In grappling with the complex issue of how to provide high-quality palliative care to an aging population, I have frequently argued for hospice as a philosophy, rather than a place. Dr. Sarah McGann’s book The Production of Hospice Space: Conceptualising the Space of Caring and Dying was a welcome reorientation to my thinking. In this well-written book, McGann sets out to propose conceptual principles that unite the ideas of hospice philosophy and hospice space, arguing for a hospice philosophy that is anchored by space and spatial practices. As the head of the Department of Architecture and Interior Architecture at Curtin University in Australia, and a participant in the design of St. Francis Hospice in Dublin, McGann is well positioned to speak to the relationship between hospice space and hospice philosophy.

The first three chapters are devoted to an analysis of the various places and spaces in which death and dying occur. First, in chapter 1 McGann situates the study by describing the complexity the team encountered upon being challenged with the task of designing St. Francis Hospice. McGann describes setting out to create a building, specifically a place where the design team might like to die. McGann soon learned the task was much bigger – to create space and spatial practices that were capable of supporting the philosophy of hospice. In chapter 2, McGann explores how buildings are created in response to particular questions. Hospitals, for example, were designed to answer the question of how to efficiently care for the sick. However, the mismatch between efficient care of the sick and compassionate care of the dying often results in end-of-life care being seen as something apart from the core business of the hospital, which in turn has a profound effect on the experience of dying. In chapter 3, McGann traces the historical development of hospice and explores modern hospice trends. An apt quote reveals the complexity confronting architectural design of the modern hospice:

McGann also explores the origins of the artificial separation between hospice philosophy and hospice space, attributing this to the dying-at-home movement that arose during the 1980s.

The final three chapters investigate the attributes of a “successful” hospice space. In chapter 4, McGann explores hospice spatial practices through the illustration of the design of St. Francis Hospice. Three ideals informed the design: part home/part community centre, part hotel/part hospital, and part home/part garden. Carefully constructed communal and private spaces, boutique hotel–style finishing, extensive views of garden spaces, and careful attention to natural lighting facilitated the realization of these ideals. St. Francis Hospice was conceptualized as an inside-out design, inside-out philosophy, and inside-out community. First, an inside-out design blurs the distinctions between outside space and inside space so that those who enter the building do not get the sense that they are being “incarcerated”. Second, the inside-out philosophy promotes the idea that patients can move seamlessly between the hospice and the community and that entering hospice is not seen as a failure of the family to cope with caregiving demands. Lastly, the inside-out community seeks to balance privacy with a sense of community, avoiding the isolation that is characteristic of dying in institutionalized settings.

In chapter 5, the principles set forth in chapter 4 are now interpreted through Henri Lefebvre’s triad of perceived, conceived, and lived space. Diagrams illustrating how each theme guides hospice spatial practices are included. Perceived space suggests that “actors” in a given situation will construct their perception of that situation in relation to spatial practices. For instance, in the modern hospice this involves having clinical (back) areas which are preparatory spaces, and domestic (front) areas which are presentation spaces. These preparatory and presentation spaces are necessary for patients, family, and staff and ensure that the modern hospice is constructed such that the social enactment of dying can be presented and perceived in a way that is acceptable to those participating.

Conceived space speaks to how building design embodies a philosophical position. In the case of hospice, a homelike environment provides a place of prospect – that is, an extensive view – and refuge. Within the design are places where individuals can sit or lie and enjoy views out onto the world (e.g., gardens, sky, community) while also having private spaces of refuge whereby one can experience hiddenness, quiet, and shelter. This is accomplished through careful attention to things such as window and furniture placement. Finally, lived space addresses the delicate balance between privacy and community so necessary to hospice. Good design allows patients and families to control their desired level of privacy or community at any given time. Spatial mapping is used to illustrate how levels of privacy and community change as one moves from the outside to the inside of the hospice.

The final, brief chapter entitled “The Unbounded Hospice” returns to the central thesis that hospice as a philosophy and as hospice structures needs to be united in the idea of hospice space. The explication of design principles that foster this space allows us to create lived spaces for dying in creative ways across all contexts where individuals die (e.g., hospital, residential care, hospice).

Serendipitously, I had a trip planned to Dublin when this book arrived for review, and so I arranged a visit to St. Francis Hospice. The visit allowed me to experience what could otherwise only be viewed through the black-and-white photos in the book. Although I have visited many hospices, for the first time I understood the principles behind what I was seeing. I experienced the design concepts that allowed the interplay of light and the passage of time. I enjoyed the prospects of the garden, observed the many homelike spots of refuge, and realized how one could indeed combine the ideas of hotel and hospital through skillful use of finishing and decoration. What took me most by surprise, perhaps, was how intimately I felt the creation of a particularly compelling story around dying; I was an observer of that story, not really belonging in either the communal or the private spaces. That sense of entering a very private world caused me to reflect on how skillful we still are in rendering dying invisible to the world at large. It made me wonder, in what ways could we use these design principles to integrate hospice into a broader community story – to welcome the dying back into the lives of the living?

As a researcher pursuing innovative ways to provide quality end-of-life care for those residing in rural communities, this book was an important one. I began to understand in a deeper way the importance of place and space that my research participants had long tried to communicate. Indeed, McGann’s book should be required reading for all those responsible for designing care systems to support patients at end-of-life. Her astute analysis of the different questions answered by hospital and hospice designs is particularly relevant in light of statistics suggesting that 70 per cent of the Canadian population continues to die within hospital (Statistics Canada, 2013). Increasing attention has been paid to the challenges facing patients and families who die in residential and acute care settings. However, the debates frequently focus on health care provider knowledge and care delivery practices without sufficient attention to those spaces and/or spatial practices that are essential to quality hospice care. These design principles further challenge the idealisation of a dignified death at home if that space is not conducive to a hospice philosophy. The scholarly presentation of a set of design principles has the potential to inform unique space and spatial practices resulting in better hospice care. McGann’s book is well worth the read for clinicians and leaders in hospice care.