IPH - Institute of Hospital Research

Publications IPH Magazine IPH Magazine #16 A pathway for death: the flow and connections between environments and its occupants

Fungo Aspergillus
A pathway for death: the flow and connections between environments and its occupants Cris Vieira

Introduction


Death has always occupied our minds, often invoking negative aspects. The purpose of presenting a discussion about the architectonic environment concerning such issue is not to prevent suffering, or hide it, but to treat the environment in a humane manner so death can be lived properly by anyone affected by it. 

Throughout the centuries, the search for health has been changing its focus and practices. During Classicism, to achieve both physical and mental health such pursuit was through religious faith and mysticism, usually by visiting temples dedicated to them. In the Middle Ages, the Catholic Church was committed to promoting health and offering healthcare. There were also those who used pagan practices and believed that being ill was due to punishment, possession or witchery, that period was known as the Dark Ages. The places aimed at the promotion of health, where people used to go looking for comfort and a chance to live longer, soon became a deposit for social issues. Therefore, in the final years of the Middle Ages, hospitals had increased its size and role, absorbing the vulnerable population who was seen as a problem. The elderly, orphans, mental impaired, socially impaired, vulnerable, prostitutes, unemployed and sick people: hospitals began to impart a stronger negative reputation due to that gathering of people in such diverse situations. Death was a fact; hospital was synonym for disorder and death.

The 18th century marked the beginning of the hospital as a space for healing. Medicine had begun to be recognized as science and the hospital as a place of treatment. The focus was the disease, the technologies, the drugs and the procedures to achieve healing. 

Nowadays, hospital's philosophy is to humanize assistance, which was first designed and gained support in the end of the 20th century, when the patient, and not the illness or the healing, was praised.

Healthcare facilities have several environments defined to be used by a diversified group of people: patients, health professionals, managers, guests and employees. Every occupant with its own relationship and activities, transforming one same environment in different spaces. (SANTOS, BURSZTYN, 2014, Chapter 6)


Highlighting the death flow: defining the problem


Although hospitals have been going through profound changes concerning their role, technologies, spaces and concepts throughout time, death has always been present, which makes it relevant to adopt a more humanized approach.

When planning health architecture, the humanized approach requires a new conception of design, one capable of incorporating to the necessary technical, formal, functional and economical studies some consideration regarding the effects of the environment over its users, exploring the potential contribution the space could have over users' autonomy, well-being and reestablishment of health. (FONTES, 2007, p.55)

It is necessary to consider the influence of the environment over its occupants, and vice versa, whether when remodeling the facility or when planning new ones, focusing on everyone's well-being and on every possible occurrence, overlooking neither the moment of the death nor the deceased when conceiving the architectonic project. 

Under such conditions, the architectural elements are one of the matrices of individual and group experiences, enabling a humane and social context around them. In this sense, the space is the object of a new interpretation: the reality of our behaviors, and the social life, are produced and developed in diverse places that are more than simply exterior envelopes. (FISCHER, 1994, p.16)

This subject first got the author's attention during a conversation she had with a nurse, who was studying at the Post-Graduation Program in Architecture at the Universidade Federal do Rio de Janeiro (UFRJ) and needed help with her post-graduation research. During their talk, the nurse described an unpleasant situation she went through: the need to carry a newborn baby who had just passed away through areas where there were parents waiting for information regarding their own babies, who were being taken care of and could also die. Some parents even stopped her to ask for information, and in order not to create a feeling of sadness and disbelief among them she pretended to be carrying a sleeping baby. That situation set an example of the importance of thinking about the flow taking into consideration the work of healthcare professionals and the well-being of others.

That was how the central problem emerged: how to deal with the course of the dead, with a limited space designed after an architectonic project, to enable the healthcare professional to carry out his/her work properly, baring in mind who have suffered the loss and other users who could be overwhelmed by the situation.

Thinking about death and the hospital environment


To justify the importance of the subject and depict the national and international production regarding death in the hospital environment, the author carried out a bibliography research in February 2019. 

For that, the author chose the following phrases as descriptors: Hospital architecture; Hospital planning; Health architecture; Healthcare environments; Healthcare facilities; Healthcare institutions architecture; Death; Dealing with death; Thanatology. The search for the descriptors was carried out on the Virtual Library of Health - BVS/Decs. The death-related descriptors were paired with the architecture-related descriptors.

The research using the descriptors was carried out on CAPES database and on UFRJ's Minerva portal. As a result, there was a total of 1.267 texts, as shown on Table 1. Some limits were established to have clear specification, reducing the sampling size by excluding duplication of texts; texts based on quantitative research; and texts that were not focused on the subject matter. The texts considered relevant for the study were the ones who led to complete works available online in Portuguese, English or Spanish and that, after reading the abstract and some specific parts of it,  proved their correlation with the subject proposed by the work. A summary of the search follows:

Table 1 - Results from the search using descriptors
Descriptors* Database Total
MINERVA CAPES
1
Hospital architecture and death
 0 44 44
2
Hospital architecture and thanatology
 0 0 0
3
Hospital architecture and dealing with death
 0 12 12
4
Hospital planning and death
 1 414 415
5
Hospital planning and thanatology
 0 3 3
6
Hospital planning and dealing with death
 0 44 44
7
Healthcare facilities and death
 0 293 293
8
Healthcare facilities and thanatology
 0 1 1
9
Healthcare facilities and dealing with death
 0 72 72
10
Healthcare institutions architecture and death
 0 82 82
11
Healthcare institutions architecture and thanatology
 0 1 1
12
Healthcare institutions architecture and dealing with death
 0 36 36
13
Humanizing assistance and death
 3 222 225
14
Humanizing assistance and thanatology
 0 9 9
15
Humanizing assistance and dealing with death
 0 30 30
TOTAL 4 1.263 1267


Table 1 shows the total number of texts according to the database and the combination of descriptors. The search online was carried out in February 2019. 


Table 2 - Detailing the sampling
Descriptors* Database Total
MINERVA CAPES
1
Hospital architecture and death
 0 2 2
2
Hospital architecture and thanatology
 0 0 0
3
Hospital architecture and dealing with death
 0 0 0
4
Hospital planning and death
 0 1 1
5
Hospital planning and thanatology
 0 0 0
6
Hospital planning and dealing with death
 0 0 0
7
Healthcare facilities and death
 0 0 0
8
Healthcare facilities and thanatology
 0 0 0
9
Healthcare facilities and dealing with death
 0 1 1
10
Healthcare institutions architecture and death
 0 0 0
11
Healthcare institutions architecture and thanatology
 0 1 1
12
Healthcare institutions architecture and dealing with death
 0 0 0
13
Humanizing assistance and death
 0 3 3
14
Humanizing assistance and thanatology
 0 0 0
15
Humanizing assistance and dealing with death
 0 0 0
TOTAL 0 7 7

Table 2 shows the total number of texts according to the database and the combination of descriptors and applying the criteria of inclusion, exclusion and eliminating repeated texts. 

This first search confirmed that the bibliography about death and the flow within hospital environments regarding the architectonic project has not yet been studied, i.e., the topic would be original, justifying its relevance. 


The research methodology 


The work methodology is based on two aspects: using texts about hospital architecture and death and analyzing hospital buildings. Besides the texts found via database research, the author will use some texts received during two classes she took at the Post-Graduation Program in Architecture at the School of Architecture at Universidade Federal do Rio de Janeiro - PROARQ/FAU-UFRJ: Architecture and Healthcare Space Project; and History and Tendencies classes, both taken.

To add to the online study the author also considered the work of YIN (2010) concerning research methodology and first defined key questions to guide the research:

  1. How can we think the flow of the deceased from the beginning of the architectonic project? 
  2. How does the deceased impact the people within the hospital environment psychosocially?
  3. What can be identified in existing projects as good or bad practice regarding the pathway of the deceased within a hospital flow?
  4. What can be done when conceiving architecture projects to humanize the issue of death regarding the pathway taken and the different people inside a hospital?
  5. How can architecture impact this issue focusing on health professionals?

Table 3 shows which research methodology is more appropriate based on the questions proposed:

Table 3 - Relevant situations for different research methodologies
Methodology  Type of inquiry Does it require control over behavioral events? Does it focus on contemporary events?
Experiment How, why? Yes  Yes 
Survey Who, what, where, how many, how much?  No  Yes 
Archive analysis Who, what, where, how many, how much? No  Yes/No
Historical research How, why? No  No
Case study How, why? No  Yes
Source: YIN (2010), page 29.

Since three out of five inquiries used the term "How", it became clear the advantage towards the Case Study methodology. YIN (2010) believes it is the most appropriate one since this inquiry deals with operational bonds that must be designed throughout time, more than simply frequencies or incidences, being depicted as exploratory. It is also worth highlighting that: 

The case study is more suitable to assess contemporary events, but when relevant behaviors cannot be manipulated (...) the exclusive force of a case study is its ability to deal with a broad variety of evidences - documents, artifacts, interviews and observations (...). (YIN, 2010, page 32.)

The term "What", from the other two inquiries, enables the use of two branches of methodologies: sampling and archive analysis. In this sense, it is suitable to use such research methodologies when the intention is to identify and enumerate. 

Considering the analysis of the inquiries brought together, the case study is the most appropriate methodology to be used since, according to YIN (2010), this is an observational investigation based on experience, confirming the contemporary phenomenon of real life when the limits between phenomenon and context are not clear. The flows in different healthcare facilities give rise to technically different situations, where there are more variables than data, with substantial sources of evidence.

Conclusion


The pathway of death, within the concept of humanized hospital spaces, must be considered beforehand when conceiving the project. Since the bibliography about the relationship between death and the hospital environment is scarce, this article demonstrates the relevance of the topic. Therefore, the author concludes it is necessary to study existing hospital buildings to verify technically the flows and circulations and the relationship between death, hospital environment and its occupants.

The case study has proved to be the most suitable research methodology. And to depict the reasoning about death and the deceased in the relationship between people using hospital environments and the development of hospital architecture, the author concludes it is necessary to list recommendations to devise new architectonic projects, envisioning the humanization of architectonic spaces with focus on the flows and on the well-being of those facing the possibility of death.


*Translator's Note: The words used in the research were translated for means of clarity. The original terms in Portuguese are as follows: 1. Arquitetura hospitalar and morte, 2. Arquitetura hospitalar and tanatologia, 3. Arquitetura hospitalar and atitude frente à morte, 4. Planejamento hospitalar and morte, 5. Planejamento hospitalar and tanatologia, 6. Planejamento hospitalar and atitude frente à morte, 7. Instalações de saúde and morte, 8. Instalações de saúde and tanatologia, 9. Instalações de saúde and atitude frente à morte,10. Arquitetura de instituições de saúde and morte, 11. Arquitetura de instituições de saúde and tanatologia, 12. Arquitetura de instituições de saúde and atitude frente à morte, 13. Humanização da assistência and morte, 14. Humanização da assistência and tanatologia, 15. Humanização da assistência and atitude frente à morte.

References

FISCHER, Gustave. Psicologia Social do Ambiente. Instituto Piaget. Lisboa, 1994. (ISBN: 978-97-2929-542-3).

FONTES, Maria Paula Zambrano. Humanização dos Espaços de Saúde: Contribuições para a Arquitetura na Avaliação da Qualidade do Atendimento. Rio de Janeiro: FAU/PROARQ, 2007. [Tese]. Universidade Federal do Rio de Janeiro, Rio de Janeiro, 2007.

SANTOS, Mauro, BURSZTYN, Ivani. O Caminho do Paciente: Conceitos e Ferramentas para a Avaliação de Estabelecimentos de Atenção à Saúde. Livro Arquitetura e Engenharia Hospitalar: Planejamento, Projetos e Perspectivas - Capítulo 6. Rio de Janeiro, Rio Books, 2015. (ISBN: 978-85-6155-658-7).

YIN, K, Robert. Estudo de Caso: Planejamento e Métodos. São Paulo, Bookmed, 2010. (ISBN: 978-85-7780-655-3).


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