Transforming homes and hospitals.

Under financial pressure hospitals are discharging patients "quicker and sicker" into the care of family members or professional home care attendants. Miniaturized or simplified ventilators, drug and nutrition infusion devices, various monitors, and other hospital equipment are making this shift from hospital to home feasible, even for seriously dependent patients. How desirable is this shift? The question may seem perverse. Surely, most patients welcome early hospital discharge, and for good reason. Home is commonly conceived and experienced as a place of security, comfort, privacy, and liberty to be oneself. By contrast, the hospital is often thought of and experienced as a place of insecurity, discomfort, intrusion, and demands for compliance and conformity. But is this contrast too sharply drawn? How might these stereotypes distort our assessment of transfer of hospital equipment and care to a patient's home? As with most contrasts, there are notable exceptions--namely, homes with few homelike virtues and hospitals with various domestic amenities. But there are, I think, more general troubles with this stark contrast between home and hospital. Most importantly for assessments of hospital-to-home transfers, it ignores transformations that illness often makes in family life and home. For example, illnesses and treatments can make familiar domestic settings alien, or they can confuse family roles and foster mutual deception, detachment, and resentment, even (or especially) in well-ordered families. Contrary to the common assumption, given such transformations hospitals may often allow patients greater autonomy than home and may better preserve family relationships than would home care. If so, then current domestication of care for seriously ill patients may be morally questionable in ways the stereotypes of home and hospital obscure. Stereotypes of Home and Hospital On a view reflected in law, poetry, and cliches, home is defined as a refuge--a castle, a haven, a nest. As Sir Edward Coke (seventeenth century) cited Justinian (sixth century), "One's home is the safest refuge to everyone, . . . for a man's house is his castle, et domus sua cuique tutissimum refugium." It is conceived as a secure place, free from unwelcome intrusions or supervision. As a refuge, it allows ready access, a place to which we can return at will. In recent centuries home is also a place of comfort and intimacy.[1] It is where we can be at ease, without public personae or pressures to conform to social norms. Indeed, for many people, home is where they feel most truly themselves, the very center of their lives, closest relationships, and most intense emotions. As such, home is their natural or, in Aristotelian terms, their "telic" place where mature selves are realized and revealed. This ideal clearly best fits middleclass family and living conditions. Too few rooms or too many children, close neighbors, or servants would seem to defeat this ideal, and yet it is widely shared, even by solitary dwellers and collective groups. For example, urban "homeless" people recreate minimal homes out of scrap materials in abandoned railway tunnels, concealed bridge niches, and other secure, sheltered spaces.[2] People attracted to a simpler life in the wild or on the highway may reject furniture or fixed abodes, but nonetheless look for security, access, personal accommodation, however idiosyncratically defined. For people whose identity and chosen life are strongly communal, home may have few, if any, private spaces. In the army, convent, or kibbutz, privacy may be provided primarily by the gates or walls which restrict the entry or gaze of outsiders. As with all ideals, this concept of home poses practical problems, even for the most fortunate middle class families. Security, comfort, and personal accommodations require regular thought and effort, especially for homes with children and other dependent residents. …