The Architecture for the Dying: Understanding the existing approaches in successful Hospice model

Dissertation, Semester 9, Year 5, 2019-20 A.Y

Abstract

Architecture is a multidisciplinary field and has managed to rise as a necessity than a luxury in recent times. Architecture for the Dying is a branch which will focus on the spaces designed for the terminally ill patients across the globe. Known in simple terms as Hospice or End-of-Life care, the significance and gravity of the sector are yet to be fully understood. Hospice care under the umbrella term Palliative care is a subject of rising concern. WHO defines Hospice as “an approach that improves the quality of life of patients and their families facing the problem associated with a life-threatening illness, through the prevention and relief of suffering utilizing early identification and impeccable assessment and treatment of pain and other problems which could be physical, psychosocial and spiritual.’’ The sudden need for Hospice care facilities will lead to a phenomenon of replication of existing models without looking into the design process. To handle this, existing design approaches are chosen and are studied. Further, the traditional knowledge system adds the context to the design guide to ensure sustainability and adaptability. Five Maggie Centres out of twenty-one around the globe, St Joseph’s Home in Singapore, Assisi Hospice, TIPS in Trivandrum and Karunashraya in Bangalore were studied and the case of St.Joseph hospice has been outlined in-depth to support the evidence-based approach. The findings and discussion will formulate a design guide that can be easily fitted into the social fabric of any city when compiled with the traditional knowledge systems of the city.

Keywords: Hospice, End-of-life care, architecture, design approach, universal approach

Chapter One: Introduction

1.1 Background

A part of our society that is often not given relevance to is those who are terminally ill and do not have a life expectancy of more than 6 months or a year. These people form a marginalized section of society yet cannot be neglected. Hospice care is a facility wherein this section of the society is taken into consideration. The life of a terminally ill patient and his or her family members are more or less monotonous and they require psychological and emotional support to move forward. Spaces designed to uphold the dignity of these patients where they can have ‘good life until death’ rather than a ‘good death’; can significantly help in their well being. A good hospice can be referred to as one which has everything that a home can offer and one where the patient can come to terms with the inevitable death and live to life’s fullest.

India has a vast majority of the ailing population. Even though there are policies for Palliative care, nothing much has been done to cater to their needs. More than 50% of the terminally ill population constitutes of Cancer patients. Cancer is the second most high cause of death in India and the rate of mortality due to cancer is at an alarming rate. A disease which affects people from all age groups, races or gender cripples the life of the patient as well as his or her well-wishers. Considering the Right to die in dignity, Hospice care comes into the picture. Less than 1% of India’s population has access to hospice. Kerala remains the only state who has managed to cater to the needs of terminally ill patients with it's palliative and hospice services. With several big names in the sector like Pallium India, the lack of proper infrastructure is a concern that has to be addressed. The understanding of what sets apart a hospital and hospice is what has to be dealt with through proper architectural as well as landscape inputs.

The hospice care movement, founded just over 40 years ago, recognizes this process in three stages; Dying, Death, and Bereavement. Each stage is an equally important part of an individual’s experience, requiring a focus on personal counseling and palliative medicine with the intent of achieving a desired quality of life at the end of life (Schreur, 2009). Architecture and landscape have the potential to heal one’s mind and bring peace and serenity to its users. This notion has been explored across the globe by various architects while designing hospices, hospitals, and caring homes. The materials used, spacial configurations, textures, and colors chosen, equipping it to offer proper treatment, the transition spaces and the ratio of built and open spaces can play an important role in the functioning of a hospice.

The Architecture of Death tries to meddle in the deep dark notion about death and dying. The taboos and myths that cloud the judgment and make us act insensibly.

1.2 Aim

To explore the design approaches undertaken in hospice design around the world to draw guidelines and formulate a design model that can be woven into the fabric of any city when incorporated with the traditional knowledge system and context.

1.3 Objective

To understand hospice and the role of architecture in its design
To identify the design approaches in Hospice Design and successful hospice models
Study these design approaches and draw guidelines and formulate a guidebook

1.4 Need for study

“India ranks 67th out of 100 countries in the Quality of Death Index. Currently, there are over 908 Palliative Care centers in India, which are accessible to a mere 1% of a population of over 1.2 billion people. India is a nation which has the worst of both worlds- communicable diseases and infections are still rampant and there has been an exponential rise in the prevalence of chronic lifestyle diseases and cancer. It is estimated that 5.4 million people a year are in need of Palliative Care in India (Khanna & Lal, 2016).” The state of Kerala alone consists of 841 centres out of the total 908 in the country indicating the lack of awareness and importance.Even though Kerala serves as a WHO model for Palliative Care services for the developing world, the rest of the country is lagging behind due to lower literacy rates, unawareness of the concept of Palliative Care and varied cultural attitudes to chronic illness and death across different communities (Khanna & Lal, 2016).

Architecture can play a vital role in sensitising the people about the importance of palliative care and to boost this sector. However, no design model or guideline exists to take forward this mission. The architects and designers in the country are thus unequipped to deal with the challenges that a palliative care centre design involves ranging from the varied user group to the changing needs and social norms.The design models adopted else where in the world need to be studied and broken down into a model which can be adapted to the Indian context. This study will bridge the gap between architecture and palliative care in the country. Architecture can also give a new meaning to Death and Dying and normalise it as a part of day to day life.

India with its varied cultural and religious roots cannot have a single guidebook that will fit into every city. Thus, a universal model that can be merged with the vernacular architecture and principles coupled with the context can produce effective design and improve in-patient experience within hospice.

1.5 Scope

Architecture is an interdisciplinary field and the contextual application is the need of the hour. In the next few years, the importance and relevance of Hospice will be realised in the country and the lack of data on hospice design will be the biggest problem. This study is aimed to make up for this research gap.

1.6 Limitations

This study will not focus on the financial aspects of a hospice construction, feasibility and maintenance and running of a hospice facility. It will also not focus on the management and the stake holders of a hospice care centre. The study will focus on generating a universal hospice model guidebook and will not cover any city or country in particular. It will not focus on the quantitative aspects of design and will cater only to the qualitative aspects.

1.7 Contribution

The architecture for the Dying is a relatively a new concept and this study will help in sensitising and strengthening the significance of this notion. It will act as a guide with design approaches and methods that will help proceed with a hospice design. It will present a design model that can be easily adapted in the Indian context.This study will also contribute to redefining the concepts and notions pertaining to Death and Dying through Architecture. This paper also aims to encourage conversations around the topic of death and dying until we turn ourselves into a society that can comfortably talk about death in a similar way we talk about marriage and birth. It will also shred the dark clouds of stigma, taboo and fear that surrounds and engulfs our minds and free the future generations from its clutches.

1.8 Research Questions

The state of Hospice care in India is not sufficient to meet the requirements. A model design for Hospice care becomes a prime need which does not exist at present. Architecture has been known to delve into allied fields to enhance and enrich them. The involvement of architects and as a matter of fact the field of architecture in contribution to the terminally ill or dying section of the society is minimal. The research gap between architecture of the dying and hospice care is yet to be addressed. A single suitable approach does not exist and a combination of the best approaches will give the necessary guidebook that can be merged with the traditional knowledge systems of the place is required.

Chapter Two: Literature Review

2.1 Understanding Hospice care

Hospice care is a branch palliative care provided to terminally ill patients and their families when their life expectancy is less than six months. However, in India, both the terms Palliative and Hospice care are used interchangeably and does not define a life expectancy time period. The main goal that lies within hospice care is to provide comfort and support along with easing the pain and suffering. Hospice focuses on the well being and comfort of both the patient as well as the family and this is what sets it apart from a nursing home or hospital. A major characteristic of the hospice movement has been their espousal of homely and smaller-scale buildings and settings (Worpole, 2009).This differentiates it from being a hospital complex.The urge for further innovation in the field is best demonstrated in the architecture and associated landscapes of Britain’s Maggie’s Centres, a series of award-winning, small-scale buildings designed by some of the world’s best known architects. Maggie’s Centres are included in this article as attempts to answer some of the questions about the relevance of domestic and hospital architecture for patients who have been diagnosed with cancer, a major constituency of palliative-care patients.

2.2 Role of architecture in hospice care

The urge for further innovation in the field is best demonstrated in the architecture and associated landscapes of Britain’s Maggie’s Centres, a series of award-winning, small-scale buildings designed by some of the world’s best known architects. Maggie’s Centres are included in this article as attempts to answer some of the questions about the relevance of domestic and hospital architecture for patients who have been diagnosed with cancer, a major constituency of palliative-care patients (Adams, 2016). The hospice holds different meaning to different people. It is a place of rethinking, reliving memories, living life to the fullest, finding meaning to life and as such the place has to be designed in the best possible way as you cannot afford to go wrong. The lessons of the Maggie’s Centres: that a healthy society confronts serious illness openly; that top architects are interested in working on architectures that support and enhance our understanding of sickness, dying, and death; that disguising healing spaces as homes helps nobody; that palliative and hospice care are as much about sharing as about being isolated; and that architecture can help to alleviate deep fears, have had little impact (Adams, 2016). Countless stories from healthcare professionals, patients and families recount the importance of the role that built environments can play in providing a desired quality of life to the dying individual (Schreur, 2009).

2.3 Design Approaches in Hospice design

2.3.1 Architecture for the Dying: Hospice

The architecture for the dying includes spaces that fall into the major categories of tribute, experience, and mourning like memorials, cenotaphs and crematoriums. However this only deals with the architecture concerned after life rather than architecture at the end of life. A person’s end moments form the latest memories of his or her family. These memories can be made pleasant if the space where the person spends his or her final moments contributes to creating a healthy attitude towards death and life.architects can push past their professional and cultural biases against death to fully engage in the human experience through the practice of an architecture, not of remembrance and grief, but of an ‘Architecture of Dying’ (Schreur, 2009). The fact that in spite of the value that architecture can add to a hospice, the number of architects responding to this cause is minimal. This can be pegged with the cultural notion tied to death and dying. Death is always tarnished in black and painted in a negative tone. The shift of this ideology will mark the point when much significance and importance is given to ‘Architecture for the Dying’.Hospice acts as the liaison between the individual and the architect, translating the authority of the patient, the wishes of their families and the requirements of their caretakers into inspiration for the design of environments at the end of life (Schreur, 2009). Hospice care should not be seen as a place where one goes to die in dignity rather it should be interwoven into the main social fabric thus lending it more meaning and not isolating it to form yet another hospital or nursing home.

2.3.2 Therapeutic architecture and landscape

Spaces and buildings have the capacity to control over one’s emotions and behaviour. They stimulate the senses and create neural message which can impact the overall health and well being of a person. Research shows that architecture of a building can intern impact the psychological and physiological well being of a person. Palliative architecture is a subset of Healing architecture but the ideology shifts from healing to comforting the patient. (Poulsen, Knudstrup, Hoff, & Lund, 2017) Healing architecture is the evidential concept that architecture can influence the healing process in patients through alterations of the architectural parameters that affect the healing process(Poulsen, Knudstrup, Hoff, & Lund, 2017). The parameters can be considered in three groups namely; Body, Relationships and safety. The sensory influencers like the daylight, open spaces and visual corridors affect the body and can cause therapeutic benefits if optimally used. The spatial configurations, the arrangement of rooms and the circulation affects the relationship parameter. Assuring the safety of the space through the usage of simple and readable layout and materials like copper which have disinfectant properties can feed a message of safety and hygiene within the user’s mind.The therapeutic role of the physical environment should be taken advantage of and used as part of a patients therapy. If the physical environment can assist in positive clinical outcomes, then it is the duty if the architect to provide such an environment which can contribute to the overall wellbeing of a patient (Osei, 2014).

A hospice garden facilitates mentally restorative experiences for the patients, family and staff that spend time in the hospice. Spending time in a hospice garden gives one a sense of being away and a sense of connection with nature, these feelings alleviate mental fatigue, or stress, and bring about mental restoration, or serenity (Sadler, 2007). Clare Cooper Marcus has highlighted the benefits of including landscape in one’s design for hospice is highly beneficial in her book Healing Garden – Therapeutic Benefits and Design Recommendations. Healing gardens are majorly aligned across the design guidelines guided by Kaplan’s four properties of restoration, being away, extent, fascination, and compatibility as well as by Marcus’s Healthcare garden design recommendations ( Marcus 1999; Kaplan 190-193, 1995).

2.3.3 Architectural Placebo

The lack of a qualitative scale to measure the intent of how therapeutic or healing an architectural space is in practicality is what gave rise to the notion of Architectural Placebo. Discussed in great length by the Architectural critic and co founder of Maggie’s Centres, Jencks suggests that the Maggie Centres are a kind of architectural placebo and that can be credited to the overall well being of a person rather than actual therapeutic effects. A placebo operates on the beliefs of the patient, yet it is a fake drug. Since 1950s with the work of Henry Beecher, the scientific community has taken the placebo very seriously. Experiments on patients with ailments such as pain and inflammation, have shown that in many cases a placebo works very well (Borrett, 2013).

2.3.4 Design Thinking approach

The design thinking approach caters to the formulation of principles and guidelines based on what the three major user groups of a hospice namely the patient, family and caregivers expect from a hospice care centre. This also takes into consideration the emotional and behavioural aspects that can aid in the design of a hospice. The topics that the design thinking approach takes into consideration also includes but is not limited to; the taboo surrounding death and funeral, the extend of personalisation and customisation a patient requires, the isolated and alienated nature of palliative care centres, and integration between hospice and bereavement services. Other parameters that may’ve a direct or indirect link with the design process can be listed down as the rise in ageing population and terminal illnesses, disintegration into nuclear families, Generation Y as the future care givers, designers death and funerals (Hospitable hospice: Redesigning care for tomorrow, 2013).

This design approach also arises thoughts pertaining to the ideal hospice. The integration of hospice with the city and thereby forming an Open Hospice and the integration of small functions and duties to form a Patient’s Voice Hospice. The integration of hospice with other institutions to form a township and the inclusion of hospice service into the lifestyle of the people of all age groups are the major categories that arise from the Design Thinking approach.

2.3.5 Tectonic design approach

With the book Studies in tectonic culture by Kenneth Frampton (2001) tec- tonic architectural theory was reintroduced as the structural genius of built environments linked with the ethical role of architecture. This was done on the background of architectural thinkers like Gottfried Semper (1863), Karl Bötticher (1852), Eduard Sekler (1964) and a very sensitive and poetic un- derstanding of the synergy between the visual, tangible appearance of mate- rials and the structural techniques of construction (Tenn Tvedebrink & Hvejsel, 2017). The linkage of the experienced aesthetic quality and technical realization of architecture is implied with both the theory of Frascari (1984) and Semper (1863), therefore giving rise to three key-notions, as background for an everyday ‘tectonic approach’: ‘Theatricality’ As describing the aspect of atmosphere – referring to the programming of the overall architectural scenery, explaining what it invites for; ‘Gesture’ As describing the aspect of construing – referring to the experienced spatial quality of the architectural detail, explaining what it does; ’Principle’ As describing the aspect of construction – referring to the structural build-up of the architectural detail, explaining how it does it (Tenn Tvedebrink & Hvejsel, 2017). This approach can be understood better with the analysis of The Willow Tearooms.

2.3.6 Evidence based approach

This is a qualitative method of design approach which draws inferences from the experience of the present residents in a hospice. This method has been widely undertaken but the adaptability of this design approach depends on the ethnicity, cultural and religious background of the user group and hence cannot be recommended as a universal approach. Research on the relationship between the built environment and human health can help us to understand the psychosocial, physiological, and cultural dimensions of terminal illness (Verderber, 2014). The evidence based approach also takes into consideration the comparative study of similar projects in a particular region. The evidence based approach primarily consists of documentation, interviews, discussions, review meetings and analytical reports.

Figure1:Architectural and Landscape Design Considerations in Residential Hospice Environments (Verderber, 2014)

2.4 Case studies

2.4.1 St Joseph’s Home, Singapore

St. Joseph’s home is one of the finest examples of providing care to the terminally ill. With a varied composition in the patients and care givers, they set out a mission to provide universal care. Their integrated model also stitches the hospice into the neighbourhood of Jurong West. The day care facility and the community care centres within the centre ensure that they are an active part of the society. The rooftop garden and inclusion of several small scale businesses within the fabric turns it into an effective model where hospice becomes an environment worth spending time that is etched onto the lives of every citizen. St. Joseph’s Home was born out of the well wishers of the Catholic Welfare Services in 1978 hat aimed to provide shelter, care and love for the aged and destitute, regardless of race or religion. They offer nursing, hospice, therapy, social work as well as infant & childcare services that are integrated into the hospice by various community programmes. The new integrated complex was designed by SAA Architects.

2.4.2 Assisi Home, Singapore

Assisi Hospice is yet another brilliant example of hospice in the world. They are equipped to provide palliative care to patients with life-limiting illnesses, caring for them considering them as individuals rather than carriers of diseases and their families regardless of faith, age, race and financial position. Their team consists a multitude of professionals who come from all walks of life and aim to dedicate their lives in serving and caring for the terminally ill like doctors, nurses, medical social workers, counsellors, pastoral care workers and therapists.

With the many cosy quiet spaces and comfortable furnishing, they provide comfort and dignity for patients and loved ones in a life-affirming space. With a doubled capacity for Home Care and Day Care, 85 Inpatient beds, new wards for Dementia Palliative Care and Paediatric Palliative care, a Sensory Garden, Chapel and Roof Terrace, they serve more than 2,000 patients a year.

Chapter Three: Research Methodology

3.1 Data collection

The data has been completely mainly via secondary sources which includes books, published journal, theses projects and the internet. The history and pre existing studies by similar enthusiastic researchers and authors have been carefully read through to arrive at a fitting conclusion.

Extensive research into the design and layouts of various hospice care centres were obtained from websites and Magazines relevant to the field. Journals published over the last decade have been taken into consideration to avoid repetition or replication of data. All authors and publishers have been cited and referenced wherever deemed necessary.

Chapter Four: Findings & Discussion

Creating an integrated care service has helped in improving the overall well being of the residents. It also helps in inculcating a sense of care and sensitivity among the growing generation. An integrated model would ensure that the hospice is well woven into the community and would intern enhance the chance encounters and conversation that will add joy to the numbered days of the patients. Spaces that will allow the patient to indulge in activities that were a part of his or her routine life has to be included. The sudden news of a terminal illness may drive the person into the thinking of being useless and having to lead a meaningful life. The routine incorporation would keep these negative thoughts at bay.A facility where the patient, caregivers and family are given equal importance and consideration in design will enhance the atmosphere of the hospice and adds value to the space. Also this would mean the journey begins with the admission of the patient until the bereavement period where the professionals would help the family grieve in a dignified manner.

Inculcate the caring culture within the growing generation is the need of the hour. In this generation of smartphones and internet, we have forgotten emotions and feelings. Compulsory services and frequent visits from the neighbouring schools, colleges, and offices will add a layer of belonging. Incentives and offers for volunteers to increase participation is another way to encourage and develop emotional and sentimental values.

Respecting and accepting emotions that come along with the residents have to be addressed. The patients may break down and may need a space where solitude can help them cope with their feelings. Such spaces like a hospice garden will encourage people to shed a tear or two and celebrate their lives.The most important aim would be to cater to the needs of the person beyond the tag of the illness he or she suffers from. Humane treatment and provision of ample amount of facilities are to be inculcated.

Customisation and personalisation within the hospice where every person can give the room or space they stay a character that they desire, leaving behind a footprint.Empowering patients by giving the right to make decisions Strictly following a non-institutional approach. A hospice is not meant to be another hospital and hence this guideline has to be properly considered before any small decision has to be made.Care that is accessible to everyone irrespective of caste, creed or race and that is affordable. Most hospice care and services are insured or funded completely by the Governments.

Building integrated communities to strengthen relationships and not alienating the residents and the small scale that will render the required intimacy to the residents. This will also fostering an environment where the ill and the healthy together live and work in the same community. Adaptive spaces that can accommodate the change of use efficiently will ensure that the space does not fall short with the passing years. The dynamics in spaces can also be worked out so as to achieve maximum efficiency. Integration with modern building techniques and technologies will further help in achieving a successful model.

Enjoying the little pleasures in life is what that will drive the patients in their last days. Elements and spaces where one can relive his or her best moments, cherish them or instil a sense of nostalgia will keep their last days memorable for both the family and care givers.

Chapter Five: Conclusion

These design principles and guidelines give us a framework that helps in design exploration and identification of factors that can greatly improve the in-patient hospice experiences. The universality of these design guidelines gives a clear picture of how humans deal with mortality and dying and our coping mechanisms remain the same inspire of cultural or racial differences. These guidelines also challenges of what is as of now acceptable and considered normal in our society. The dead walls separating the dying can be broken and a new ray of sunshine in end-of-life care can penetrate into our communities.

The key spaces that are to be considered within a hospice facility includes but not limited to : small scale to keep the intimacy and warmth of a neighbourhood, Admin office, Reception, Medical staff office, staff quarters or rooms, Quiet spaces or counselling areas, Bed space with option from single double or triple sharing with provision for expansion, Transition spaces within the room beyond four walls, expandable space to accommodate family and friends, privately accessible gardens, Nature integrated areas and naturally lighted and ventilated spaces, small congregation spaces, therapy rooms, gaming arena, day care patient areas, cafeteria, midnight canteen, kitchen, multiple dining areas, healing gardens, use of natural materials and colour palette, library and reading areas, learning rooms, combinations of courtyards, bereavement zones, memorial spaces, secular praying areas, meditation rooms, activity halls, vegetable and fruit gardens, movie lounge, laundry and hospitality services, crafts and arts centre, waste management systems.

These pointers also guide us in setting up a hospice that is welcomed by all people as a part of their day to life and do not alienate them. A model where the patients are empowered by giving a role in the decision making and routine activities within the community would improve the confidence and sense of well-being of a person. The hospice designs that are generated based on these principles will ensure that these patients will celebrate the best of life until the end. These principles also take care of the families and the care givers that are dedicated to providing service to the patients. It also aims at fostering a generation sensitive to the dying citizens and considers service towards them as a duty rather than a burden.

References

Literature :

Schreur, K. (2009). The Architecture of Dying: Understanding the Role of Architecture in the Hospice Community. (Electronic Thesis or Dissertation). Retrieved from https://etd.ohiolink.edu/

Khanna, I., & Lal, A. (2016). Palliative Care - An Indian Perspective. ARC Journal of Public Health and Community Medicine, 1(4), 27–34. doi: 10.20431/2456-0596.0104005

Adams, A. (2016). Home and/or Hospital: The Architectures of End-of-Life Care. Change Over Time 6(2), 248-263. doi:10.1353/cot.2016.0015.

Jencks, C., & Heathcote, E. (2015). The architecture of hope Maggies cancer caring centres. London: Frances Lincoln.

Osei, Y. M. (2014).Exploring Sensory Design in Therapeutic Architecture. (Electronic Thesis or Dissertation).

Sadler, C. K. (2007).Design Guidelines for Effective Hospice Gardens Using Japanese Garden Principles. (Electronic Thesis or Dissertation).

Borrett Emily Sîoned. (2013).The Maggie Centres: Architecture and Healing. (Electronic Thesis or Dissertation).

fuelfor Healthcare Innovation. (2013). Hospitable hospice: redesigning care for tomorrow. Singapore.

Tenn Tvedebrink, T. O., & Hvejsel, M. F. (2017). A tectonic approach to healthcare- and welfare architecture? The Willow Tearooms as an example. In ARCH17 3RD INTERNATIONAL CONFERENCE ON ARCHITECTURE, RESEARCH, CARE AND HEALTH (pp. 396–414). Anker Engelundsvej 1, DK 2800 Lyngby, Denmark: Polyteknisk forlag. Retrieved from https://vbn.aau.dk/en/publications/future-design-of-a-childrens-hospice-2

Verderber, S. (2014). Residential Hospice Environments: Evidence-Based Architectural and Landscape Design Considerations. Journal of Palliative Care, 30(2), 69–82. doi: 10.1177/082585971403000202

Poulsen, M., Knudstrup, M.-A., Hoff, P., & Lund, M. (n.d.). Future design of a children’s hospice. In ARCH17 3RD INTERNATIONAL CONFERENCE ON ARCHITECTURE, RESEARCH, CARE AND HEALTH (1st ed., pp. 72–91). Lyngby: Polyteknisk forlag. Retrieved from https://vbn.aau.dk/en/publications/future-design-of-a-childrens-hospice-2

Worpole, K. (2009). Modern hospice design: the architecture of palliative care. London: Routledge.

Kar, S., Subitha, L., & Iswarya, S. (2015). Palliative care in India: Situation assessment and future scope. Indian Journal of Cancer, 52(1), 99. doi: 10.4103/0019-509x.175578

Websites:

"WHO Definition of Palliative Care - WHO." https://www.who.int/cancer/palliative/definition/en/. Accessed 10 Oct. 2019.

“The current status of palliative care in India | Cancer Control." http://www.cancercontrol.info/cc2015/the-current-status-of-palliative-care-in-india/. Accessed 10 Oct. 2019.

"The Story of Maggie's Centres: How 17 Architects Came to ... - ArchDaily." 27 Apr. 2014, https://www.archdaily.com/498519/the-story-of-maggie-s-centres-how-17-architects-came-to-tackle-cancer-care. Accessed 10 Oct. 2019.

"Traditional Knowledge System - Assam Science Technology ...." http://www.astec.gov.in/ncsc/agb_5_tks.pdf. Accessed 11 Oct. 2019.

"Maggie's Centres | mysite - Charles Jencks." https://www.charlesjencks.com/maggie-s-centres. Accessed 11 Oct. 2019.

“St Joseph's Home, a Home Centered on the Heart of Residents.” (2017, December 11). Retrieved from https://www.caritas-singapore.org/st-josephs-home-a-home-centered-on-the-heart-of-residents/#.XcRMaJIzYWp.

“Evidence-based design practices for the palliative care environment”. (n.d.). Retrieved from https://www.bdcnetwork.com/blog/evidence-based-design-practices-palliative-care-environment.