The physical environment of an older person’s home or living space in residential care can affect their quality of life. Age-related disabilities may require modifications to be made to the living environment to optimise autonomy and social connectedness, maintain a safe environment for the older person or to enable care to be provided in the home.
In relation to the delivery of palliative care, the physical environment will have a bearing on the person receiving palliative care as well as on their family, friends and carers. As quality of life is important in the delivery of palliative care, certain aspects of the physical environment merit consideration and perhaps modification. [1,2] For people living in atypical environments such as those encountered with homelessness or in prisons these modifications may be more difficult to achieve although equally relevant.
A broad review of institutional settings including residential aged care (RAC) by Sagha Zadeh et al.  found that good quality of life through to death was promoted through design that supported social interactions, positive distractions, protected the individual’s privacy, was homelike, and supported an ambient environment.  A common theme was the person’s ability to control or personalise surroundings, with spaces optimally designed for flexibility and personalisation.  Another favourable environmental design element identified in that study was the support of family presence. This review also notes the potential influence of the physical environment on spiritual wellbeing and spirituality of patients, family members and carers and the urgent need for research in this area.
In 2007, Rasmussen and Edvardsson  proposed a preliminary framework that describes the influences of the environment in meeting a person’s needs and expectations in a palliative care setting. Their definition of environment includes “at-homeness” and “atmosphere” to identify the factors that help a person feel at ease. These factors included hospitality (welcoming and generosity), safety (cleanliness, privacy, accessible care and staff availability), and everydayness (homeliness of the environment, activities). The concept of at-homeness has been studied more recently in the management of severe and long-term conditions but is yet to be investigated in residential aged care settings. 
A review by Brereton et al.  focused on the key elements of the hospital environment in the delivery of palliative care for older people. The authors surmised that there is a need to balance privacy and the loneliness or isolation a person may feel. Proximity to home, visitors and nature were important as were homeliness and cleanliness of the hospital environment. Screening of noise and the ability to have a personalised and private space were important in the feelings of dignity and comfort of the person and visitors. 
No systematic reviews assessing environmental modifications to enable the provision of palliative care for older persons have been identified. However, Lawton cross-mapped desired and tangible outcomes for residents with dementia against the implications for the residential hospice environment.  This work has since been adapted by others to develop a compendium of architectural and landscape design considerations for residential hospice care. A total of 58 architectural and planning considerations relevant to design in this setting are listed in terms of site and context, arrival spaces, communal and private spaces of the residential milieu, transitional spaces, and nature connectivity.  These elements range from a protected entrance that symbolically reaches outwards to more practical considerations such as options for in-room privacy and accommodation for pets.
The effectiveness of environmental modifications to reduce the risk of falls is assessed in two systematic reviews. [3,4] A combination of physical activity and home modifications is more successful in reducing the number of falls, limiting fear of falling, and preserving independence in community-dwelling older adults than either approach alone.  Occupation therapists play an important role in fall prevention through facilitation of exercise, education about strategies to remain safe and independent, and recommendations for assistive technology and home modifications. [3,4]
A systematic review by Brooke (2011)  notes the importance of access to a suitable and private outside area and a consistent view of the outside can support spiritual beliefs of the dying trajectory for Aboriginal and Torres Strait Islander clients residing in Australian residential aged-care facilities. More research is needed to better understand the attributes of the environment that best support culturally appropriate care for older Aboriginal and Torres Strait Islander residents at the end of their life.
Environmental design in dementia care
The specific environmental needs of people living with dementia in aged care facilities has also been studied.  The environment in which people with dementia live may have a positive or negative effect on their behaviour, social engagement or cognitive ability. The evidence suggests that a home-like environment with adequate general lighting, low noise levels, comfortable room temperature, and the careful use of colours and contrast positively affects the outcomes of residents with dementia.  Careful use of sensory stimulation through visual, auditory, tactile, and olfactory stimuli can help to reduce agitation  In contrast, too much stimulation through, for example, high levels of noise has been associated with increased wandering and aggressive and disruptive behaviour, and very bright light has been associated with agitation, restlessness, or aggression.
It is likely that some adaptation of the home environment will be required to meet the palliative care needs of older persons.  Home modifications may include structural alterations such as installation of handrails or ramps or the provision of exterior lighting to allow care providers safe access at all hours. Simple assistive technology like wheelchairs, shower chairs, hospital-style beds, lifting aids or portable threshold ramps may also be useful. 
Physiotherapists can advise on patient mobility aids and occupational therapists can advise on equipment and home modifications to make activities of daily living safer and more manageable for patients and carers.  Both can advise on safe manual handling for carers.  Modifications may be implemented pragmatically in response to assessed individual needs, or may have been implemented earlier in the disease process and not specifically to meet palliative care needs. 
Only six systematic reviews were identified in relation to the hospital environment, prevention of falls and assistance for people living at home with dementia, and residential aged care for Aboriginal and Torres Strait Islander people. The lack of evidence for environmental modification to facilitate palliative care provision may reflect the difficulty of undertaking research in palliative care.
Gaps in the evidence include
- the effectiveness of home modifications in assisting older persons to remain in their own homes.
- the effect large pieces of equipment have on the home environment and how this may affect others living in the home.
- the degree to which older people receiving palliative care and their families are satisfied with home modifications to facilitate the provision of palliative care, and what modifications are most useful
- the concept of at-homeness needs further research to understand how it can support the care of older people at the end of their life
- the attributes of the environment that best support culturally appropriate care for older Aboriginal and Torres Strait Islander persons
- the effect of the natural environment (views or access to gardens or natural spaces) on older people with dementia or older people at the end of their life, and those who care for them.
Page updated 25 June 2021