes and Topics

variables (design interventions), mediating variables (environmental factors affected by

Factor 1. Facilitated Social Interaction

appropriately designed care environment supports multiple forms of social interaction

Patient-Family Interaction—Improved social interaction between patients and their

Professional Caregiver-Patient/Family Interaction—Caregiver-to-patient/family

Environmental design interventions found to aid in this type of communication included

Patient-Patient Interaction—In the case of certain terminal illnesses, patient-to-patient

Facility-Community Interaction—Facility-to-community interactions may generate

Environment Program, which was developed in response to the UK Department of Health’s

Factor 2. Positive Distractions

In a qualitative study of interviews with 19 caregivers of 82 deceased patients who

room when death became imminent (26).

In an empirical research study of 46 postsurgical patients recovering in a US hospital,

Furthermore, in a qualitative analysis of structured interviews with 40 elderly patients in 3

Positive Sensory Stimulation—When properly employed, positive sensory stimulation

researchers identified a common theme of music improving spiritual well-being and

to one EOL environmental design expert (51).

Factor 4. Personalization and Home-like Environments

Staff members were similarly affected by personalization: Questionnaires completed by 673

institutionalized settings provided by many hospitals (79).

Factor 5. Optimization of Ambient Environment

Acoustics—Sound is a vital component of the ambient EOL environment. Deliberate

significant reductions in total agitated behaviors (63.4%), physically aggressive behaviors

Conversely, unwanted sounds can be detrimental to quality of life. EOL environments

patients (85). A conceptual framework article on the impacts of the environment on

as access to a room-specific thermostat, is beneficial. Irrespective of age, patient morbidity

Light—Lighting is a critical environmental factor in care quality, with documented impact

Environmental design for EOL must:

2. Promote privacy—Provide single-occupancy rooms, visual screens, patient

family, and ultimately reduces stress and sleep problems.

4. Facilitate social engagement—Provide shared spaces and common areas for

5. Address connections to the community—Enhance the visual appeal of the

6. Provide direct access to nature—Develop pleasant outdoor natural elements,

7. Provide indirect access to nature—Design interior spaces to not only incorporate

9. Foster a home-like environment—Hide medical equipment, enable patients to

10. Control noise—Employ sound-absorbing surfaces and optimize interior layout of

11. Provide thermal comfort—Provide patients with adjustable temperature controls

type over the other.

Limitations and Future Research Directions

perspective? J Palliat Care. 2002; 18:48–58. [PubMed: 12001403]

Umeå, Sweden: Umeå University medical dissertations; 2005.

increased satisfaction. Crit Care Med. 2004; 32:1484–1488. [PubMed: 15241092]

Mortality. 2012; 17:92–105.

in Int J Palliat Nurs 2003;9:178]. [PubMed: 12682575]

Med. 2003; 167:708–715. [PubMed: 12598213]

85. Garre-Olmo J, López-Pousa S, Turon-Estrada A, et al. Environmental determinants of quality of

Available from: https://www.nih.gov/news-events/news-releases/nih-tips-older-adults-combat-heat-

31:461–467. [PubMed: 24147658]

and cortisol rhythms. Brain Res. 1997; 759:166–170. [PubMed: 9219878]