In Memoriam: Dame Cicely M Saunders
Dame Cicely Saunders, OM, DBE, FRCP, FRCN
Not many physicians manage to influence the practice of medicine by developing a new approach to care which has become a recognized medical specialty and (in the UK) is taught to every medical student. An approach to care that has created a resonance around the world in both developed and developing countries, with burgeoning clinical services, academic departments, scientific journals, textbooks, symposia and all of the accoutrements of an emerging specialism. Such is the story of Cicely Saunders and palliative care.
Cicely Saunders raised charitable funds to build St Christopher's Hospice in south London, admitting its first patient in 1967. Today, 38 years later, there are some 300 accredited specialists in palliative medicine in Britain, medical students can expect questions on various aspects of palliative care in their qualifying examinations, and no oncology service can be accredited without providing specialist palliative care as one of its core services. Worldwide it is estimated that there are more than 8000 hospice and palliative care services. All this has been a consequence of the determination of Cicely Saunders to make things different for dying patients, to take up the cause of the ‘dissatisfied dead’ (an epigram coined by John Hinton).
Cicely Saunders was born in 1918 in North London and was educated at Roedean and Oxford but abandoned her university course to train as a nurse. A longstanding back problem forced her to give up nurse training and she returned to Oxford and subsequently qualified in 1947 as a lady almoner (social worker). It was in the course of her work as a social worker that she become particularly conscious of the poor care that dying patients received in hospital. One particular patient, David Tasma, a young Polish émigré with advanced cancer had a particular effect on her. They developed a close relationship and she discussed with him the concept of a home for dying patients where they could be more adequately cared for. When Tasma died he left her £500 (a substantial sum at that time). This money was later to provide the starting point for the funds required to build St Christopher's.
Saunders decided that she would pursue this interest in the care of the dying. She was advised by a surgeon at St Thomas' that it would be difficult for her as a nurse or social worker to have much influence in changing the way dying patients were cared for. She took this advice to heart and decided to train as a doctor. She qualified at the age of 38. Shortly after qualifying she took a research job at St Mary's Hospital and also began working at St Joseph's Hospice in London. Here she started to develop her approach to hospice care. She revived the practice of using oral opioids given regularly to treat cancer pain, rather than the commonplace approach of administering “as required” intramuscular injections of morphine, invariably given in inadequate, infrequent doses and leaving much pain unrelieved. She started to publish and was invited to lecture widely, particular in the United States. At the same time she started to raise the funds required to build St Christopher's Hospice.
St Christopher's was different from the homes for the dying and the early hospices that were already in existence. Cicely Saunders set out to provide true holistic care encompassing physical, psychological, spiritual and social problems, but importantly from the outset she was determined to evaluate the care that was delivered. One observer described her approach as a combination of “compassion and science”.
Saunders would not have described herself as a great researcher and she was a clinician rather than an academic. However she had a knack of surrounding herself with outstanding individuals who played significant roles in the evolving story of St Christopher's, hospice and palliative care. She set up a Research Committee chaired by Professor Harold Stewart, Professor of Pharmacology at St Mary's Hospital. Also involved in this research, inter alia, were John Hinton, Professor of Psychiatry at the Middlesex Hospital, and Duncan Vere, Professor of Pharmacology and Therapeutics at the London, both prominent leaders in their respective fields. Hinton carried out seminal studies in the early days of the Hospice, evaluating the quality of care that was being delivered, and wrote the widely influential Penguin paperback “Dying”. Duncan Vere acted as supervisor to the newly appointed research fellow Robert Twycross who embarked on a programme of studies with oral morphine and diamorphine, which had a major impact on clinical practice, encouraging physicians to eschew oral diamorphine in favour of morphine and to use simple solutions or tablets rather than the traditional Brompton Cocktail. Duncan Vere was probably the first person to think of creating a slow release formulation of morphine for oral administration, the realisation of which had a substantial influence in encouraging the use of oral morphine for chronic cancer pain.
Cicely Saunders was tall and had great presence, and great vision. She understood that in order to achieve her objectives for the Hospice she would need help from not just the general public, but also from people of influence and position who could make things happen, just as she had done in identifying research advisors. Gill Ford was a physician who helped by providing some of the weekend medical cover and happened to be also Deputy Chief Medical Officer for England. Ford was instrumental, with Derek Doyle and Graham Thorpe, in achieving recognition of Palliative Medicine, initially as a sub-specialty, by the Royal College of Physicians. Thelma Bates was a clinical oncologist at St Thomas' Hospital, also part of the weekend rota, who started the first hospital palliative care team in Europe. There were many others who responded to Cicely's powers of persuasion to become enthusiastic supporters and workers for the cause.
What of Saunder's own contribution to the science and practice of pain relief? Perhaps the most important idea she had was the concept of ‘total pain’, that the perception of painful stimuli may be influenced by many other physical symptoms, mental distress, social problems and emotional difficulties. This is the principle that in many ways encompasses the philosophy of palliative care. The number of patients who have experienced relief of their pain and suffering as a result, directly or indirectly, of the work of Cicely Saunders must be counted in many millions.
Cicely Saunders has been justly honoured around the world and has won an exceptional number of prizes and awards, several of them rarely given. She has more than 25 honorary degrees and one of them was an MD awarded by the Archbishop of Canterbury. Included amongst her awards are the Onassis Prize for Services to Humanity, the Franklin D. Roosevelt Four Freedoms-for-Worship Medal, the British Medical Association Gold Medal for Services to Medicine and the Templeton Prize for Progress in Religion. She was made a Dame of the Order of the British Empire in 1980 and received the rare honour of admission to the Order of Merit in 1989. In 2001, St Christopher's Hospice received the Conrad N. Hilton Humanitarian Price, the world's largest humanitarian award. St Christopher's remains a centre of education and teaching in palliative care at the same time as providing direct clinical services to patients.
Naturally enough when she become ill some months ago, Cicely Saunders decided that the best place in which to be cared for was St Christopher's. She died there peacefully on 14 July, surrounded by a multiprofessional team whom she had taught and worked with, who were the evidence of her enormous contribution to medicine. She was a remarkable woman.
Obituary written by: Geoffrey Hanks and Karen Forbes
Bristol Haematology & Oncology Centre, Department of Palliative Medicine, University of Bristol, Horfield Road, BS28ED Bristol, UK
Available online 14 November 2005:
PAIN Volume 118, Issue 3, 5 December 2005, Pages 283-284