From the traditional nursing home to an EHPAD (elderly care facility). Institutional changes and psychological challenges of end-of-life care. History, organization, and paradoxes of the living-care environment

Abstract

This article is the first in a series of four papers devoted to Établissements d'Hébergement pour Personnes Aînés Dependantes (EHPAD, French long-term residential care facilities for dependent elderly adults). The first volume (I) analyzes the historical and institutional transition from the former "retirement/nursing home" to the modern EHPAD, highlighting the contemporary paradoxes inherent in the "living-care environment": clashes between the home-like model and hospital-based approach, between security issues and freedom of movement, between managerial rationalization and the recognition of subjectivity. By integrating demographic data, legal frameworks, and assessment tools (AGGIR, PATHOS), the study examines their effect on the quality of life, the temporality of dying, and the psychic containment provided within institutions. The second paper will explore the subjective experiences of residents and their relatives — including transitions, consent, relational bonds, and loss. The third will propose a comprehensive approach to palliative care in an EHPAD, integrating psychological, social, and legal dimensions around the medical axis. The fourth will focus on clinical and organizational expertise within an EHPAD — addressing issues of sexuality, addictions, grief, behavioral disorders, and the environmental development of the living space. These interviews, undertaken and conducted by Professor Jean-Pierre Bouchard, a clinical psychologist, bring together a multidisciplinary group of professionals — clinical psychologists and researchers, a geriatrician and facility coordinator, a neuropsychologist and nursing home director, and a professor of private law and criminal sciences — offer a pluralistic, dialogical, and interdisciplinary perspective of the contemporary challenges in institutional care. Through a series of cross-disciplinary interviews, the reader is invited to explore the ethical, clinical, and existential complexity of palliative care in an EHPAD, examining how these institutions might once again become settings of life, relationships, and meaning, rather than mere systems of maintenance or dependency management. The authors advocate for the development — with the support of public authorities — of a genuine palliative culture of presence and relational care, centered on recognizing the individual in their vulnerability and desires. Grounded in the concept that subjectivity is at the very heart of care, this approach invites us to reimagine the EHPAD as a space of hospitality, where the elderly person remains a subject of history, memory, and temporality, even when faced with their own mortality.