Lighting for end-of-life care
I’ve been privileged to work with a hospice team recently – a humbling and inspiring experience.
The client has heard of ‘circadian lighting’ and is open to investing in the technology if it will help the team in their remarkable work to support patients and their loved ones through these most fragile and emotionally charged moments in their lives.
The solution has to be flexible to support future changes in clinical needs that may include longer stays than the average of 14 days in the hospice setting. So the potential for the lighting system to deliver a circadian cycle should obviously be a consideration in the specification – Effect of Light on Human Circadian Physiology.
But anxiety, insomnia and pain, plus medications and treatments such as chemotherapy, all make us exponentially more sensitive to light.
The tension between delivering the brightness needed for circadian entrainment comfortably and safely in these acute settings is clear.
As I toured this urban facility, even though the current installation was relatively recent – and mostly delivering well below the recommended circadian standard 250 melanopic lux – light fittings had been disconnected or switched off because they caused headaches, night staff used standard lamps because the overhead fittings were too harsh, and salt lamps were the only alternative to the main lights in the bedrooms at night. One family had draped a scarf over the strip light at the head of the bed to reduce the glare.
Instead of facilitating their work and supporting these rare and precious moments of connection, the lighting was a source of friction and frustration.
This anecdotal evidence is borne out by a recent study in a cardiac ward comparing a six-channel circadian system with a standard ‘on-off’ fluorescent installation. It noted that, while the intervention significantly improved sleep for patients, 88% of staff reported that ‘all or most patients complained about the study lighting’. They agreed with statements that the fittings were too bright compared to other rooms and wanted more control. Presumably, they were keen to turn the lights down, potentially reducing the efficacy of the intervention itself – The Impact of Dynamic Lighting on Sleep Timing and Duration for Hospitalised Patients.
It’s hard to know whether the problem lies with the lights or the cycle used in the project (the paper suggests that a more gradual ‘wake-up’ phase may help), other environmental factors, such as nurses moving between bright and dimly-lit control spaces, or the level of engagement with the care delivery teams and patients themselves.
So, although offering flexibility over the long term is important, recommending my client pays a premium for an ‘off the shelf’ circadian system that simply drives a dose of melanopic lux into a uniquely vulnerable eye is completely missing the point.
It’s time to work with the real experts, the staff themselves, to talk about what daylight and lighting can and should do for them and the people they care for, what the options are and how much they cost.
Together, we can design a sensitive and sustainable solution that meets the needs of patients, their loved ones and those who care for them. Not to create a permanent twilight bubble, but to invite connection with the natural cycle of bright days and dark nights for those who are able to enjoy it.
‘You should get your eyes tested’ was an insult in the playground and on the football pitch directed at the referee.
But now I’ve reached the ripe old age where I get free eye tests every 6 months, I’m happy when the automated message pings onto my phone.
I’m so grateful for this gift.
It means that I – and millions of others in the UK – don’t have to worry about whether I can afford it or not.
Not only does that visit help to pick up early signs of diabetes and other conditions, keeping my glasses prescription up to date can help me stay steady on my feet – Risk factors of falls in elderly patients with visual impairment, stay safe on the road – Abnormal Visual Function: An Under-recognized Risk Factor of Road Traffic Injuries, and stave off dementia for a bit longer, too – Visual Impairment and Risk of Dementia in 2 Population-Based Prospective Cohorts: UK Biobank and EPIC-Norfolk.
Interestingly, those with visual impairment are at greater risk of experiencing medication errors too – visual impairment and medication safety: a protocol for a scoping review.
It can be much harder for those living in residential care to get that vital piece of the preventative puzzle.
This recent report from Anglia Ruskin University reporting on the UK National Eye Health and Hearing Study noted that that a quarter of adults aged 50 and over had vision impairment in at least one eye, 76% had hearing loss and 81% of participants had never undergone a hearing test – New UK study finds widespread hidden sensory loss.
Eye tests can fall of the priority list in a busy care home – it’s not seen as a life-threatening consition, it’s a hassle and staff may lack the training to spot the issues in the first place.
This excellent document from the NHS Integrated Care Board for Cumbria and South Lancashire is an excellent, practical guide for healthcare providers who may be wondering where to start – Optimising Eye Care in Regulated Care Settings.
I’m off to get my eyes tested – Maybe you should do the same and make sure the people you care for can see clearly too!