This past week has been National Palliative Care Awareness week so now is a good time for us to draw your attention to this very important aspect of care and the crucial role played by therapeutic gardens in palliative care institutions.The modern definition of palliative care has altered in recent times. Palliative care is no longer only for patients who are experiencing the end of their lives from terminal illness; palliative care institutions now also care for individuals with life-limiting, chronic medical conditions. It is available for any individual that has been diagnosed with a serious medical condition that cannot be cured.According to the World Health Organisation (WHO), Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.Palliative care is used for many types of illness, ranging from cancer to motor neurone disease or kidney disease. The care offered to each patient is different, according to their individual needs but can include:

• Relief of pain and other symptoms, e.g. vomiting, pain or shortness of breath
• Resources such as equipment needed to aid care at home
• Assistance for families to come together to talk about sensitive issues
• Links to other services, such as home help and financial support
• Support for people to meet cultural obligations
• Support for emotional, social and spiritual concerns
• Counselling and grief support
• Referrals to respite care services.

Unfortunately, whilst 70% of Australians express a wish to die at home, only 14% of people actually do so. There are a number of reasons for this, principally the cost of home care services, as well as access to the range of community-based services often needed by individuals and their families. Individuals choosing to die at home will often require palliative care specialists, general practitioners, community nurses and nurse practitioners, pharmacists, allied health professionals, personal carers, as well as social support for themselves and their loved ones. It can be very difficult even within institutional palliative care to coordinate these services but they can also be costly and difficult to access in a home environment.Palliative care, either within a hospice, hospital or other institution, or in the home environment, should aim for a minimum of disruption to life for patients and family. It should aim to support both normal daily activities, as well as provide access and time to reflect and socialise with family and friends. Healing therapeutic gardens can be an excellent way of supporting these goals if the gardens are well designed, implemented and maintained.There are many crucial roles that healing, therapeutic gardens can play in palliative care, including but in way limited to:

• Research has shown that interaction with nature, even interaction as simple as gazing at a garden through a window, can improve a person’s sense of wellbeing and quality of life. Studies have also shown that it can also speed recovery from surgery, possibly through a boost to the body’s immune system.
• Accessibly designed and thoughtfully implemented therapeutic gardens are the ideal environment for conducting horticultural therapy. In palliative care, the goals of horticultural therapy focus on alleviating stress and anxiety, decreasing social isolation, rebuilding self-esteem, and maximising functioning.

Indoor table-top gardening sessions, for example, meet high standards of person-centred therapy and offer meaningful and valuable occupation. Each participant is enabled to undertake tasks within their capability and energy levels, restoring skills, as well as enabling adjustment and acceptance. Outcomes indicate that distress levels decrease.Active gardening and horticultural therapy can also be a way for meeting the individual wishes of patients, while also providing a sense of normal activity for those who have been used to gardening in their everyday lives.

• Interaction and engagement with nature, even by just sitting in a garden, can bring a sense of peace and tranquility. It can stimulate feelings of joy and feel like home for patients in institutionalised palliative care. Careful attention to the planning and implantation of sensory elements in the garden can also heighten levels of engagement and stimulation.
• Spending time communing with nature can be a relief and break from the seemingly endless rounds of hospital appointments and the like, and can be an excellent way of coping with fatigue, anxiety, pain, as well as feelings of loss.
• Gardening can be an excellent way for people facing the end of their lives to learn to accept their position by gaining a sense of the circle of life. Some people report a sense of relief and closure through planting new plants and leaving a living legacy for future generations. This can be especially true when using bonsai plants for horticultural therapy.
• Therapeutic gardens are highly appropriate spaces for self-reflection and meditation. They are an excellent addition to other supports offered by palliative care facilities and services and cater to the individual’s psychological, social and spiritual concerns.

The psychological impacts of dying are monumental and frequently involve a search for meaning, confronting fears, dealing with loss of control and issues of loss, leading to feelings of anger, guilt, disorganisation, isolation and depression (Kubler and Ross, 1969).Interacting with nature and engaging with the natural world can help patients to enjoy a sense of healing and regain perspective. According to Sourby (1998), some individuals are also spiritually aided by specifically interacting with plants from the bible. A well-designed healing therapeutic garden can also cater to the normalisation of life and the social needs of patients, families, friends and carers. Brietbart and Holland (1993) state that those receiving palliative care need to socialise. Support is derived from seeing others in similar situations. Research demonstrates an elevated sense of hope and a better outlook following social interactions with peers.Families, friends and carers are also frequently facing very difficult emotional and spiritual times. Therapeutic gardens can be a wonderful resource for respite not only for the patient but for their entire support network.Providing appropriate barbeque and picnic areas, as well as playground equipment for children can also help to facilitate normal interaction with family and friends.As stated above, the goal of palliative care is to provide treatment to control the pain and other symptoms of life-limiting conditions whilst simultaneously addressing the individual patient’s psychololgical, social and spiritual concerns, in an effort to provide the best possible quality of life for the dying patient, as well as his or her family. It is clear that therapeutic gardens can be a crucial aid in facilitating these goals and bringing real physical and mental relief to individuals. Even in institutions handling patients with a variety of conditions, a therapeutic garden that is thoughtfully designed and accessibly built can cater to a vast number of needs. For patients receiving care in their own homes, many therapeutic gardening ideas can be adapted to the available site and the individual’s specific needs and wishes.This discussion is really just the tip of the iceberg in terms of the benefits that can be gained for palliative care patients and their loved ones. Therapeutic gardens will be developing a wider discussion of design principles and benefits of healing gardens and palliative gardens in the future so continue to visit our website for more information.SourcesPalliative Care Australia - http://palliativecare.org.au/Pilgrem, L (2015) - http://www.ehospice.com/articlepreview.aspx?articleid=16545San Foundation Newsletter, Autumn 2016 - http://www.sanfoundation.org.au/_images/SF%20PDF%20Files/SAN013_SanFoundation_Newsletter_Autumn2016%20NEW%20130819%20FINAL_web.pdfSourby, C (2014) - http://www.slideserve.com/dewei/palliative-care