Dame Cicely Saunders, founder of the modern hospice movement, dies

Dame Cicely Saunders

Founder of the modern hospice movement

Cicely Mary Strode Saunders, medical director St Christopher’s Hospice 1967-85 (b Barnet, Hertfordshire, 22 June 1918; q St Thomas’ Hospital, London, 1957; OM, DBE, FRCP), died 14 July 2005.

Cicely Saunders founded the first modern hospice and, more than anybody else, was responsible for establishing the discipline and the culture of palliative care. She introduced effective pain management and insisted that dying people needed dignity, compassion, and respect, as well as rigorous scientific methodology in the testing of treatments. She abolished the prevailing ethic that patients should be cured, that those who could not be cured were a sign of failure, and that it was acceptable and even desirable to lie to them about their prognosis.

She put paid to the notion that dying people should wait until their painkillers had worn off before they received another dose, and scotched the notion that the risk of opiate addiction was an issue in their pain management.

Cicely Saunders became, and perhaps always was, a grande dame and natural leader, and established a reputation in the national consciousness almost on a par with that of Florence Nightingale. She became a folk hero after the journalist Victor Zorza and his wife wrote a persuasive and moving account of their daughter’s death in a hospice.

In 1967 she founded St Christopher’s Hospice in south west London. It is now one of many but is still the leader in the field. It was her personal achievement and has been imitated all over the world. St Christopher’s was the first modern hospice, although there were a number of homes in existence for the dying, most of which were run by religious orders. She raised the funds for the hospice and contributed some of her own money.

Saunders introduced the idea of "total pain," which included the physical, emotional, social, and spiritual dimensions of distress. She regarded each person, whether patient or staff, as an individual to the end.

A good listener, she paid systematic attention to patient narratives. She did away with "visiting hours," which had been an excuse for having non-visiting hours. One St Christopher’s patient, transferred from another hospital, said, "They used to see how long I could go without an injection. I used to be pouring with sweat because of the pain. I couldn’t speak to anyone and I was having crying fits. I think I’ve only cried once since I’ve been here . . . The biggest difference is feeling so calm. I don’t get worked up or upset."

Cicely Mary Strode Saunders was born in Barnet, Hertfordshire, in 1918, the eldest of three children, into a well-off but unhappy family. Her domineering father was an estate agent, and they lived in some comfort in a large house with lawns and tennis courts. Her mother was cold and withdrawn. She was given into the care of her unmarried Aunt Daisy when she was one, only to be snatched back again through jealousy of Daisy’s influence. She was sent to Roedean School when she was 10. Taller than the other girls, she felt she never fitted in, which, she said, gave her a feeling for people who were outsiders. She also suffered from a painful and slightly crooked spine, and was made to lie flat on the floor for 40 minutes a day.

Her father disapproved of her desire to be a nurse, and so instead she went to St Anne’s College, Oxford, where she read politics, philosophy, and economics, intending to become a secretary to an MP. After the outbreak of the second world war she abandoned her course and defied her parents’ advice, enrolling as a student nurse at St Thomas’ Hospital in 1944, where she was recognised as a potential high flyer. However, her back was still painful, and she was advised her to quit nursing. After returning to Oxford for a year she gained a "war degree" and qualified as a social worker, or what was then called a lady almoner, in 1947.

Saunders was originally an agnostic, but, while on holiday in Cornwall with some Christian friends, she discovered she really believed in God. It was, she said, "as if a switch had flipped."

A year later, during her work as an almoner, at Archway Hospital, she cared for a dying 40 year old Polish Jewish émigré called David Tasma. He felt that his life had been wasted. He had no relatives in England, and only a handful of friends. In a brief and intense relationship—which probably amounted to a spiritual love affair—they discussed the idea that she might found a home for dying people to find peace in their final days. He left her £500, then a substantial sum, and the prophecy "I’ll be a window in your home." There is now a window dedicated to him at St Christopher’s; it is plain and has a view of the car park.

David Tasma’s death coincided with the death of Cicely Saunders’ father and that of a close friend, and she fell into a state of "pathological grief." She felt that, at last, she knew what God had called her to do, which was to build a home for dying people, where scientific knowledge should be combined with care and love. She supplemented her almoner work with being a volunteer sister at St Luke’s Hospital in north London.

Saunders sought closer contact with patients and asked her orthopaedic surgeon if she might work as a night nurse, which would put less strain on her back, since most of the lifting work is done by day staff. His opinion was that people wouldn’t listen to her as a nurse, that doctors desert the dying, and that she could best help dying patients by becoming a doctor. She was accepted as a medical student at St Thomas’ Hospital aged 33. Her father funded her studies.

Her fellow students made little effort to include her because she was much older. However, she impressed her teachers with her emotional maturity; one, Alex Paton, recalls her spending her free time reading to a patient who had suddenly become blind.

In 1958, shortly after she qualified, she wrote an article arguing for a new approach to the end of life. In it she said, "It appears that many patients feel deserted by their doctors at the end. Ideally the doctor should remain the centre of a team who work together to relieve where they cannot heal, to keep the patient’s own struggle within his compass and to bring hope and consolation to the end."

After qualifying as a doctor, she obtained a research scholarship at St Mary’s Hospital, Paddington, where she studied pain management in the incurably ill, and at the same time worked at St Joseph’s, a hospice for the dying poor in Bayswater, run by nuns. Here she used her medical expertise and research findings to help the nuns improve their standard of care. She developed record-keeping methods on 1100 patients, introducing a punch-card system. Notably, she wrote six articles on care of the dying in Nursing Times in 1959; they were favourably reviewed in the Lancet.

At St Joseph’s she introduced the system of pain control she had developed at St Luke’s. It was a hardheaded approach ("constant pain needs constant control"), whereby patients were given regular relief and not forced to wait until their pain returned and they cried out. This greatly reduced their fear and anxiety and this, in turn, reduced pain and their need for pain relief. She said that there was no such thing as intractable pain, though she had met intractable doctors. She argued that if physical pain was alleviated, then mental pain was also relieved. She distinguished between mild, medium, and severe pain, each of which was to be treated differently. She also used medicines to relieve other problems of the dying, including bedsores, nausea, depression, constipation, and breathlessness.

In 1960, at St Joseph’s, she met Antoni Michniewicz, the second of the three Polish men who influenced her life. Again, they had a close spiritual relationship.

At the same time she devoted herself to the cause she had chosen, which was to found a hospice, a remarkable thing for a newly qualified doctor to do. She read widely on death and dying, and was impressed by the view of Elisabeth Kübler-Ross (obituary BMJ 2004;329:627) that there were five psychological stages of dying: anger, denial, bargaining, depression, and acceptance. In late 1959 she had drawn up a 10 page proposal that she circulated to friends. It outlined the structure and organisation of a 60 bed hospice.

She named it after St Christopher, patron saint of travellers, and initially wanted it to be a Church of England hospice, but several grant-giving organisations required her to make it open to people of all faiths, so she modified the plan; the hospice was to be "a religious foundation of an open character."

She drew up detailed plans and costed every stage of the process. She met her architect in 1959, and the St Christopher’s charity was registered in 1961. Her brother found a location in 1963 at Sydenham. Between 1961 and 1964 she raised £330 000. By 1966 the estimated cost was £400 000 and a year later it stood at £480 000. All this time she was working at St Joseph’s. In 1963 she went on a "voyage of discovery" to the United States, which was ahead of the United Kingdom in pain research. Building work started in 1965—the year she was awarded an OBE—and money was still not coming in fast enough: at times the builder wasn’t paid on time.

Cicely Saunders had tremendous support from a wide spectrum of society: local children helped prepare the garden, and fire officers hung the curtains. The hospice contained 54 inpatient beds. An article published shortly after opening said that the hospice "will try to fill the gap that exists in both research and teaching." There were plans for those who needed respite care, and for a home care service. The first patient was admitted in 1967. Princess Alexandra performed the opening ceremony and still visits every year, shortly before Christmas. The hospice soon extended its activities to research, and added a study centre. By 1970 the NHS contributed two-thirds of the running costs, and NHS doctors undertook part of their specialist training there.

In 1963, three years after the death of Antoni Michniewicz, Cicely Saunders met another Polish man, who was to become her husband. Marian Bohusz-Szyszko was an émigré painter with a degree in fine art. She admired a sombre blue crucifixion he showed at a London gallery, wrote to him, and later became his patron; a substantial amount of his work is hung at the hospice. He had a long-estranged wife in Poland, whom he supported, and he was a devout Catholic. In 1969, he and Cicely and another couple bought a house in Sydenham, which they shared; they called it their kibbutz and it was a lasting domestic arrangement. Marian’s wife died in 1975, and in 1980 he married Cicely; she was 61 and he was 79. That same year she was made a dame.

Marian died in 1995, spending his last days at St Christopher’s. Cicely Saunders stepped down as medical director of St Christopher’s in 1985, remaining as chairman. She received awards from all over the world.

She was strongly against euthanasia, partly because she was a committed Christian, and also because she argued that effective pain control is always possible and that euthanasia is therefore not needed. She did acknowledge, however, that both sides in the euthanasia debate were against pointless pain and impersonal indignity.

She developed breast cancer but continued to work, even from her deathbed. She died at St Christopher’s.[Caroline Richmond]