Wellbeing, Space and Society 2 (2021) 100012

Contents lists available at ScienceDirect

Wellbeing, Space and Society

journal homepage: www.elsevier.com/locate/wss

Locating death anxieties: End-of-life care and the built environment

Michelle Knox
Department of Medicine, University of Alberta, 1-198 Clinical Sciences Building 11350 - 83 Ave, Edmonton, AB T6G 2P4, Canada

a r t i c l e i n f o a b s t r a c t

Keywords: As quality of life improves with better and more accessible healthcare, populations worldwide continue to age.
Built environment Although fewer people die at home now than ever before, hospitals remain a significant site of death, while other
End-of-life care locations—including hospices, long-term care residences, and cancer care centres—increasingly change social
Design for health
conceptions of ageing, dying, and palliative care. Within these rapidly changing scenarios, and in the wake of
Location of death
unprecedented industrial and technological progress, the palliative building is on the verge of disappearance. At
Sociology of death
this juncture, this paper asks whether—and how—the designed location figures into the end of life. Do places
have the power to mediate our experiences of and attitudes towards dying? Since we have limited authority
over how and what kills us, do we then root our control of, dignity in, and reconciliation with death based on
where we die? Drawing links between architectural design and end-of-life studies, this paper will consider how
we register—and may address—our anxieties around death and dying within built environments of care.

1. Introduction
In 2014, the World Health Organization (Worldwide Palliative Care
Alliance, 2014) reported that access to palliative care is significantly
limited around the world, with only 14% of those in need receiving
it. Within our ageing societies, the need for specialized facilities that
are well-supported for providing—and receiving—better palliative care
services, is expected to increase steadily (Morrison et al., 2011). While
global efforts to ameliorate end-of-life suffering—through biomedical
interventions and health policy implementations—continue to increase,
the designed environment has factored much less in strategies for im-
proving palliative care experiences.
Over the last five years, roughly 60% of all deaths in Canada oc-
curred in hospitals—showing a small but consistent decrease each year
(Statistics Canada, 2018). Scholars from various disciplines (e.g. medi-
cal geography, sociology, and design studies) have long been sceptical
of hospitals as holistic health environments. For example, as Dutch ar-
chitect Cor Wagenaar (van den Berg and Wagenaar, 2006) has noted:
Hospitals are also built catastrophes, anonymous institutional com-
plexes run by vast bureaucracies, and totally unfit for the purpose
they have been designed for […] They are hardly ever functional,
and instead of making patients feel at home, they produce stress and
anxiety. (p. 254)
In view of this sentiment, it is necessary to question whether medical
environments serving diverse patient groups can be expected to meet the
needs and expectations of a highly specialized patient group, namely,
those at the end of life. An important difference between places for the
sick and places for the dying is that while one operates within a cura-
tive paradigm, the other does not. When a medical site does not promise
a return to good health—instead, managing bodily deterioration to fa-
cilitate a compassionate end—then its physical ambience must extend
beyond postmodern preoccupations with efficiency, precision, and tech-
nological flair. Moreover, physical environments of care have the power
to break cultures of silence surrounding death—by affording it its right-
ful place, and indeed, much-needed social visibility. The hospital-based
palliative unit has been criticized for frequently being tucked away from
sight in “the uppermost levels or most distant areas, perhaps as an effort
to either safeguard it; ensure peace and quiet; or to minimalize the vi-
sual impact of death” (p. 259) (Adams, 2016). Yet, others have argued
that completely segregating places of death from the medical institution
may inadvertently foreground the idea of a place apart, to which a pa-
tient is sentenced, after all hope has been exhausted (Worpole, 2009).
In overview, the tensions between how palliative sites are conceived,
utilized, and interpreted must be acknowledged as end-of-life care un-
dergoes changes and places of death transform.
In recent years, several healthcare innovation initiatives have ap-
plied the principles of evidence-based medicine to the built environ-
ment, giving rise to the evidence-based design movement, which aims
to “carefully observe, quantify and analyse the way people use build-
ings” (Macleod, 2005). As a result, much research has been undertaken
over the past few decades to establish the relationship between medical
architectures and patient experience (Martin, 2000). Consulting with
patients, families, and healthcare providers is critical for determining
their needs and expectations vis-a-vis the palliative environment. Yet,
identifying opportunities for such collaborations is beset with numer-
ous tensions of a pragmatic and philosophical nature. As design critic
Alice Rawsthorn explains, dying is a sphere where “the interests of [the]

E-mail address: michelle.knox@ualberta.ca

https://doi.org/10.1016/j.wss.2020.100012
Received 4 June 2020; Received in revised form 15 November 2020; Accepted 27 November 2020
Available online 1 December 2020
2666-5581/© 2020 The Author. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
M. Knox
government, religion, the law, capitalism and free will all converge,
making it an unusually complex field.” (Rawsthorn, 2015) Although
design-led change has yielded vast benefits—primarily improving navi-
gational and wayfinding problems in clinical spaces—the end-of-life do-
main must now consider whether evidence-based problem-solving ap-
proaches might actually reiterate the idea that managing death is merely
a matter of human skill and technical expertise.
Sociologist Zygmunt Bauman (Bauman, 1992), in discussing modern
attitudes towards death, has commented upon our tendency of “dissolv-
ing the issue of the struggle against death by an ever growing and never
exhausted set of battles against particular diseases and threats to life”
(p. 10). As such, this paper does not aim to collate and critique architec-
tural projects and design undertakings in palliative care. Rather, it steps
back to situate death and dying within the precincts of social life—and
by extension—to social sites that humans build and inhabit. To do so,
it begins with a brief rationale for why space and place achieve signif-
icance in this domain, moving on to examine temporal experience in
the built environment, and finally, reviewing how end-of-life design has
sought—or may further seek—to address these concerns.
2. Fostering wellbeing in the palliative environment
Upon tracing where people have been spending their final days, it
becomes clear that the place of death has shifted in tandem with tran-
sitions in the palliative care landscape. Trends in the location of death
have come almost full circle—from the home at first, to hospitals as
medicine advanced, to modern hospice spaces, and now back to home
again (McGann, 2011). It is necessary to recognize that there are many
types of end-of-life sites today where palliative supports and services are
provided, including hospices, hospitals, homes, and increasingly, long-
term care residences. The evolution of sites of death cannot be sepa-
rated from their changing social meanings—i.e., the health discourses
they have come to embody and the institutional roles and social atti-
tudes they signify—often reflecting, if not modelling, public perceptions
about dying well. It is not so much the aim of this paper to typify the ar-
chitectural characteristics of different kinds of end-of-life locations as it
is to observe the underlying links between existential anxiety, designed
space, and care—proposing further work within this obscure, but criti-
cal, area of human wellbeing.
Despite the growing recognition of designing context-appropriate
health environments, there is a perplexing dearth of literature that
specifically focuses on human-centred and experience-based design
practices that might transform the palliative building. In fact, in the
last couple of decades, only two major texts have examined design for
the end of life in substantial detail. First, Verderber and Refuerzo’s Inno-
vations in Hospice Architecture (2003) located palliative care—from me-
dieval, through modern, to postmodern times—in detailed analyses of
numerous hospice facilities from around the world. Second, Ken Wor-
pole’s Modern Hospice Design (2009) compiled exemplars of good hospice
design from many countries—including actual design briefs—placing ar-
chitectural particularities under the lens of existential suffering. Noting
that hospice philosophy originated to resist the medicalization of end-
of-life service, Worpole (2009) has stated, “It is within this burgeoning
concern with the institutionalisation of death that the hospice move-
ment gained a foothold and a purchase on the modern social imagina-
tion" (p. 6).
The next three sections will attempt to reframe the site of death be-
yond a material construction towards a metaphoric construct—imbued
with social and personal meanings in relation to belonging in place, ex-
periencing time, and reconciling existential anxieties.
2.1. From space to place: some general comments
Sociologist Henri Lefebvre (Lefebvre, 1991) has described the ’pro-
duction of space’ as involving an abstract conglomeration of material
2
Wellbeing, Space and Society 2 (2021) 100012
objects within it, with ’social space’ being created when human activ-
ity unfolds through experience, cognition, and imagination. First con-
ceived and explained in such manner by scholars in phenomenolog-
ical geography (Relph, 1976), ’space’ is now increasingly understood
as that which is “universal, abstract, [and] quantifiable”, while ’place’
may be considered as a “qualitative, historically emergent, experien-
tially grounded mode of inhabiting or dwelling in the world that in-
vests particular locations with personal and collective significance” (p.
214) (Whitridge, 2004). Whitridge (2004) further acknowledges that
there is no “imaginative place-world wholly apart from quantifiably
real landscapes, bodies, and things, but neither is there a material
world that is not thoroughly invested with significance as a precondi-
tion of human thought and action” (p. 216). Place has also been said
to arise “from particular localities and not from space itself” (p. 332)
(Heidegger, 1977), expanding past physical territory towards a psycho-
logical map (Strang, 2008). In the same vein, anthropologist Peter Jo-
hansen (Johansen, 2004) believes human dwelling to occur within cul-
tural landscapes, which are formulated from “spatial and temporal fields
of action [where] material and conceptual contexts are constructed and
negotiated through the processual articulation of social action, structure
and the physical environment” (p. 310).
It may then be concluded that all location is bridled with some man-
ner of social substance, articulated in culture through diverse ways of
knowing and varied forms of expression. All sites carry meanings that
have been established, sustained, and re-structured over time by the
people that populate them, their everyday practices, their connections
to other sites, and the material objects placed within and across these
sites.
In the field of architecture, Bill Hillier and Julienne Hanson
(Hillier and Hanson, 1988) developed the ’space syntax theory’ to ex-
amine the social impact of designed spaces and built layouts. Spatial
organization reveals how a society functions by uncovering the nuances
of social hierarchies, interactions, inter-relationships and navigational
patterns (Hillier and Hanson, 1988; Hillier, 2007; Bafna, 2003). Accord-
ing to Hillier (2007), buildings “elaborate spaces into socially work-
able patterns to generate and constrain some socially sanctioned […]
pattern of encounter and avoidance and elaborate physical forms and
surfaces into patterns through which culturally or aesthetically sanc-
tioned identities are expressed” (p.16). While built space acquires mean-
ing and identity from both its practical functionality as well as so-
cial processes, it is important to note that these spaces can, in turn,
shape pragmatic features as well as social practices. Jeremy Bentham’s
1791 panopticon—a design that enabled a centralized view of all in-
mates in a prison—is a classic example of how built spaces launch dis-
courses of omniscient power, surveillance, and control (Foucault, 1977;
Leone, 1995). The panoptician notion of watching and being watched
is applied in many modern spaces—shopping malls, airports, hospitals,
political institutions, and the like—that is, wherever a certain authority,
whether governmental or corporate, asserts power and control over the
collective.
In The Birth of the Clinic, Foucault (Foucault, 1973) calls domains of
illness and cure not only ’pathological spaces’ but also ’social spaces’.
Healthcare facilities standardize human behaviour, direct patterns of
navigation, and ensure that most human interactions occur not just pub-
licly, but also in dictated forms. The mediscape becomes a place where
power relations fix the patient in the role of the recipient of treatment,
rather than an equal participant in the care journey. Hospital architec-
ture may then be said to take on a disciplinary role; the London Asylum
being an early and frequently cited example, resembling the panopti-
cian “physical enclosure in which docile bodies are subject to constant
surveillance” (p. 101) (Prior, 1988). In medical sites, control and segre-
gation is achieved through a sophisticated corpus of directional signage,
explicit rules for sanitation, implicit rules for social conduct between
involved parties, regulated points of contact between practitioners and
patients, and designated areas for various activities, such as medical pro-
cedures, seating, waiting, consulting, and grieving. Prior (Prior, 1988)
M. Knox
argues, however, that control and segregation are not the sole purposes
of spatial organization in the clinical environment. She draws attention
to how an architect might use disciplinary spatial divisioning as per bod-
ily functions or cultural habit and, finally, according to the distribution
of labour across particular professional spheres:
The bathrooms, day rooms, airing grounds, wash-houses, bed-rooms,
spell out in some detail the elements of a culture in which the body
and its functions are closely regulated… Such a division of space and
time [is made] according to bodily function and the principles of pri-
vacy… we see before us a history of the body as well as a history of
illness and disease, for the building represented by these plans consti-
tute[s] our modern image of bodily care and organization… Finally,
we see expressed in this architecture a nascent division of labour…
one’s place in the hierarchy of labour, and volume and status over-
lap so as to ensure that those who inhabit the higher echelons of the
disciplinary apparatus obtain the largest amount of space. The great-
est amounts of space to supervisors, less to the keepers, yet still less
to the menial functionaries. It is an architecture of social hierarchy
which echoes throughout the nineteenth and twentieth centuries,
and serves to underpin the strict division of tasks which define mod-
ern medical practice (p. 105).
Clinical spaces often appear to be threatening, overbearing, and omi-
nous structures that invoke despair and hopelessness—designs that reaf-
firm the idea of illness as punishment and confinement (Sontag, 1979).
Within end-of-life architecture, it is imperative to consider how “id-
iosyncrasies of style, building and settlement… though most puzzling
and variable” (p. 10) (Hillier, 2007) can instead envision care spaces
that feel less disciplinary, creating room for us to assert dignity and
selfhood in death.
2.2. Cultivating time and place through architecture
The awareness of time’s passage is heightened at life’s end. Apart
from keeping out external hostilities, built space also alleviates meta-
physical despair, enabling humans to avert the deep "terror of time" and
“wrest place from space” (p. 59) (Harries, 1982). Philosopher Gaston
Bachelard (1969), in his conception of the ’oneiric house’, proposes that
“life begins well, it begins enclosed, protected, all warm in the bosom
of the house” (p. 7). In constructing and inhabiting new built struc-
tures, man asserts his lust for the permanent, the indestructible, and the
ageless—referencing what Bachelard calls the ’motionless childhood’,
where the home once provided "illusions of stability [becoming] an in-
strument by which we confront the cosmos…” (p. 17). All buildings, by
invoking memories of past unperturbed life, invariably contain some no-
tion of the home—embedding “fixations of happiness” borrowed from
places in which we have lived earlier (p. 6) (Bachelard, 1969). Places for
the end of life, sometimes likened to our ’last homes’, have consistently
reflected these sentiments, particularly in hospice settings.
Architectural theorist Juhani Pallasmaa (Pallasmaa, 1998) has writ-
ten extensively about architecture’s ability to "enable us to see and un-
derstand slow processes of history, and to participate in time cycles that
surpass the scope of an individual life" (p. 56). Extending the notion of
the space-time continuum beyond theoretical physics into man’s existen-
tial “anxiety of death, disappearance, insignificance and non-existence”
(p. 55), he contends that architecture’s fundamental function is not only
to grant us “our domicile in space,” but also to arbitrate our relation-
ship with the “fleeting element of time” (p. 54). Critiquing the “rushed
and impatient” post-industrial building for its disengagement with the
"specificity of space and place", Pallasmaa (2016) protests that:
Instead of creating existential microcosms, embodied representa-
tions of the world, architecture projects retinal images for the pur-
pose of immediate persuasion. Flatness of surfaces and materials,
uniformity of illumination, as well as the elimination of micro-
climatic differences, further reinforce the tiresome and soporific uni-
3
Wellbeing, Space and Society 2 (2021) 100012
formity of experience. All in all, the tendency of technological culture
to standardize environmental conditions and make the environment
entirely predictable is causing a serious sensory impoverishment.
Our buildings have lost their opacity and depth, sensory invitation
and discovery, mystery and shadow (p. 78).
With wayfinding forming a central concern of evidence-based de-
sign interventions, navigation challenges in clinical environments were
first met by painting signage on colour-coded stripes on the ground
(Verderber, 2010). In later years, signage with big lettering and bold
colour schemes—what Adams (Adams, 2016) has related to Disney
park graphics—were plastered around hospital interiors, in an at-
tempt to disguise deeper underlying problems. Echoing Pallasmaa’s
(Pallasmaa, 2016) sentiments, Adams charges the present day ’con-
sumerist’ hospital with bearing close resemblance to a high-end ho-
tel. According to her, such buildings are like “suburban office parks,
with spreading pavilions, circular drop-offs and gardens, and brightly
coloured facades…[with] multistory atria and retail establishments,
looking more like shopping malls than homes” (p. 257).
With respect to these criticisms, it becomes vital to question whether
clinical spaces—while needing overall enhancement of experiential fac-
tors—might be especially unfeasible to host our most profound existen-
tial moments. In order for man to reconcile himself with the fact of his
mortality, Pallasmaa (Pallasmaa, 1998, 2016, 2000) proposes that ar-
chitects today should consciously embrace the ’devices of time’—which
include signs of erosion and wear, imperfect materials, and natural el-
ements like water and vegetation. By incorporating such elements into
our built spaces, we discard the arrogant autocracy of modern structures
(Pallasmaa, 2016), instead embracing fragility, individuality, and weak-
ness in buildings that mirror the human condition (Pallasmaa, 2016,
2017, 2007). As all physical matter traces temporal duration through
erosion and change, these material elements not only remind us of our
own biological mortality, but also situate us firmly and comfortingly
in life’s continuum (Pallasmaa, 2016). Pallasmaa favors the haptic and
emotive in buildings over the formal, technical, and uniformly func-
tional. For example, he argues that man’s desire to consume images
of the built ruin—historical settings that measure and mark out pro-
cesses of birth, decay, death, and renewal—heighten the sense of ’being
in time’. Modern buildings should similarly evoke and pacify our tem-
poral sensibility—through the layering of materials, styles, and activi-
ties—creating space for performing the everyday and the ceremonial,
the functional and the metaphorical. Such buildings may then offer us
slow participation in dense visual, auditory and tactile stimuli, nourish-
ing our experience of inhabiting both place and time, and appeasing our
anxieties of deterioration and demise (Pallasmaa, 2016, 2000).
Since human beings associate the slowing of time with spaces of do-
mesticity and private ownership, design practices must carefully con-
sider material and spatial choices in palliative settings. Further, religious
and cultural differences affect how people conceive of time and place
in their final days. Utilizing secular design language is critical in order
to ensure that the environment remains flexible and adaptable to indi-
vidual wishes, preferences, rituals and beliefs. The metaphor of the ’last
journey’ is often used by patients and staff to describe the end of life, al-
luding to the experience of key thresholds in time’s trajectory. Architect
and design critic Edwin Heathcote (Heathcote, 2005) observes that in
the hospital “your time doesn’t really matter anymore”—an assessment
that hospice philosophy hopes to overturn in its attempts to make time
count for those it serves (Worpole, 2009).
2.3. Re/de-medicalization of places of death
In the first half of the twentieth century, hospital geriatric wards
housed the aged and the invalids, usually those with incurable ail-
ments, in the back end of the building, away from the heart of social
life and activity. Non-terminal patients were assigned the front wards,
a spatial arrangement that reflected institutional and social hierarchy
M. Knox
(Verderber and Refuerzo, 2003). In 1967, when the world’s first mod-
ern hospice—St. Christopher’s—was built in London, nineteenth cen-
tury ’death-houses’ were still associated with the hospice movement
(Verderber and Refuerzo, 2003). While St. Christopher’s garnered much
criticism for its institutional scale and cold ambience, palliative care
wards today continue to be disparaged similarly for their institutional
features—as busy, disorienting, and melancholic environments. Often
hidden away as extensions of modern oncology wings in large general
hospitals (Verderber and Refuerzo, 2003), they also suggest that a death
outside the home is “a death outside society—because, in a hospital en-
vironment and despite the existence of palliative care units, death is still
something of which to be ashamed” (p. 127) (Degrémont, 1998).
Over the decades, the demographic correlated with death has al-
tered considerably—now bearing a strong association with old age. In
earlier periods of history, death was more randomized and unforesee-
able as lesser understood diseases were able to suddenly strike peo-
ple of all ages. With medical advancements, increasing immunization,
more accessible and often state-funded healthcare, developed societies
later transformed into ageing societies (Worpole, 2009). Bolstered by
the palliative movement, sites of death were championed as places
"where ordinary people face up to extraordinary challenges and with
the help of skilled and dedicated health care professionals, triumph
in the face of progressive physical deterioration and sequential losses"
(p. 36) (Worpole, 2009). Since the earliest days of its conception, hos-
pice philosophy has rejected the hospital as the medical machine, in-
stead supporting the emergence of an idealized opposite—the natural
and the domestic (Verderber and Refuerzo, 2003). In many ways, the
modern hospice facility symbolizes a home-like place that promises
to provide “solace, strength, and meaning… in both metaphoric and
instrumental ways” (p. 31) (Verderber and Refuerzo, 2003). Some
commentators, however, have noted that hospice buildings—initiatives
to re-locate death within the frame of homely comfort and familiar-
ity—are merely "hospitals disguised as houses" (p. 253) (Adams, 2016),
reinforcing the age-old sentiment that death had best take place at
home.
With worldwide trends showing a decline in the number of deaths oc-
curring in hospitals each year (Statistics Canada, 2018; Teno et al., 2018;
Cole, 2012), the home has resurfaced as the ideal(ized) place to die. It is,
however, problematic to generalize such a view. Architectural scholar
Sarah McGann (2011) suggests that dying at home is an idea reliant
upon older conceptions of home, family, and community—borrowed
from a time when birth, death, sickness and care were more visible,
commonplace, and expected occurrences within the domestic domain.
She claims that ’care’ was an assumed characteristic of relationships
between family and community members, just as the designs of older
homes also involved spatial considerations for these activities across the
spectrum of life. Today, dying is generally not imagined as one of the
obvious purposes for which a house is built or lived in. Additionally,
she argues that the nature of modern social life affects whether or not
every person has family members with the capacity to become suitable
carers—with respect to economic, geographical or other considerations
(McGann, 2011). Further, as Lawton’s (Lawton, 1998) work has shown,
some patients may not wish for family members to witness their bod-
ily decline, and instead, prefer to receive professional palliative care to
manage their ailments. In such a situation, the dying person’s sense of
dignity and autonomy may necessitate deliberate dissociation from the
overly intimate spaces of domesticity, instead favoring a move away
from home at the end of life.
How people live in contemporary society would affect how people
might die at home in the future. Living alone through divorce, wid-
owhood, or by choice, residing in an apartment building, shared or
rented houses, or in aged-care unit, and moving houses, neighbour-
hoods, suburbs and cities frequently—all these patterns affect how
we live, as they affect the notion of ’home’ and our capacity to die
there (p. 495) (McGann, 2011).
4
Wellbeing, Space and Society 2 (2021) 100012
With changes in how people interact with health systems and ac-
cess health services today, Verderber (2010) has drawn attention to
what he terms as ’functional deconstruction’—i.e., the fragmentation
of medical care and the emergence of new service delivery locations,
such as those built inside roadside strip malls (for e.g. diagnostic cen-
tres, cardiac health institutes, etc.). He believes that such a fractured and
stripped-down model points to cultural rootlessness and a loss of critical
regionalism, local vernacular, and sense of place. This rise in medical-
mall culture (Sloane and Sloane, 2003) may be contrasted against a
quickly growing alternative—the development of health villages (e.g.
the Freeport Health Care Village, Canada, or the Hogeweyk Dementia
Village in the Netherlands). A health village may be described as “an ag-
gregation of health-related services, geographically located on a single
campus, such as a medical centre… or as a loose affiliation of inde-
pendent facilities located in close proximity yet non-contagious to one
another” (p. 128) (Verderber, 2010). Being more "human-scaled, patient
and family-centred," the modern health village may be a superior ’func-
tional deconstruction’ of the modern megahospital—providing a “one-
stop point of service care model", involving communities in the normal-
ization of ageing, death, and care—especially if "located at the core of
a population centre, not on its periphery” (p. 128) (Verderber, 2010).
2.4. A note on Maggie’s centres
The brief for Maggie’s Centres—which have arguably become one
of the most visible proponents of thoughtful design in healthcare—calls
for a building that can “rise to the occasion” (p.219) (Jencks and Heath-
cote, 2010) and communicate its purpose through “the redemptive
power of space, light, and sculptural form” (p. 253) (Adams, 2016).
Maggie’s are a group of small non-residential cancer care buildings,
designed by some of the foremost names in architecture (e.g. Frank
Gehry, Zaha Hadid, Richard Rogers, Kisho Kurokawa, and others). An
initiative started by cancer patient Maggie Jencks and her architectural-
theorist husband Charles Jencks, Maggie’s Centres are resolute, con-
spicuous, outspoken structures that evade conformity to residential or
hospital templates. In deliberately avoiding these weary associations,
they make a crucial statement—that a healthy society confronts sick-
ness and death openly (p. 261) (Adams, 2016)—with forethought, com-
passion, and courage. Bold and powerful, they exemplify what Adams
(Adams, 2016) has called “look-at-me architecture, an image that is nor-
mally reserved for larger, monumental building types such as museums,
and are thus a counterpoint to the history of hospices, which tended to
be rather invisible in buildings designed as houses” (p. 253).
The first Maggie’s Centre was built in 1994 by Richard Murphy, who
details the dilemmas of pioneering a new building-type. Much of his
uncertainty is still valid today and designers would benefit from con-
templating the questions that he probed when first approached with the
project. Murphy (Jencks and Heathcote, 2010) says: “There were prob-
lems with the brief, the wooliness of it. What exactly was the building
for? We knew it wasn’t going to be a clinical building, but Maggie was
going on about all kinds of things, relaxation, a library, meetings, yoga,
beauty care. How would we fit all this in?” (p. 94) The risk taken by Mur-
phy paid off, and ultimately, the Edinburgh Maggie’s Centre marked a
pivotal point in palliative architecture, one that affected the tone and
conception of all subsequent Maggie’s Centres. As Martin (2016) has
noted, Maggie’s Centres extend the notion of therapeutic space beyond
that which is clinical, and instead, "demonstrate the efficacy of every-
day objects and spaces in achieving new understandings and practices
of care" (p. 53).
Maggie’s Centres co-founder, Charles Jencks (Jencks and Heath-
cote, 2010), writes in The Architecture of Hope about the difficulties of
classifying these buildings, calling them a ’mixed type’. He believes that
they are houses, but not homes; community hospitals, but not institu-
tions; places for spirituality, but non-denominational; art galleries, but
not museums (p. 14). American architect, Frank Gehry (Gehry, 2003),
M. Knox
whose design for the Maggie’s Centre in Dundee (Scotland), received
much public and media interest, said at its opening:
I wanted to create a building that would be calming and accommo-
dating, and one that would be a fitting tribute to Maggie. I think
it’s an inviting building, I think people will want to come inside and
spend time there, and I really hope that in some small way, it might
contribute to a sense of rejuvenated vigor for moving forward and
living life.
Despite the fact that Maggie’s Centres are always non-residential and
outwardly undemure, they bask in an interior domestic warmth—or
to use Jencks’ term—they celebrate ’kitchenism’. The dining space is
always a core design element that sustains the idea of hearth and
home—with tea, coffee, cookies and cushions forming a recurrent mo-
tif throughout the interiors (Jencks and Heathcote, 2010). According to
Jencks (Jencks and Heathcote, 2010), a Maggie’s Centre is "welcoming,
warm, skittish, personal, small-scaled and centred around the kitchen
or place to make coffee and tea. The centrality of food and drink allows
people to enter and exit without declaring themselves, try things out,
listen or leave without being noticed" (p. 13).
Maggie’s Centres consider offices, counselling rooms, meeting
rooms, and toilets secondary, while gardens and kitchens are more in-
tegral, with building layouts exhibiting "tight, surprising corners, am-
biguous overlapping spaces" (p. 27) (Jencks and Heathcote, 2010) and
continuations in the flooring to connect indoor and outdoor areas—a
feature that Verderber (2010) has termed ’theraserialization’ (therapeu-
tic serialization). These elements come together to enrich and celebrate
sensory experience at life’s end, and in so doing, reject cancer’s other-
worldliness. They also bring patients under the fold of everyday nor-
malcy, community acceptance, and yet, become a canvas for personal
vulnerability, dignity, and fortitude. Writing in praise of Zaha Hadid’s
compelling Maggie’s Centre in Fife (Scotland), Heathcote (2006) has de-
manded provocatively: “Why should spaces built to contain some of our
more traumatic moments always be modest and domestic; bland and in-
offensive as an old folks’ dining room or a municipal crematorium?” (p.
1305)
Maggie’s Centres offer useful lessons for visible and communicative
architectures at the end of life, declaring the role of the built environ-
ment in our experience of illness and wellness, assuaging deep human
angst, and bringing difficult medical situations to the forefront of social
dialogue.
3. Conclusion
With growing attention on the importance of patient experience,
many healthcare institutions have attempted to harness specialized
professional expertise—from the fields of design, architecture, human
factors, usability studies, anthropology, and industrial engineering—to
make themselves more accessible to the communities they serve. As a
setting that does not quite fit into medicine’s primary enterprise—of
defeating sickness with scientific knowledge—the end-of-life environ-
ment stands at an increased risk of erasure. Not only does this highlight
medicine’s grave failure to prioritize one of life’s most profound phases,
it also ensures the containment of dying persons at the peripheries of
society.
Research continues to reveal that the public is death-denying and
conversations about the end of life are still taboo (Ipsos MORI and NHS
2010; Seymour et al., 2010). Yet, cultural attitudes towards death and
how society deals with it are poised at a turning point today. The high in-
cidence of pandemic-related fatalities in long-term care residences, new
legislations sanctioning medically assisted death in many jurisdictions,
and increasing awareness of the importance of advance care directives
are only a few factors that have reinvigorated dialogue on death and
dying. These events have opened up discussions not only about how,
but also where people will die in coming years, and what society most
needs in order to foster wellbeing, compassion, and care.
5
Wellbeing, Space and Society 2 (2021) 100012
This paper has offered theoretical perspectives and design prac-
tice examples to position the death—and its anxieties—as a criti-
cal avenue for fulfilling the “societal mission of architecture” (p. 56)
(Pallasmaa, 1998). It has argued that places of death hold social, moral,
personal, and political meanings and—as sites of fundamental human
anguish—demand to be cultivated as such. Moving forward, transdisci-
plinary work—from research as well as practice standpoints—is urgently
needed in order to expose and address the complexities with which end-
of-life spaces are invested. Participatory design and service design ap-
proaches hold promise for involving patients and providers—and more
generally, the public—in designing future palliative sites. As Cottam and
Leadbeater (2004) have said, "we need a different way forward: not fur-
ther incremental innovation but rather radical transformation and a new
approach" (p. 6). Considering the rapidly morphing end-of-life sphere,
the time is ripe to re-examine our places of death and reassess the mean-
ing of dying well within social and medical discourses.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
The author thanks Aidan Rowe (University of Alberta) and the
anonymous reviewers at Wellbeing, Space and Society for their feed-
back and thoughtful comments on the paper.
References
Adams, A., 2016. Home and/or hospital: the architectures of end-of-life care. Chang. Over
Time doi:10.1353/cot.2016.0015.
Bachelard, G., 1969. The Poetics of Space, translated by Maria Jolas (Boston: Beacon).
Bafna, S., 2003. Space syntax: a brief introduction to its logic and analytical techniques.
Environ. Behav. doi:10.1177/0013916502238863.
Bauman, Z., 1992. Mortality, Immortality and Other Life Strategies. Polity Press, Cam-
bridge.
Cole, A., 2012. Hospital deaths are on decline, but change is slow, says new report. BMJ
344. doi:10.1136/bmj.e3307.
Cottam, H., Leadbeater, C., 2004. RED paper 01: health: co-creating services.
www.designcouncil.org.uk/RED (Accessed June 3, 2020).
Degrémont, N., 1998. Palliative care and architecture: from hospital to people. Eur. J.
Palliat. Care 5, 127–129.
Foucault, M., 1973. The Birth of the Clinic. Pantheon, New York.
Foucault, M., 1977. Discipline and Punish: The birth of the prison. Harmondsworth: Pere-
grine.
Gehry, F., 2003. Maggie’s centre Dundee by Frank Gehry, http://www.
galinsky.com/buildings/maggiescentre/ (Accessed June 2, 2020).
Harries, K., 1982. Building and the Terror of Time. Perspecta doi:10.2307/1567050.
Heathcote, E., 2005. Where Architecture Meets Healing. Financial Times
https://www.ft.com/content/374ffa48-5db1-11da-be9c-0000779e2340.
Heathcote, E., 2006. Maggie’s centres. Br. Med. J. 333, 1304–1305.
doi:10.1136/bmj.39062.614132.55.
Heidegger, M., 1977. The question concerning technology’in Krell. PhD diss., D.(ed.) Mar-
tin Heidegger Basic Writings. New York: Harper & Row.
Hillier, B., 2007. Space is the machine: a configurational theory of architecture. Space Syntax.
Hillier, B., Hanson, J., 1988. The social logic of space. Soc. Log. Sp.
doi:10.4324/9780429450174-9.
Ipsos MORI and NHS, Attitudes towards death and dying in the east of England - qualita-
tive report research to inform the development of, (2010). https://www.ipsos.com/
ipsos-mori/en-uk/attitudes-towards-death-and-dying-east-england (Accessed May 23,
2020).
Jencks, C., Heathcote, E., 2010. The Architecture of Hope : Maggie’s Cancer Caring Cen-
tres. Frances Lincoln, London.
Johansen, P.G., 2004. Landscape, monumental architecture, and ritual: a re-
consideration of the South Indian ashmounds. J. Anthropol. Archaeol.
doi:10.1016/j.jaa.2004.05.003.
Lawton, J., 1998. Contemporary hospice care: the sequestration of the unbounded body
and “dirty dying. Sociol. Heal. Illn. doi:10.1111/1467-9566.00094.
Lefebvre, H., 1991. The production of space. Prod. Sp. doi:10.2307/490789.
Leone, M.P., 1995. A historical archaeology of capitalism. Am. Anthropol.
doi:10.1525/aa.1995.97.2.02a00050.
Macleod, D., 2005. Healthy measures: architecture borrows from evidence-based
design medical practices to achieve better design and massive cost savings,
https://www.canadianarchitect.com/healthy-measures/ (Accessed June 2, 2020).
M. Knox
Martin, C., 2000. Putting patients first: integrating hospital design and care. Lancet 356,
518. doi:10.1016/S0140-6736(05)74196-9.
Martin, D., 2016. Curating space, choreographing care: the efficacy of the everyday. In:
Bates, C., Imrie, R., Kullman, K. (Eds.), Care and Design: Bodies, Buildings, Cities.
John Wiley & Sons, pp. 37–55.
McGann, S., 2011. Spatial practices and the home as hospice. Australas. Med. J
doi:10.4066/AMJ.2011.931.
Morrison, R.S., Augustin, R., Souvanna, P., Meier, D.E., 2011. America’s care of serious
illness: a state-by-state report card on access to palliative care in our nation’s hospitals.
J. Palliat. Med. doi:10.1089/jpm.2011.9634.
Pallasmaa, J., 1998. The Space of Time. Oz 20. https://doi.org/10.4148/
2378-5853.1324.
Pallasmaa, J., 2000. Hapticity and time: notes on fragile architecture. Archit. Rev. 78–84.
Pallasma, J., 2007. The eyes of the skin: architecture and the senses. John Wiley & Sons,
UK.
Pallasmaa, J., 2016a. Inhabiting time. Archit. Des. doi:10.1002/ad.2001.
Pallasmaa, J., 2016b. Matter, hapticity and time material imagination and the voice of
matter. Build. Mater. 20, 171–189. https://www.jstor.org/stable/26445108.
Pallasmaa, J., 2017. Embodied and existential wisdom in architecture. Body Soc. 23, 96–
111. doi:10.1177/1357034X16681443.
Prior, L., 1988. The architecture of the hospital: a study of spatial organization and medical
knowledge. Br. J. Sociol. doi:10.2307/590995.
Rawsthorn, A., 2015. Quoted in J. Pallister, reinventing death for the twenty-first century.
The Design Economy Series, Design Council UK, https://www.designcouncil.org.uk/
news-opinion/reinventing-death-twenty-first-century-0.
Relph, E.C., 1976. Place and Placelessness. Pion.
Wellbeing, Space and Society 2 (2021) 100012
Seymour, J.E., French, J., Richardson, E., 2010. Dying matters: let’s talk about it. BMJ
doi:10.1136/bmj.c4860.
Sloane, D.C., Sloane, B.C., 2003. Medicine Moves to the Mall. Johns Hopkins University
Press.
Sontag, Susan., 1979. Illness as metaphor. 1978. Nueva York: Vintage.
Statistics Canada, Table: 13-10-0715-01, Deaths, by place of death (hospital or non-
hospital). https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310071501/,
2018. doi: 10.25318/1310071501-eng.
Strang, V., 2008. Uncommon ground: landscape as social geography. In: David, B.,
Thomas, J. (Eds.), Handbook of Landscape Archaeology. Routledge, pp. 51–59.
Teno, J.M., Gozalo, P., Trivedi, A.N., Bunker, J., Lima, J., Ogarek, J., Mor, V., 2018. Site
of death, place of care, and health care transitions among US medicare beneficiaries,
2000-2015. J. Am. Med. Assoc. 264–271. doi:10.1001/jama.2018.8981.
van den Berg, A.E., Wagenaar, C., 2006. Healing by architecture. In: Wagenaar, C (Ed.),
The architecture of hospitals. NAi Publishers, Rotterdam, pp. 254–257.
Verderber, S., Refuerzo, B.J., 2003. Innovations in Hospice Architecture. Taylor & Francis.
Verderber, S., 2010. Innovations in Hospital Architecture. Routledge.
Whitridge, P., 2004. Landscapes, houses, bodies, things: “place” and
the archaeology of inuit imaginaries. J. Archaeol. Method Theory
doi:10.1023/b:jarm.0000038067.06670.34.
Worldwide Palliative Care Alliance, Global atlas of palliative care at the end of life,
2014. https://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf (Accessed June
2, 2020).
Worpole, K., 2009. Modern hospice design: The architecture of palliative care. Routledge,
Oxford, UK.