”Architecture as medicine rethinking care for the terminally ill”

Adam Bergendal Handledare/ Supervisor

Leif Brodersen, Teres Selberg


Examinator/ Examiner

Anders Johansson


Examensarbete inom arkitektur, avancerad nivå 30 hp
 Degree Project in Architecture, Second Level 30 credits




15 januari 2015

ARCHITECTURE AS MEDICINE RETHINKING CARE FOR THE TERMINALLY ILL

Contents 04 Topic 07 Aim 09 Site 16 Program 20 Strategies 24 Design 43 Structure 55 Process 62 Literature

Topic Palliative care aims to improve quality of life for the terminally ill. Its philosophy is based on a holistic approach, which focuses on physical symptoms as well as the psychological, social and existential or spiritual needs of patients and their relatives. Societies have an ethical responsibility to provide the dying with the highest possible quality of care. However, currently the healthcare system is fractured through the separation of treatments and therapies. The three facets of terminal illness care; in-patient care, day care and rehabilitation, are often part of completely separate facilities and institutions, which provides little continuity for patients throughout the treatment process. The time frame of terminal illness is often short and the splintering of care can be traumatic and leave patients and families feeling systemised at an already vulnerable time. Palliative care provides a meaningful alternative that focuses on the needs of the individual and their relatives. The concept is to provide a clinical method, which is coupled with a psychosocial and existential approach to care.

Axlagården Umeå Hospice Umeå

Mellannorrlands Hospice Sundsvall

1km 5km 10km

Hospice Gabriel Lidköping Änggårdens Hospice Göteborg Källtorps Hospice Göteborg Bräcke Diakoni Göteborg Ängelholms Hospice

Akademiska Sjukhuset Hospice Uppsala Ersta Sjukhus Hospice

15km

Maria Regina Hospice Nacka

20km 25km 30km

Lunds Hospice hospice palliative care unit advanced home care

hospices in europe

hospices in sweden

palliative care mapping europe, sweden, stockholm

palliative care in stockholm

Capio Palliativa enheten Dalen

Södertälje Sjukhus AB

Stiftelsen Stockholms sjukhem

Ersta diakonisällskap

Löwet ASIH AB

Maria Regina hospice

Byle Gård Förenade Care AB

Capio palliativ vård Nacka

ASIH vårdavdelning Stockholm Norr

ASIH Långbro park Stockholm Södra

Praktikertjänst geriatrik AB Haninge

Förenade Care Finsta Gård

source: belport - beläggningsportal för sjukvården

cancer deaths

available beds

15 weeks

12 weeks

9 weeks

6 weeks

available beds

3 weeks

population

beds / 1000 people

cancer deaths

beds / 1000 cancer deaths

stockholm city stockholm county

stockholm city

3984

1757

864

312

1146

506

917

405

688

304

459

203

230

101

adv. home care

260

36

closed care

52

7

total

312

1176

291

339

271

203

136

43

30 1757

178

northern county adv. home care closed care total

northern county

723 960

148

244

36

47

7

291

723 960

43

148 30 1757

178

68 southern county

southern county

1051

261

303

242

182

121

61

adv. home care closed care total

221

36

40

7

261

723 960

43

148 30 1757

178

population and mortality compared to available palliative care beds

need for palliative care beds in stockholm county

source: kartläggning av palliativa vårdenheter i stockholms län - onkologiskt centrum stockholm gotland

palliative care statistics stockholm county

Aim Most hospices are run through churches or as units within larger hospitals. This project envisions a different approach, a gathering of functions within a combined framework, which facilitates a restructuring of the current care system to combine rehabilitation, home care and end of life care within a shared facility. By bridging this gap between facilities and home care this project promotes social exchange and increased access to medical staff, facilities and treatments. The project is aimed towards patients between 18-65; this age group is often ignored in the dialogue regarding terminal care facilities. However they, and their families, require extensive support due to the premature nature of their illness. Therefore this demographic and their varied circumstances was at the forefront when considering the project’s location. With this is mind, the validity of the greenfield but ultimately remote facility came into question, many patients within this age group will have young families and urban-centered lives. The primary concern for most terminal patients is proximity and access to family and friends, and therefore a central location with excellent communications was prioritized.

design for both patients and public

rehab medical

adaptive re-use of existing building

light

water

art

counseling

holistic approach to care

garden

grief care

gathering of programs

physical

range of rehabilitation therapies

approach diagrams

separation of life and grief

Site Located at the edge of Kronobergsparken, in the middle of Kungsholmen in Stockholm, the site is one of only a few instances within the city of available land with a rich, varied green space. The park has a changing topography and protective character; due to its location in-between housing blocks that hide it from plain view. The proximity to this green space goes some ways to reconcile the program with its traditional greenfield setting. The site itself has been home to the fire station of Kungsholmen since its completion in 1930. The momentous building is a significant landmark in the area, however its future is currently unclear, as the fire department will move to a new site in 2015. This decision has left the existing building without a clear purpose, and potentially under threat of demolition. The site elevates the issue of care for the terminally ill, a topic that rarely gets discussed in a public forum, to a prominent place in the community. It is hoped that this will work to address the taboos surrounding the topic.

aerial site view kungsholmen

site photos site and surroundings

site photos interior

gatan

Flemi

ngga

Sank

t Eriks

tan

Drottningholmsvägen

Hantv

erkarg

atan

fire station today fire station re-located hospital law enforcement university high school pre school kindergarten playground subway bus stop

0

5

site mapping 1:15000

7,5km

proximity to park

proximity to public transport

space for play & recreation

building pushed back from street

park access

park activity

site analysis diagrams

orientate site towards park not road

maintain deep setback from street

softening of edges between public and private

new modes of establishing boundaries

sequential experience

extending park through building

site strategies diagrams

Program The program and spatial development of the project has been carried out through extensive research into the topic of palliative care. Precedents from around the world has been analysed in terms of spatial configuration and compiled into a set of common functions that exists between all references. Apart from these spaces, a group of special functions were added. These functions were not prevalent among all references but deemed valuable additions to the program. At last, functions were added that were not part of any precedents but instead came from literature about the topic. The three sets of functions were then grouped into different types of spaces and compiled according to a set of desirable criteria, such as whether they should be private or communal, light or dark and what views were desirable. The following program study was used throughout the process as a rational example of spatial configuration. The final project deviates from the study where necessary in order to fulfil other important criteria.

North London Hospice

The Ark Center for Palliative care

Maitri AIDS Hospice

Seirei-Mikatagahara Hospital Hospice

program analysis case studies

Jerusalem House

Sakuramachi Hospice

Staff room

Kitchen

Nurses station

Cafe

Meeting room

Bookable office

Creative therapies

Outdoor play for children

Yoga / Meditation

Reception

Dayroom / multipurpose

Patient room

Accomodation for families

Electrical

Utility & cleaning room

Library

Outdoor meditation spaces

Interaction with animals

Conservatory

Foyer

Living room

WC

Counseling room

Recreation / physical therapy

Sluice

Supply room / pharmacy

Conference room

Grieving room

Dressing rooms

Recreational space (park)

Staff parking

Dining room

Storage

Contemplation / meditation

Sun terrace

Rest room

Server room

Mechanical

Nature immersion room

Group session room

Multidisciplinary team office

Visitor parking

Administration

Laundry room

Spa / hydrotherapy

Consulting room

Day care

Interview room

Fringe seating

Activity room for children

Staff dressing room & WC

Staff rest room

common functions

Restorative garden

special functions

program analysis functional mapping

additional functions

Mechanical

Administration

Bookable office

Dayroom / multipurpose

Library

Patient room

Day care

Sun terrace

Staff parking

Electrical

Staff room

Meeting room

Living room

Creative therapies

WC

Rest room

Nature immersion room

Visitor parking

Server room

Staff dressing room & WC

Conference room

Dining room

Interaction with animals

Nurses station

Spa / hydrotherapy

Fringe seating

Restorative garden

Foyer

Utility & cleaning room

Staff rest room

Interview room

Kitchen

Activity room for children

Sluice

Accomodation for families

Contemplation / meditation

Outdoor play for children

private Counseling room

Yoga / Meditation

Recreational space (park)

communal contemplative rational daylight dark

Reception

Storage

Multidisciplinary team office

Consulting room

Group session room

Cafe

Recreation / physical therapy

Dressing rooms

Supply room / pharmacy

Laundry room

Grieving room

Outdoor meditation spaces

Conservatory

natural view city view high ceiling

arrival spaces

maintenance spaces

administrative spaces

common spaces

program analysis spatial qualities

private spaces

transitional spaces

outdoor spaces

Strategies The existing site has a generous and welcoming entrance at the front; it houses characteristics that were the reason behind focusing on this site. But the front facade stands in heavy contrast to the rear of the site which is cluttered, shaded, inaccessible and cut off from the social and public atmosphere of the park. The garage, tower and previous extension have been removed in order to raise the ground plane to meet the level of the bordering park and thereby bridging the barrier between green space and the building. Underneath the newly formed park ground plane is an extension to the existing building which utilizes the available floor area of the existing site while not protruding outside of the site limits. Above this horizontal element sits a lightweight and translucent vertical addition, which houses the in-patient care facilities. The park is now accessible and useable by patients via the extended park plane; it can be accessed from the day spaces on the ground floor of the addition. The existing street barrier has been turned into a private and dignified entrance walkway that provides a much-needed barrier between the public park and the private garden.

existing site

removal

addition

site strategy axo

proposal

vertical layout adapts to urban condition

prioritizing private living

introducing vegetation through built space

extension of social amenities

managing access to park

softening of edges

urban strategies diagrams

intervention through addition

minimising shade crawl

engaging with scale of the city

internal vegetation buffering

contrasting of material

focusing of view & light

design strategies diagrams

Design To unify the park and site, the existing ground level was raised one storey to create a continuous plane, which provided an opportunity for a semi-subterranean extension at the rear of the building. The backalley road, which borders the site and park, has been built up and now reads as a narrow slit in the ground that acts as a buffer between the park and facility. Separation between end of life care and the grieving process was a key consideration of the project. The new extension includes a grieving facility and separate entrances from the street and the park. The front of the site has been left largely untouched. It contains the character of the site, through a generous setback, and a welcoming entrance. The rear facade however has none of these attributes, its shaded, bare and partially hidden from view. These flaws promoted the decision to add a thin, light extension at the rear of the building to house the additional program. The existing building has been altered through the partial removal of some floor plates and expansions of north facing openings. The new facility is comprised of alterations to the existing building, above ground addition and below ground extension.

ingg

atan

sank

t eri ksg

atan

flem

drottningholmsv

ägen

han

tve

rka

rga

tan

0

250m

siteplan 1:5000

Hantverka

Kronobergsgatan

rgatan

Kronobergsgatan

Kronobergsgatan

Kronobergsgatan

Hantverka

Hantverka

rgatan

0

25

existing vs proposed site 1:1000

50m

rgatan

Hantverka

rgatan

A B

C

C

Kronobergsgatan

B

0

7

siteplan 1:275

14m

A

0

25

axo 1:1000

50m

3

-2,70

-2,70

4

6

4

4

4

4

2

1

basement 1. 2. 3. 4. 5. 6.

5

0

5

basement plan 1:200

10m

server room boiler room mechanical & electrical storage gas meter water meter

26

25

24

23

22

21

20

20

19

18

17

16

15

14

13

12

11

+0,00

+0,00

entrance floor

4 10

+1,08

+1,08

6 3

7

5 2

9

8

entrance floor plan 1:200

1

1. staff room 2. staff dressing room 3. common WC 4. staff lunch room 5. cafe 6. entrance hall 7. waiting area 8. bookable office 9. administration office 10. care team office 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

light therapy / waiting sluice day care / recovery interview / examination doctor's office counselling group counselling / meeting refuse courtyard WC storage

22. 23. 24. 25. 26.

waiting hall ceremony space grieving space preparation space hall for recieving coffins

12

11

10

9

8

4

+4,50

+4,50

1st floor 3

7

6

2

5

0

5

1st floor plan 1:200

10m

1

1. kitchen 2. pantry 3. common WC 4. informal kitchen 5. storage 6. children's room 7. children's WC 8. family lounge 9. dining room 10. day room 11. living room 12. garden

8

1

+7,80

+7,80

7 3

6

2nd floor

5

2

4

0

5

2nd floor plan 1:200

10m

1

1. 2. 3. 4. 5. 6. 7. 8.

accommodation for families dressing room men physical therapy dressing room women massage room spa waiting hydrotherapy void

10

9

8

7

4

4

5 +11,00

+11,00

3

3rd floor

1

6

2

0

5

3rd floor plan 1:200

10m

1

1. patient room 2. supply closet 3. common WC 4. quiet space 5. yoga mezzanine 6. laundry 7. reading space 8. resource library 9. internet access 10. creative therapies

7

6

5

4

3

+14,25

+14,25

2

2

4th floor

1

1

1

0

1

5

4th floor plan 1:200

1

1

10m

1

1. 2. 3. 4. 5. 6. 7.

patient room sun terrace sluice common area nurses station medication room horticultural garden

1

+18,95

+18,95

rooftop 1. rooftop garden

0

5

roof plan 1:200

10m

0

5

facade south 1:200

10m

0

5

facade north 1:200

10m

0

5

facade west 1:200

10m

0

5

facade east 1:200

10m

0

5

section a-a 1:200

10m

0

5

section b-b 1:200

10m

0

5

section c-c 1:200

10m

Structure The weight of the existing building is transferred through the facade in a strict grid pattern. Since the facade functions as a load-bearing shell, the horizontal elements of the building could be changed without damaging the external structure. This made it possible to remove the first and top floors to make the very condensed building feel much more open and spacious. The load-bearing grid became the basis for the addition, which adheres to the same structural logic but with different materials. The north facade has been opened towards the addition, to allow for a greater unity between the old and new elements. The addition has a steel frame structure cladded in insulated double wall polycarbonate panels. The new openings prioritise the user and align to the internal program. They are offset from the strict grid, which the rest of the building adheres to. The light materiality of the addition sits in contrast with the heaviness of the existing building, thereby introducing a much needed light and ephemeral element to the site as well as to the program.

exploded view building structure

stainless steel capping

danpatherm K7 translucent polycarb panel

glass roof

350mm sedum roof

stainless steel roof frame

closure plate seal

300mm steel beam 20mm timber flooring

precast concrete slab

peripheral insulation

spacer

300mm steel beam with fire protective paint

translucent polycarbonate panel

20mm interior ceiling suspended glass ceiling with internal lighting

geotextile mat and vapor barrier 350mm in situ concrete slab

glass partition with concealed joint

roof detail 1:10

facade - slab detail 1:20

peripheral insulation geotextile mat

1000mm

course gravel 30mm screed

water proofing

70 mm

drainage pipe

420mm in situ concrete translucent insulation

16 + 12mm translucent polycarbonate panel

aluminum joint profile 50mm lean concrete

facade - horizontal detail 1:5

underground slab detail 1:20

details 1:5 - 1:20

* View from day spaces, first floor The first floor of the addition houses common spaces for closed care patients and staff, including a living room, dining room and day room. The space is double height and is dividable through full height curtains.

* View from the park The raised ground level facilitates access to the park via the private gardens, which extends the park’s boundaries beyond what exists today. The courtyard void seen from the garden provides light to the day care and grieving spaces below.

* View from patient garden The fourth floor horticultural therapy garden provides patients with purpose and a sense of ownership.

* View from courtyard The vegetated courtyard separates day care from grieving spaces, while permitting natural light to penetrate. It offers visitors and patients close contact to nature, while being in a protected and safe environment.

* View from light therapy space This transitional space separates the public entrance hall from the private medical wing. It functions as a light therapy space that provides patients and visitors with beneficial light as they wait to be treated.

view from grieving space waiting hall & entrance

model photos 1:200

model photos 1:200

model photos 1:200

Process The process of creating this thesis project has been driven by extensive research into all focus areas. Since the project is dealing with a topic that is unfamiliar to most, emphasis was put on understanding as much as possible regarding palliative care, in order to be able to propose a considered scheme. The process has been linear. After researching different topics and choosing to focus on palliative care, the next step became choosing an appropriate site. After careful consideration of a set of sites around Stockholm, the existing building of the fire station of Kungsholmen was chosen. Site visits were made, including a guided tour inside of the station. After that, more extensive research into the topic was carried out before compiling a large set of guidelines for how to design for palliative care. Precedents were studied and analysed and a program was devised according to those studies. The research phase culminated in a mid semester proposal, largely focused on the topic, site and discussing different strategies for how to design a scheme. As part of researching the topic, several study visits were made to existing palliative care units within Stockholm. Interviews were carried out of professionals working within the field, among them Peter Strang, Cancer specialist & professor in Palliative Medicine at Karolinska Institutet, Stockholm and researcher at Stockholms Sjukhem. Peter became an external tutor for the project and made himself available for interviews and tutorials during the research phase. After mid semester review the focus shifted from researching the topic and sites into testing and developing different design schemes. The method of developing the project consisted of all relevant media but was focused around sketching on paper and in model, planning and modelling in 2D and 3D, as well as rendering. As the project demanded a high level of research, writing was used throughout the process as a means of collecting and developing ideas and concepts. The process was developed and catalogued through the use of a set of process booklets, which acted as a common thread throughout the project. This method of containing all work in one location and being able to easily follow the process of the project was of great help and importance in producing a complete and considered proposal.

pitched roof patient houses

full enclosure

tilted roof patient houses

two enclosures

design process sketch models

tilted roof with raised courtyard

cut and fill building

final presentation 2015.01.15

THESIS B O O KL E T

PROCESS BOOKLET

PROCESS BOOKLET

PROCESS BOOKLET

PROCESS BOOKLET

Info

Topics

Sites

Research

P R O CE S S B O O K L E T

PROCESS BOOKLET

PROCESS BOOKLET

PROCESS BOOKLET

PROCESS BOOKLET

References

Guidelines

Program

Design

Presentations

Adam Bergendal • Degree Project HT2014 • KTH Arkitektur

Adam Bergendal • Degree Project HT2014 • KTH Arkitektu r

Adam Bergendal • Degree Project HT2014 • KTH Arkitektu r

Adam Bergendal • Degree Project HT2014 • KTH Arkitektu r

Adam Bergendal • Degree Project HT2014 • KTH Arkitektur

Adam Bergendal • Degree Project HT2014 • KTH Arkitektur

process booklets collected research

Adam Bergendal • Degree Project HT2014 • KTH Arkitektur

Ad a m Bergend a l • Degree Proj ect H T2014 • KTH Arki tektur

Adam Bergendal • Degree Project HT2014 • KTH Arkitektur

Adam Bergendal • Degree Project HT2014 • KTH Arkitektur

Paimio sanitorium, Alvar Aalto Paimio, Finland 1930-33

North london hospice, Alford Hall Monaghan Morris London, United Kingdom 2013

Centre for cancer and health, NORD architects Copenhagen, Denmark 2011

House in Tousienn, Suppose Design Office Hiroshima, Japan 2012

Maison Latapie, Lacaton & Vassall Floirac, France 1993

House S, SANAA Okayama, Japan 1995

references precedents

Japanese pavillion venice biennale, Junya Ishigami Venice, Italy 2008

House for a young couple, Junya Ishigami Tokyo, Japan 2013

Serpentine pavillion, Peter Zumthor & Piet Oudolf London, United Kingdom 2011

Chichu art museum, Tadao Ando Naoshima, Japan 2004

House near tokyo, Shigeru Ban Tokyo, Japan 2001

Maggie Centers, Norman Foster among others

references precedents

Literature • •

•

• •

•

•

•

Verderber, Stephen & Refuerzo, Ben J. Innovations in Hospice Architecture. New York: Taylor & Francis Inc, 2006. E-book. From, Lena & Lundin, Stefan. Architecture as Medicine - The Importance of Architecture for Treatment Outcomes in Psychiatry. Uppsala: ARQ – the Architecture Research Foundation, 2010. E-book. Signal Architects. Programme for the Good Hospice in Denmark - An outline for the hospice as part of palliative care. Realdania Fund, 2005-2006. Report. Mullins, Michael. Arkitektur og Lindring: Forksknings viden om rumlige og fysiske sansepåverkninger. Report. Hallquist, Emmy & Einarsson, Karin. Den palliativa slutenvården i Sverige - En kartläggning av organisation, värdegrund, behov och närståendestöd. Göteborgs Universitet, 2009. Dissertation. Valdimarsdóttir, Unnur., Lind, Susanne., Fürst, Carl-Johan & Adolfsson, Jan. Kartläggning av Palliativa vårdenheter i Stockholms län. Stockholm. Onkologiskt Centrum Stockholm-Gotland, 2005. Report. Wright, Michael., Wood, Justin., Lynch, Tom & Clark, David. Mapping levels of palliative care development: a global view. Lancaster University, UK: International Observatory on End of Life Care, 2006. Report. Folmer., Mullins & Fransen. Healing Architecture - Exploratory case study of the influence of 1 and 3-bed wards on the interaction between relatives and patients on two Intensive units in Denmark. Aalborg Universitet, Danmark: Arkitektur og Medieteknologi. Report.

Interviews •

•

Strang, Peter. Cancer specialist & professor in Palliative Medicine at Karolinska Institutet, Stockholm. Interviewed 2014-06-15 & 201410-10. Lindén, Carina. Department head dpt. 4, Stockholms Sjukhem, Stockholm. Interviewed 2014-06-21

references literature