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Palliative Medicine 1999; 13: 485–501

An annotated bibliography of the publications of

Cicely Saunders – 2: 1968–77
David Clark Professor of Medical Sociology, Department of Palliative Medicine, University of Sheffield,
Sheffield

This is the second instalment of what is intended to Saunders C. Care of the dying. Nursing
become a full annotated bibliography of the pub- Outlook, 1968b; 64(11): [page numbers
lished work of the founder of the modern hospice not known]
movement. The first instalment was published last
year.1 The bibliography has two aims: first, to ensure A copy of this article has not yet been traced. In
that a complete record of Dr Saunders’ publications translation, however, it appeared as 1968d.
is established as a matter of record; second, to
stimulate the interest of those involved in modern
palliative care and related scholarship, but who may
Saunders C. The last stages of life.
be unfamiliar with the original works. The bibliog-
Recover, 1968c; Summer: 26–29
raphy should therefore be of use to any students,
practitioners and researchers who wish to deepen
their understanding of the principles and practice of This article appeared in a Catholic quarterly for
modern palliative care. the sick and those who care for them. It is based on
experiences with patients at St Joseph’s Hackney,
and deals with ‘the feelings of guilt, failure and
Weist V, Saunders C, Winner A. rejection that so often beset the dying’. Five
Bedsores [Letter]. Lancet, 1968a; themes are explored. First, a positive approach is
1(534): 140 called for which sees the last stages of life ‘not as
defeat, but as life’s fulfilment’ and where we look
Cicely Saunders’ first co-authored publication chal- not at the patients’ dependence but at their digni-
lenged a leading article in The Lancet which had ty. Second, a sense of fulfilment is important; this
asserted that bedsores are always preventable and does not mean that we should have preconceived
which therefore could ‘arouse considerable guilt in ideas about what a person’s death should be like,
the minds of many nurses’. Patients with extensive but it does involve the recognition that everyone has
metastases may find constant turning and handling their own path to life’s ending. Third, comfort and
intolerable. Various prevention strategies (sheep- care become the prominent aims, since ‘the time for
skins, large cell ripple mattresses) are suggested but active treatment is over when patients are admitted
the problem may be insoluble in the terminal stages to our wards’, and for both doctor and patient
when, paradoxically it ‘may not be of major impor- ‘accepting death’s coming is the very opposite of
tance’. To accept this is not merely to adopt a coun- doing nothing’. Fourth, a middle way is proposed
sel of despair. The authors are, respectively, matron, between too much and too little treatment – again
deputy medical director and medical director of the making use of the experience of the patient who
newly opened St Christopher’s Hospice, Sydenham. observed ‘all of me is wrong’; above all the objec-
References: 1. tive should be to enable patients to ‘LIVE until they
die’. Fifth, understanding and compassion are
Address for correspondence: Professor David Clark, required if we are to know ‘the right moment and
Department of Palliative Medicine, Division of Surgical and
Anaesthetic Sciences, K Floor, Royal Hallamshire Hospital, the right way to help patients’.
Sheffield S10 2JF, UK. E-mail: [email protected] No references.
© Arnold 1999 0267–6591(99)PM280OA

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486 D Clark

Saunders C. Pleie av døende [Care of son should be at the centre of all considerations.
the dying]. Sykeplein, 1968d; 55(20): Again, the vehicle for exploring this is the author’s
589–90 experience at St Joseph’s Hospice, where work with
patients begins ‘when the stage of active treatment
Translated for this Norwegian nursing journal by is over’. For an American audience, it is pointed out
Ingeborg Morland, this article first appeared in that this care is both free and not limited in time
English as 1968b. (‘no “parking meter”, as it were, ticking away beside
No references. the bed’).
Now we see the ‘moment’ of approaching death
and the sense of ‘person’ in inter-relationship, so
Saunders C. Die Pflege Sterbender that a criterion for success is how the patient is being
[Care of the dying]. Deutsche (original emphasis) in the face of physical deterio-
Schwesternzeitung, 1968e; 29(11): ration. This is a matter of attitudes more than
565–67 details, a question of attention, of security and of
hospitality; what is described as ‘full time concern
This piece, in a German journal, is a translation of for the patient’.
the paper which had previously appeared in the Subsequent sections deal with a variety of
series on care of the dying, written for the Nursing themes. The distinction is made between ‘prolong-
Times, and referred to in the first part of this ing living and prolonging dying’ and the importance
bibliography as 1959d.1 of recognizing ‘the moment when our treatment
turns into care of the dying person’. Family consid-
erations are attended to – particularly the issue of
Saunders C. The moment of truth: relieving physical symptoms in order that relatives
care of the dying person. In Pearson L can focus upon their communication with each
ed. Death and dying: current issues in other. In turn, communication with dying patients
the treatment of the dying person. themselves is often simply a matter of seeing ‘this’
Cleveland, OH: The Press of Case person as himself, ‘indefinably the same, still with
Western Reserve University, 1969a: his own worth until the moment he dies’. This is
49–78 apparently something that comes rather easily to
young, untrained nurses, who have ‘not yet been
This volume, edited by a psychologist, draws taught to hurry’. On the question of awareness of
together a series of lectures given at Case Western dying, it is noted that 50% of patients at St Joseph’s
Reserve University. The lectures had sought to pre- ‘not only knew that they were dying but talked about
sent the current thinking of eminent clinicians and it with me’. However: ‘The rule is that there are no
scientists in the fast developing field of thanatology. general rules here except that you must listen’.
In addition to the editor, who compiled a selected Several pages are devoted to pain, particularly to
bibliography on death and dying, and Cicely Saun- chronic pain, which appears to serve no useful func-
ders, the contributors were: Robert Kastenbaum tion, being ‘timeless and endless as well as mean-
(Psychological death), Lawrence Le Shan (Psy- ingless’. Preventing pain in advance is advocated,
chotherapy and the dying patient), Richard Kalish using opiates; but the value of listening to the
(The effects of death upon the family) and Anselm patient is also emphasized, as in one who said ‘The
Strauss (Awareness of dying). pain seemed to go by just talking’. Avoiding a stu-
The chapter departs from an earlier usage and porose condition is important and this can involve
begins by emphasizing that the subtitle – care of the a balance of tranquillizers, sedatives and analgesics.
dying person, rather than simply care of the dying – Alcohol can also have its place, although the
is important. The chapter makes reference at vari- author is mindful that an American audience may
ous points to the works of Buber, Teilhard de have concerns about this. Choice is highlighted as
Chardin, Boros and Eissler. being of importance, and in particular choice based
The moment of truth in question in the title upon the patient’s informed knowledge of what is
occurs when a person is dying, and when that per- going on. Relief of pain is also seen as being the

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The publications of Cicely Saunders – 2: 1968–77 487

most vital component in avoiding the issue of ples without dogma and turns repeatedly to the
euthanasia: ‘I do not believe in taking a deliberate patient as the solution to the problem; so often, ‘the
step to end a patient’s life – but then, I do not get key to the whole situation is in the patient’. In the
asked’. final paragraph a significant goal of terminal care is
The question of ward dynamics when a patient stated: ‘helping the patient to have his own death
dies is also considered. The author is opposed to and his own dignity’.
patients being moved to side wards when they are References: 9.
dying. Patients always die peacefully and quietly,
and are rarely conscious at the time. Afterwards,
family members must be helped, often most effec- Saunders C. Relief of pain in
tively by nurses who will simply listen, ‘and can inoperable malignant diseases.
make a crucial difference to the whole grieving Medical News, 1969c; [volume and
process’. page numbers not known]
Finally, it can be the problem of meaninglessness
which is the hardest pain of all to bear. Some find An abridged version of 1970a, this paper begins with
solace in formal religion, but many patients do not. the assertion that terminal pain, unlike forms of
Nevertheless, for most there is some ‘moment’ that acute pain, has no useful function and should be
is fully personal and when, somehow, ‘everything is treated as an illness in itself. Terminal pain there-
summed up’. fore requires a ‘positive approach’. The treatment
No references. of terminal pain is summed up under three head-
ings: listening; attention to detail; and skill and con-
fidence in handling analgesic drugs.
Saunders C. The management of fatal No references.
illness in childhood. Proceedings of the
Royal Society of Medicine, 1969b;
62(6): 550–53 (Section of Paediatrics, Saunders C. Nature and management
pp 16–19) of terminal pain. In Shotter EF ed.
Matters of life and death. London:
This paper begins with the author acknowledging Darton, Longman and Todd, 1970a:
her relative lack of experience in caring for dying 15–26
children, although she goes on to emphasize some
of the similarities in caring for adults. Through the Here terminal pain is described as ‘not just an event,
exploration of a case discussion, observed in an or a series of events … but rather a situation in
American hospital, there is a detailed account of the which the patient is, as it were, held a captive’.
problem of dealing with staff members’ own anxi- Because it can be meaningless as well as endless, it
eties. Importantly, in this article on children, it is can bring a sense of isolation and despair. The
here that we see for the first time the acknowl- author draws on literature from pain clinics con-
edgement that her approach can sit alongside cura- cerning the specifics of cancer pain, complemented
tive endeavours: ‘Nor should skill in symptomatic with quotations from her own patients: ‘all of me is
treatment wait until other treatment ends – it is wrong’; ‘it was all pain’. In such circumstances the
often needed while the other continues’. Here it is aim is ‘not for recovery but for relief coupled with
a matter of confidence in forming a judgement dignity and enjoyment – that the patient should nei-
about when ‘we need to change our aim’. Commu- ther be swamped by distress nor smothered by treat-
nication is also an important principle, particularly ment but remain alive as a person …’.
in helping to establish a sense of security in the Listening to the patient is the first step in
patient, for ‘Security does what deception or denial addressing this ‘total pain’. Attention to the detail of
cannot do’ (original emphasis). This means dealing the story, to all the facets of the physical pain, but
with people honestly, but again it is emphasized also to the various symptoms which may accompa-
‘Honesty does not mean only stark truth’. As with ny it, come next. Thus: ‘symptomatic treatment, so
other papers, the author creates a sense of princi- wrong when definitive treatment is possible, is here

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488 D Clark

not only demanded, but also extremely rewarding’. social worker and the sociologist. A need exists to
Thirdly, skill and confidence is required in handling develop respect for age among students. Such an
analgesics and their adjuvants. The current literature attitude is best fostered in the context of a special-
on the incidence of pain among the terminally ill is ist unit, but not one which is detached from the
reviewed. The importance of anticipating pain in wider community.
advance is emphasized. The preferred mild anal- The author suggests that the recognition of the
gesics are listed, but the value of placebo is also imminence of death may prove just as difficult in the
emphasized: ‘Enthusiasm, instruction and the doc- geriatric unit as on the general ward. Accordingly,
tor’s own confidence often do more to relieve pain the concept of ‘the good death’ is ignored. ‘Indeed,
than any drugs …’. In cases of mild pain, it is sug- a persistent and often bitter denial of the fact of
gested, the choice of sedative is often more difficult death may even be encouraged’. The care of the
than the choice of analgesic and patients often dying therefore involves the discovery of ‘a new cri-
receive too many unsuitable sedatives. For mild pain terion of success’, and this means attending to what
the following drugs are most useful: methadone, dip- individual patients themselves are accomplishing in
ipanone, levorphanol and phenazocine. ‘For severe the face of physical deterioration. This is likely to
pain nothing has yet replaced the opiates’ but there be a matter of ‘being’ rather than ‘doing’. To talk of
continues to be a lack of adequate comparisons of accepting death is not mere resignation on the part
the effects and side-effects of the different members of the patient, or defeatism on the part of the doc-
of this group of drugs and of the synthetic groups tor. The task is to alter the character of this stage,
also. Yet, it is acknowledged that both patients and to see a positive achievement in dying itself.
doctors have their preferences and idiosyncrasies. This kind of awareness can be encouraged in stu-
One observation at St Joseph’s is that if drugs are dents in a ward round, but is best fostered by let-
well managed from the early stages, then large doses ting them talk to patients alone and informally.
are rarely needed. Again, the oft-repeated injunction Students have frequently observed how helpful they
occurs: ‘Constant pain calls for constant control’. have found even a comparatively short visit, but
However, drugs by themselves are insufficient: opportunities for a longer stay should also be
interest and attention are paramount, at the same afforded.
time these must be produced not as a technique but Above all, students must be taught ‘to do more
by ‘one that expresses the real commitment of one than merely treat physical symptoms’. So: ‘If they
person to another’. The chapter concludes with a listen they will learn how lonely and isolated the
short extract from an interview between the author dying often feel but also how very quietly and objec-
and a patient. tively the near approach of death is usually regard-
References: 5. ed by the very ill and the very old’. Such
observation will also help students come to terms
with their own feelings about death. Above all, it is
Saunders C. Training for the practice patients who teach us ‘more than we expect con-
of clinical gerontology: the role of cerning the whole of gerontology, of social medicine
social medicine. Interdisciplinary and indeed the whole of life’.
Topics in Gerontology, 1970b; 5: 72–78 No references.

By 1970 it was commonly acknowledged that the

predominant tendency in clinical gerontology was Saunders C. An individual approach to
an orientation to the elderly person’s potential for the relief of pain. In People and cancer.
living. This paper is therefore unusual in focusing London: The British Cancer Council,
on thoughts of dying – ‘the more neglected field’. 1970c; 34–38
Students of gerontology need to learn that the
patient must be seen as part of a total situation, and Pain is not inevitable in those with incurable cancer,
not merely as a ‘case’. Their learning can be as Wilkes has shown, but where it occurs it attracts
enhanced by in-depth studies of individual much public interest and is often a part of the
patients, drawing also on the knowledge of the debate on euthanasia. It is important to be aware

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The publications of Cicely Saunders – 2: 1968–77 489

that ‘ “the impossible pain of terminal cancer”, can there is need for more teaching in its proper
be relieved’. diagnosis and treatment’.
The approach should begin with ‘an analysis of No references.
the illness of terminal or chronic pain’. Terminal
pain ‘is commonly constant in character and so calls
for constant control’. This can extend beyond the Saunders C. The patient’s response to
patient: ‘I remember a family doctor who said in treatment. A photographic
describing a patient she was sending to us, “The presentation showing patients and
whole house is full of her pain” ’. However, once the their families. In Catastrophic illness in
control of pain was balanced to her need the patient the seventies: critical issues and
became the one giving strength to those around her. complex decisions. Proceedings of
Moderate doses of strong opiates can often produce Fourth National Symposium, 15–16
this effect, with no adverse effects on the patient’s October 1970. New York: Cancer Care
concentration. ‘Only 10 per cent of our patients ever Inc., 1971b: 33–46
need more than a 30 mg maximum dose of diamor-
phine, but among these are some where occasion- Other contributors to this symposium included
ally we go up to a dose of 90 mg at a time, given Edyth H Schoenrich (Comprehensive care for the
four-hourly and combined with a drug of the catastrophically ill), Elisabeth Kübler-Ross (Coping
phenothiazine group.’ patterns of patients who known their diagnosis) and
It is found that in talking about the physical relief Jerome Pollack (The economics of illness). The arti-
of pain, opportunities arise ‘of communicating with cle contains 35 clear, black-and-white photographs,
the patient on a much deeper level’. In most cases taken at St Christopher’s Hospice and in patients’
it is not a question of what to tell the patient: ‘it is own homes. They show patients and staff singly,
what you let your patient tell you’. In that place of in groups and with relatives. Three of the photo-
safety which is the true presence of another person, graphs are of artwork produced by patients; one
‘people matter more than drugs’. shows a drawing of her pain made by a patient
No references. before admission to the hospice and is contrasted
with another made 3 months later when she was
about to return home; a third, made 4 days before
Saunders C, Winner A. Analgesics in a patient died, shows a child standing fearlessly
terminal disease [Letter]. British before a dragon (of death) which is being fed
Medical Journal, 1971a; 3(768): 245 flowers.
The article begins with a brief account of St
The authors begin by endorsing the plea of an Christopher’s Hospice, described as ‘a Christian
earlier writer for a more liberal attitude to the foundation’, which was opened in 1967. Built using
giving of analgesics. ‘Too often we admit patients charitable grants and gifts, the National Health Ser-
from both hospital and home who have severe pain vice now pays two-thirds of its annual budget. Its
which has not been adequately relieved’. The research programme and experimental outpatient
dosage used should be adequate for a slightly longer and domiciliary service are presently wholly sup-
time than the interval between drug rounds. This ported by the NHS. There are 54 inpatient beds and
prevents both the recurrence of the pain and clock a wing with 16 bedsitting rooms for elderly people.
watching. It is found helpful to combine analgesics A teaching unit is under construction. Some 400
with a tranquillizer. Pain consists of various com- patients die each year at the hospice and 40–60 are
ponents, many of which can be controlled by other discharged home, at least for a short time.
means, particularly listening to the patient’s story. Taking up the theme of the conference, the
However, when the time for palliative radiothera- notion is advanced that, whilst catastrophe is
py, internal fixation or other more active measures defined in the dictionary as ‘a disastrous end’, it can
is over then nerve blocks, cytotoxic drugs and bring good from people and serve to bind them
steroids may also be useful. They conclude: ‘Termi- together. ‘We see this positive force repeatedly in St
nal pain can be regarded as an illness in itself and Christopher’s Hospice.’

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490 D Clark

Seven photographs, with associated commentary, kind of caring and involvement is a religious com-
explore the theme of the patient’s response to ill- mitment for many of us.’ It is suggested that there
ness. They reveal a range of dispositions: feelings of is too great a division between the well and the ill,
threat, doubt, longing, anxiety, depression; denial which masks our unity. Illness and suffering should
and resolute cheerfulness; longing and weariness; not simply be accepted without trying to help, ‘but
and fighting back. The following exchange is it does mean that we are not the only givers’.
recounted: CS: ‘ “Mrs. E … couldn’t you just let No references. Photographs: 35.
go?” Her reply, “Well, you know I might if you went
away” was astringent as ever but came from real
friendship. Next morning she died quietly’. Saunders C. The care of the dying
Twenty-eight photographs are used as a vehicle patient and his family. Contact, 1972a;
for examining the patient’s response to treatment Supplement 38, Summer: 12–18
and this is considered under three headings: science,
art and religion. Readers of this article are asked to put the patients
The science at St Christopher’s takes the shape described into their own particular setting in order
of a programme of research which includes psy- that what is known already can be developed and
chosocial studies of grief and bereavement, as well extended. In this way ‘terminal care everywhere
as pharmacological work ‘on the relative merits of should become so good that no one need ever ask for
different narcotics and their management’; future voluntary euthanasia’. Six key areas are discussed.
work is planned on the control of symptoms other First, the family should be regarded as the unit of
than pain, as well as biochemical studies. The care and for many care at home may be practicable,
photographs show how the relief of pain and other with help and support from family members. Sec-
symptoms can subserve other important work ond, terminal pain can be a kind of ‘total pain’, quite
which patients and families may need to undertake different from acute distress, but it can be relieved
in the final weeks and months of life. and forgotten. Figures are presented showing the
Whereas ‘science tries to look at things in their maximum dose of narcotics ever needed among a
generality in order to use them; art tries to observe group of 500 patients at St Christopher’s. Third, the
things – and people – in their individuality, in order relief of mental distress involves various skills; dis-
to know them’ (original emphasis). The pho- tinguishing between clinical depression and sorrow
tographs illustrate the importance of welcoming – drugs may help the former, but only the real lis-
patients and the involvement of the staff’s own chil- tener will assist with the latter; and sometimes
dren in the life of the hospice. One shows a patient ‘needs can only be met by touch and silent commu-
busily writing her life story. ‘Part of the art of med- nication’. Fourth, is care of the spirit; this includes
icine is concerned with values and therefore judge- the informal and the personal ‘but more often than
ments. It is the way we look at the essence of a might be expected people are helped by long-for-
situation, at people with their particular needs and gotten sacraments’. Staff support through small
at what is relevant treatment for them.’ This is fur- group discussion is also important. Fifth, there are
ther amplified in the distinction between ‘the path issues about decisions – about giving and with-
of vigorous treatment’ and ‘the way of doing noth- drawing treatment, for example in relation to
ing’, both of which are judged to be wrong. Instead, chemotherapy, blood transfusions, infusions (‘It is
‘we are called on to find the middle way of respon- far better to have a cup of tea given slowly on your
sibility and judgement’. last afternoon than to have drips and tubes in all
Finally, the dimension of religion is explored, directions’). Finally, a very small proportion of
defined very broadly, following McMurray as, ‘the patients have wished to discuss euthanasia, but once
field of personal relationships between people pre- pain and the feeling of isolation are removed they
pared to give themselves to each other in the con- never ask again. ‘Anything which says to the very ill
text of a common life’. In this context the or the very old that there is no longer anything that
relationships between staff and patients, and matters in their life would be a deep impoverish-
between patients and their relatives, are of partic- ment to the whole of society.’
ular importance. ‘We are a community, and this References: 2. Diagrams: 1.

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The publications of Cicely Saunders – 2: 1968–77 491

Saunders C. A therapeutic community: 1972 and published in the British Medical Journal
St Christopher’s Hospice. In with other papers by Sheila Hancock (a lay view),
Schoenberg B, Carr AC, Peretz D, W Ferguson Anderson (a professional view), Eric
Kutscher AH eds. Psychosocial aspects Wilkes (where to die), Sir David Smithers (where to
of terminal care. New York: Columbia die), Ronald Gibson (supporting the patient at
University Press, 1972b: 275–89 home), J McTrusty (nurse training), Barbara
McNulty (continuity of care), W Mitchell (local gov-
Prepared under the sponsorship of the Foundation ernment services) and KRO Porter (four recurring
of Thanatology in New York, this volume contains themes). The Cicely Saunders paper begins with an
sections on education, medical and surgical care, account of how patient and family ‘are often sepa-
paediatrics, care of the family, institutional care rated by unshared knowledge’. Another factor
(where the Cicely Saunders chapter is located) and which may separate patients from those around
ethical issues. them is pain. It can be controlled using a combina-
The chapter opens by declaring that all profes- tion of analgesics, adjuvants and other methods,
sionals, across cultures and settings, have something including listening to ‘the various facets of distress’.
in common: ‘we are concerned with persons and we Once in the inpatient unit it may be possible for
are concerned as persons’ (original emphasis). For families to be reunited, such as in the case of the
this reason some 22 photographs (a few of which sons who after admission ‘met their father again,
had appeared in 1971b) are included, to bring other when at home they had been refusing to speak to
persons before us. Four photographs illustrate him, resentful and uncomfortable with the illness of
some of the stages, described by Kübler-Ross, which which they were so frightened’. It then becomes a
patients may pass through. Another series shows matter of helping to produce ‘a climate in which the
how patients may help each other, even when they patients can find their own meanings’. This may be
do not share a common language. Others show a matter of listening without necessarily knowing
patients who, over time and in the hospice, came to the answers, whilst at the same time persevering
some acceptance of the ending of life: ‘We cannot with the development of practical skills. Simplicity
change what has happened to us but we may change and simply being there may be all important. The
its meaning.’ This calls for a fairly wide definition article concludes with the phrase, so important to
of religion as ‘the field of the relationships of one this overall approach: ‘you matter because you are
person to another, commitment in the context of a you’. In this way the patients can live until they die
common life’. One photograph of a smiling patient and the relatives may go on living afterwards.
sums up thoughts about ‘the good death’: ‘She knew No references.
she was dying and was as ready to go as she was to
stay until the time came’. Patients are often the
source of inspiration to staff, ‘for this kind of car- Saunders C. The need for in-patient
ing is costly’. The chapter concludes with a question: care for the patient with terminal
‘How do we find this community wholeness and fit cancer. Middlesex Hospital Journal,
the dying patient and his family, and ourselves, into 1973b; 72(3): 125–30
the whole of life to which we all belong?’.
References: 5. Photographs: 22 (7 taken by the Adapted, with minor changes, from an article orig-
American photographer and writer, Grace Goldin; inally written for the tenth anniversary volume of
the remainder by Cicely Saunders). the Cancer Institute, Madras, referred to in the first
part of this bibliography as 1964g.1
References: 24.
Saunders C. A death in the family: a
professional view. British Medical
Journal, 1973a; 1(844): 30–31

Based on a talk given at the first National Sympo-

sium on Care of the Dying, held on 29 November

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492 D Clark

Saunders C. Patient and doctor – the present unsatisfactory’ begins this article. Modern
advanced stages of cancer. In medicine has changed the face of death, which has
Proceedings of the Eastern European become ‘the great “taboo” subject and hospitals are
Conference on Cancer Control, 1973c; unwilling to make beds available for incurable
12–14 May: 172–78 [name and location patients’. There are, however, signs that some of this
of publisher not known] is changing: ‘A small number of organizations and
regional hospital boards have set up units for the ter-
A definition opens this article: ‘ “The terminal stages minally ill, and doctors, nurses and social workers are
of cancer” can be defined as the time when all active coming for instruction’. However, much remains to
treatment becomes increasingly irrelevant to the be done, for ‘terminal care has received little atten-
needs of a particular patient’. Unfortunately, it can tion and little research is going on in this country’.
also be seen as the time when nothing more can be The current position in the UK is summarized.
done and when the doctor begins to withdraw from About one-third of cancer patients die in their own
the patient. Such a position is neither justifiable nor homes; studies show evidence both of considerable
necessary. Instead, we should focus on the quality of suffering and of a bewildering variety of care that
living, even though this may be difficult to judge for may or may not be available. In the London area
another person. Freedom from pain is an important there is a small number of well-recognized organi-
component of this, as is staying at home, where this zations which cater for the terminally ill, and spe-
is possible. When admission is required, then fami- cial units have recently opened in Sheffield and
lies need great reassurance in order to avoid bitter Manchester. There are also Marie Curie Memorial
feelings of guilt. ‘The problems of giving a diagno- Foundation nursing homes. St Christopher’s Hos-
sis of cancer or of warning of a poor prognosis are pice was opened in July 1967 and ‘came into exis-
two very different things, although not necessarily so tence to try to fill the gap existing not only in the
in the mind of the patient, or his family.’ So it is care of patients dying of cancer but also in teaching
important to recognize that ‘Patients watch us as we and research in this field’. However, the proportion
watch them’. Communication can be difficult: it of patients who can be looked after by such special
should not be the responsibility of ‘one omnipotent institutions is, ‘and will always remain’, very limit-
individual’, but should involve the whole team. Also: ed. Many patients should be able to die at home, but
‘The best communication is often indirect and we all recent research by Cartwright shows the problems
know that deep understanding which never needs to which can occur. It seems not to be in doubt, how-
be expressed in words at all’. Principles of pain relief ever, that family members wish to go on caring for
are discussed in general terms, and the link between their old and dying relatives. As a large number of
physical problems and mental distress is emphasized. patients with cancer are likely to go on dying in hos-
Above all, it is with these patients that ‘we have pitals much effort should go towards improving
reached the border-line between the practice of them.
medicine and its philosophy’. In appraising the literature in this field, the
References: 3. authors begin by drawing attention to the work of
The article is followed by a summary of the text, Worcester, whose The care of the aged, the dying and
in Serbo-Croatian. the dead was first published in 1935 and reappeared
in 1961. However, it is suggested that ‘An increas-
Saunders C, Winner A. Research into ing spate of communications has been mounting
terminal care of cancer patients. over the past ten years, much of it from the USA’.
Portfolio for Health 2. The developing Then a warning note is sounded: ‘one must still con-
programme of the DHSS in health clude that in spite of all this interest most of the arti-
services research. Published for the cles which appear in so many of the medical,
Nuffield Provincial Hospitals Trust by psychiatric, and sociological journals throughout the
the Oxford University Press, 1973d: world remain descriptive and anecdotal’. One
19–25 dominant theme which emerges, nonetheless, is the
isolation imposed by society, including various pro-
‘The position of terminal care in this country is at fessionals, upon the dying and bereaved; here the

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work of Gorer, Glaser and Strauss, and Kübler-Ross Saunders C. Foreword. In Lamerton R.
is presented as evidence; the latter’s book ‘more Care of the dying. London: Priory
than any other has stimulated people to look afresh Press, 1973e: 7–9
at the problems of terminal care’.
A section on ‘special studies’ contains two sub- A first book foreword, in which Cicely Saunders
jects: outpatient services and pain. The outpatient introduces a new volume from her medical col-
arrangements at St Christopher’s are described. league Richard Lamerton. The guidelines and
General practitioners may refer patients to it for practical advice on the care of the dying, provided
pain control; it is also an opportunity for patients to by Lamerton, are greatly to be welcomed.
become familiar with the hospice prior to admis- Although the author ‘presents the results of
sion. There were 504 outpatients in 1969–70 and research, of intuition and of practice and gives an
673 in 1970–71. In addition, there is a home care exhaustive list of references’, he is particularly
service (visits up from 16 in 1969 to 79 in 1971). St praised for his comments on individual patients. It
Christopher’s has doubled the number of people is acknowledged that the personal style of the
who are in its care at any one time by the estab- author ‘may make him vulnerable’, but it will also
lishment of its outpatient service. Few studies have challenge readers to test and try out his ideas.
compared the merits of home, hospital and hospice; Lamerton’s chapter on religion ‘with its distillation
but work is soon to be published by Cartwright, of truths from different faiths’ is seen as a special
Hockey and Anderson and by Murray Parkes, which challenge. Here then is a book about dying patients
will be of relevance. From such studies ‘we hope for which ‘will certainly make many look – perhaps for
some guidelines when planning and developing the first time – not only at the positive ways in which
institutional and community services in the future’. we can help them, but also at the treasures which
It is noted that the assessment of this kind of ser- they give us’.
vice is not easy. A pattern of care at home followed
by admission for the final week or two of life seems
the most favourable. Figures might show how many Saunders C. A place to die. Crux,
weeks at home were gained, against admission to an 1973–4; 11(3): 24–27
acute hospital, ‘but better still they should be rec-
ognized as pain relieved, personal support given, Balfour Mount was the guest editor of this special
and a peaceful death’. issue (‘On Death and Dying’) of a journal published
Pain is acknowledged to be a problem which is by the Toronto Graduate Christian Fellowship. The
still not always adequately tackled in the patient’s editor’s own piece (Death – a part of life?), plus
home or in a busy general ward. The constant pain, essays by J Arthur Boorman (Death and dying in
exacerbated on movement, of terminal cancer Christian perspective), Elisabeth Kübler-Ross
requires constant control, so that: ‘The teaching of (Death in other cultures), MO Vincent (Good grief)
the past; that doses of narcotics should be spaced and Cicely Saunders’ contribution make up the
as widely as possible to avoid the onset of depen- collection. A place to die begins with the words of
dence, does not apply in this situation’. However, a David Tasma, spoken to Cicely Saunders in 1948: ‘I
search of the literature failed to find any trial com- only want what is in your mind and in your heart’.
paring diamorphine and morphine in terminal can- St Christopher’s Hospice is described as ‘a medical
cer – and this is ‘most unsatisfactory, especially in foundation whose research reaches out widely in
view of the World Health Organisation policy con- writing and teaching’ and as ‘a community in which
cerning diamorphine’. Double-blind assessments the patients are the central members’. It is a place
are underway at St Christopher’s. The paper con- which has set out to understand the needs associat-
cludes that: ‘Results of such work and that of oth- ed with progressive and mortal illness and also
ers in the field should bring a rational approach to chronic pain. Moreover, the team employed there
the teaching in this subject that has been lacking for has gradually enlarged as physicians and nurses
too long’. have been joined by physiotherapists, occupational
References: 12. therapists and others. Particular emphasis is
placed upon collaboration within a multidisciplinary

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494 D Clark

group, so that the ‘most important and uniting The work of St Christopher’s domiciliary service
moments of the life of St Christopher’s come when is highlighted, enabling patients to be cared for at
the group tries to understand and meet the needs home or discharged there for short periods. It is
of one patient at the deepest level’. Research is argued that patients such as Mr P are not helped by
underway at the hospice into the control of pain and readmission to a general ward in the terminal stages
also into families’ reactions to mortal illness, espe- but are ‘better cared for in a smaller, specialized
cially following bereavement. unit’, which maintains good liaison with the treat-
In addition to this intellectual approach to the ment centre. It is indicated that plans exist to build
work, there is a strong emphasis on other dimen- some units of this kind within hospital settings. At
sions: ‘It is by sharing what is in our hearts that we the time of writing there are some 30 ‘hospices’ in
enable each other to live and grow into being fully the UK, of various types. Independent status and
human’. This has special implications for those who religious foundation often contribute to their spe-
work at St Christopher’s who thereby expose them- cial atmosphere. The origins of hospices on the pil-
selves to ‘constant loss and bereavement’. In this grim routes of the Middle Ages are discussed. The
context the community aspects of St Christopher’s word hospice is defined as ‘given to hospitality’.
are particularly important, and this includes the The chapter also contains a discussion of the
involvement of children, as well as elderly people nature and management of terminal pain, again
who live in the long stay wing, together with visitors with special reference to Mr P, and the concept of
of many kinds. At the same time it is a community ‘total pain’ is described. With reference to other
which must ‘be open constantly to challenge and problems such as dyspnoea, anorexia and nausea
criticism, to listen as well as to teach’. ‘symptomatic treatment is now mandatory’. There
Importantly, this paper is the first in which the is also an exploration of ‘mental pain and the prob-
term palliative care is used to denote this activity, lem of telling’; the importance of timing in the dis-
rather than to signify the palliation of symptoms cussion of his prognosis with Mr P is highlighted.
which may precede terminal care, which has been Thus: ‘acceptance is an active and creative attitude,
the earlier usage. quite distinct from the negatives of despair and res-
The paper contains quotations from poems by TS ignation’.
Eliot and William Blake. There is a section entitled ‘The staff’ which deals
No references. with patterns of recruitment and retention, the
nurse:patient ratio (1.25:1), management issues and
the wider questions entailed in working always with
Saunders C. The working of St dying people. The discussion of research reports on
Christopher’s. In Medical care of the studies in clinical pharmacology and psychosocial
dying patient. New York: Foundation issues, and there is an account of the teaching role
of Thanatology, 1974a: [page numbers of the hospice: ‘In one sense, everything that hap-
not known] pens in St Christopher’s should be looked on as
education’.
The preferred method of describing the work of St References: 5. Figures: 3.
Christopher’s chosen here ‘is to take the story of
one of its recent patients and to consider how the
Hospice helped him and his wife to live together Saunders C. Caring for the dying. In
until the moment of his death and is still support- Lack S, Lamerton R eds. The hour of
ing her as she continues life without him’. It is the our death. London: Geoffrey
story of Mr and Mrs ‘P’ and covers the period from Chapman, 1974b: 18–27
early December 1971, when Mr P was referred to
St Christopher’s, to the time of his death, in Feb- Cicely Saunders contributes a chapter to this vol-
ruary 1973. The account contains extracts from clin- ume edited by St Christopher’s medical colleagues
ical notes as well as writings by and interviews with and based on the proceedings of a conference held
Mr and Mrs P, and serves as an important guide to in London in 1973. She begins by arguing that much
the mode of care in St Christopher’s at this time. talk and writing about death is impersonal, senti-

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mental or sensational. The naturalness and ordi- David Tasma’s death and when his donation of £500
nariness is ignored. Some dying people, however, had been extended to £500 000 is one such example.
‘are cut off from living because those around dis- At the same time it is also important to beware the
engage themselves and leave them in emotional and faith that may simply become foolhardiness.
physical isolation’. Euthanasia is not the solution to Tolkein’s metaphors of the quest are taken up here
this: ‘If a patient asks to be killed, someone has to illustrate how, despite the worst adversities,
failed him’. ‘release comes unexpectedly and in the end we are
At St Christopher’s, the first meeting with more all seen to have played a part’. But faith can also be
than half of all patients is in their own homes; some about letting go or in receiving with open hands, as
are never admitted to the hospice, others require a well as being the giver.
series of brief admissions. Over the course of a long No references.
deteriorating illness, patients and families may have
many concerns and questions. ‘We have to learn
when to speak directly and when to prevaricate … .’ Saunders C. Sermon preached in
Care for the patient who is dying comes to the fore Bristol Cathedral. The Road, 1974d;
‘when active treatment of all kinds becomes 145, February–March: 9–11
increasingly irrelevant to his needs’. This is not
‘therapeutic nihilism’, rather it signals the shift This sermon was given at a service to commemorate
‘from a negative to a positive approach’. The con- the silver jubilee of The Fellowship of the Road, a
stant control of pain is one of the most important society formed to give support to the seriously and
factors in this. Imagination and persistence are also chronically sick. Louie, Terry and Alice, three
important in the control of other symptoms, such as patients from St Joseph’s, all members of the Fel-
breathlessness (‘We find that oxygen is only rarely lowship, are described. ‘Many people tend to think
necessary’). Mental and physical distress are often of the strong and active as the givers in this life and
closely interwoven: ‘The emotional component is the weak and dependent as receivers. How wrong
eased as the physical is understood and treated, but they are!’
it is the listener who helps most of all’. At the No references.
moment of death itself both quietness and com-
panionship are possible: ‘Death is a gateway’.
No references. Line drawings: 4. Photographs: 12. Saunders C. Terminal care. In
Bagshawe KD ed. Medical oncology.
Oxford: Blackwell, 1974e: 559–72
Saunders C. Faith. Guildford Lectures.
Guildford: Seven Corners Press, 1974c: ‘The time for terminal care is reached when all
1–7 active treatment of a patient’s disease becomes inef-
fective and irrelevant to his real needs’. Thus begins
Four lectures were given at Guildford Cathedral this chapter, which goes on to overturn the notion
in October of 1974 on the subjects of faith that at this point ‘there is nothing more to be done’.
(Cicely Saunders), man (Anthony Harvey), Jesus The importance of enabling patients to be at home
(Anthony Bloom) and God (Ulrich Simon). is discussed first and the falling incidence of home
The difficulty of the assignment is acknowledged, deaths from cancer is noted. Problems experienced
but so too is a source of inspiration: the patients by family doctors are described and it is noted that
from whom the author has learned so much and for ‘Even when we have the proposed improvements in
whom she tries to speak. David Tasma’s request for community services and their better coordination,
‘what is in your mind and in your heart’ created an it seems likely that there will still at times be a need
obligation to do something about the care of the for a special service to fill gaps’. The benefits are
dying, however long it might take. This is linked to described of an ‘experimental project’, where spe-
the idea of faith as obedience to a command; so that cially trained nurses operate a domiciliary service
‘It is in action that faith is seen, grows and develops’. and where admission to a bedded unit is possible.
The creation of St Christopher’s 19 years after For some patients will reach a stage where adequate

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496 D Clark

relief can no longer be given at home – for exam- tion can help create a climate in which the patient
ple where severe pain calls for regular injections, in finds his own key and can reach out trustfully
cases of incontinence or night-time restlessness, or beyond himself to what he sees as true’.
where family members are physically and mentally References: 15.
exhausted. Small specialized units to care for these
patients are advocated, maintaining flexible liaison
with doctors at the treating hospital and in the com- Saunders C. (Member of Church of
munity. Such a facility could be located on a special England Board of Social Responsibility
ward within the general hospital, but ‘the self-con- Working Party) On dying well: an
tained unit will usually be better able to maintain its Anglican contribution to the debate on
own enthusiasm and tempo and to attract and sus- euthanasia. London: Church
tain a staff community’. It is noted that there are no Information Office, 1975a: 67 pages
studies in the community to compare with Hinton’s
work in hospital. However, pain is likely to be a The Working Party which produced the report had
problem in those requiring inpatient care. These seven members, although its first Chairman, Rt Rev.
patients should be approached with a positive atti- Ian Ramsay, then Bishop of Durham, died sudden-
tude so that patients may go on living as fully as pos- ly in October 1972, and others served on the group
sible; attention to detail is vital. Not all pain calls for between 1970 and 1974. Cicely Saunders was
the use of analgesics nor is it always due directly to responsible for the drafting of Chapter 4 (Case his-
the malignant process. Similarly, some patients elect tories discussed) and Chapter 5 (Further medical
to have some discomfort in order to feel fully alert. considerations); all members endorsed the conclu-
Accordingly, ‘by one means or another we must give sions. Of these, key points raised included: the
adequate relief’. Analgesics should be used to pre- unhelpfulness of extending the term euthanasia to
vent pain, rather than to control it after recurrence. include the withdrawal of artificial means of pre-
Turning to the question of the understanding of the serving life or to include the use of pain-relieving
patients’ mental distress, it is noted that it is rare to drugs which may marginally shorten life; the recog-
find in a patient’s case files ‘any comment on his nition that if all care of the dying was at the stan-
feelings or estimation of his insight into what is hap- dard of the best then there would be no prima facie
pening’, yet these may well be significant problems. case for euthanasia; and the belief that such stan-
Such problems may take the form of ‘stages’ or may dards are more hindered by ignorance than money
be seen as a ‘journey’. The idea of ‘denial’ is con- or staff shortages. It was recommended that the law
sidered, followed by depression or despair, before on euthanasia should not be changed. Chapter 4
finally a stage of acceptance is reached. The case contains seven case histories. Chapter 5 includes
notes of ‘Mr P’ are used to illustrate some of this. sections on making clinical judgements; treating the
On the issue of information for patients and fam- elderly; ‘life before death’; and medical education.
ilies it is asserted that how patients are told is more There is also an appendix which gives details of pain
important than what they are told. This is a subtle relief among 577 patients admitted to a hospice in
process which ‘frequently lies in a relationship 1 year.
rather than in words’. All members of the caring References: 33 (whole report).
team have a part to play in this. As in 1974a, there
is extensive quotation from the words of ‘Mr P’
describing his experience of surgery, diagnosis and Saunders C. Dimensions of death. In
subsequent treatment, together with the words of Melinsky MAH ed. Religion and
‘Mrs P’ on her reactions to her husband’s illness. medicine. London: SCM, 1975b:
‘Many people are able to make this kind of 113–16
achievement especially if they have the kind of sup-
port that helped this couple.’ It is also observed that: This chapter is based on a talk commissioned by the
‘The emotional needs of a dying patient are really Religious Department of the BBC European Services
those of all of us’. Finally, the place of faith in all of and broadcast in Germany on ‘The Day of the Dead’.
this is discussed: ‘unspoken confidence and convic- It draws on both professional and personal experi-

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ences of loss, and contains the following sentences in foundations of oncology; they argue that it is an
the introduction. ‘From the moment when a little underdeveloped medical field, whose scientific
hoard of flints was placed in the grave of early man, foundations are only just being laid.
the human race has laid down its dead in grief. And The author begins by asserting ‘The treatment of
it has done so with the hope that somehow this was cancer is often pre-occupied with the disease
not the end, and that somewhere those flints would process and too little concerned with the special
be needed.’ Dying may be hard, but it is a process problems of the individual patient’. There is a reluc-
which can be marked by great achievement in which tance ‘to view the patient as a whole’, and treatments
body and mind, although linked, are secondary to the may be continued or even begun without proper
spirit. This can sometimes be seen vividly in some consideration of their value to the patient at a given
transformation, words or gesture which takes place stage of disease. ‘The opposite approach is equally
shortly before death, and which can have remarkable unsatisfactory’, where a wholly negative attitude to
depth and power: ‘a timeless “Now” when all the the final stage is in evidence. A way between these
moments of time are held in stillness’. extremes does exist, in which acceptance of death is
No references. ‘neither resignation on the part of the patient, nor
defeatism or neglect on the part of the doctor’. This
can be a difficult stage to recognize, when ‘care
Saunders C. Hope. In Thought for the rather than cure’ becomes the clinician’s aim.
day. [No publisher or place of Particular attention is given to pain, still widely
publication stated], 1975c: 16–20 prevalent among those with terminal cancer, for
whom chronic pain is a particular and multistrand-
The articles in this pamphlet were originally broad- ed problem. A hierarchy of analgesics is proposed,
cast in ‘Thought for the day’ programmes on BBC from mild drugs to strong opiates, and continuous
Radio 4 during 1974–76. Two others contribute to relief is the objective. At present the titration of
the pamphlet: Brother Roland Walls and Dr Tom such drugs is largely a subjective process, ‘but meth-
West. The Cicely Saunders broadcasts, over 4 days ods such as radioimmunoassay for measuring the
(Monday–Thursday) were made in December levels of drugs in body fluids should soon provide
1975. The first shows how hope can grow, even as valuable new information on the quantitative phar-
we face our most difficult challenges, moment by macology of effective analgesia in man’. Drawing on
moment. Next, we are shown how hope can grow, evidence from the work of Twycross, it is shown that
so long as we do not duck reality. The third talk doses of such drugs do not escalate continually, and
describes ‘Paula’, the patient who showed that may even decline.
‘hope’ means being vulnerable and ready to take off A case history, with photographs, of Mrs S is pre-
masks and pretence. The final broadcast describes sented in which pain was controlled by giving
how terminally ill people may not be defeated by diamorphine up to 30 mg in a mixture containing
difficult things, but may still reach out in expecta- cocaine and alcohol. In the final stages diamorphine
tion and hope. ‘Day by day, in every Hospice ward was given by injection.
that I know, often with no words of any kind, we see Other aspects of chronic pain are also identified:
new hopes come … .’ mental or emotional pain, social pain, and spiritual
No references. pain.
References: 25. Figures and diagrams: 3. Photo-
graphs: 2.
Saunders C. The challenge of terminal
care. In Symington T, Carter R eds. The
scientific foundations of oncology. Saunders C. Care of the dying – 1. The
London: Heinemann, 1976a: 673–79 problem of euthanasia. Nursing Times,
1976b; 72(26): 1003–1005
The editors thought it necessary to include a brief
comment on why a chapter dealing with terminal This is the first in a series of updated articles which
care should appear in a volume on The scientific originally appeared in the Nursing Times in 1959.

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The revisions to the paper on euthanasia are so Saunders C. Care of the dying – 2. The
extensive as to require its publication in two problem of euthanasia – 2. Nursing
tranches over consecutive weeks. This article Times, 1976c; 72(27): 1049–52
begins with a discussion of euthanasia debates in the
House of Lords, from the first in 1936 to the most Part 2 of the article continues with reference to two
recent in Baroness Wootton’s Incurable Patients Bill of the case studies found in the booklet On dying well
(1976). Much of the 1976 Bill’s proposals should (see 1975a). It is argued that frank requests for
already be available to patients, although not all euthanasia, even among those who apparently
receive the help they need. The danger of the pro- ‘believe in’ the idea, are still very rare. Sometimes it
posal, albeit produced by those with ‘a manifest is a question of disentangling ‘the real question’ from
concern for the relief of suffering’, is that patients a ‘somewhat confused story’; and at times relatives
deemed ‘incurable’ may feel they not only had the may question the purpose of continuing to care when
right, but also the duty, to choose a quick end. the situation is deemed by them to be ‘hopeless’. The
Rather than concentrate on assertion and counter- author takes the view that legalizing ‘the right to die’,
assertion, the article focuses on the argument that with attendant procedures and safeguards, would
people are suffering when they need not. There probably hinder proper terminal care and could
have been many therapeutic advances in the 17 impose traumatic decisions on both patient and fam-
years since the articles were written, and some add ily. The past 17 years have seen much progress in a
to the problems – particularly when no clear ratio- sound basis for widespread improvement of practice,
nale for continuing treatment exists. Pope Pius XII’s not only in specialist centres, but also in general hos-
Allocution of 1957 is referred to and it is argued pitals and patients’ own homes.
that ‘in a case in which death is deemed certain and References: 1. Photographs: 2.
life can be prolonged only by artificial methods, the
physician is not absolutely obliged to prolong life by
extraordinary means’. Saunders C. Care of the dying – 3.
In this context the notion of ‘Living Wills’ is intro- Should a patient know …? Nursing
duced and there is a brief discussion of ‘furor Times, 1976d; 72(28): 1089–91
therapeutics’ and ‘meddlesome medicine’. More
positively, the past 17 years have also seen valuable It is suggested that the title from the 1959 version
additions to the pharmacopoeia and a sounder should perhaps be altered to: ‘Does a patient know
knowledge of the use of appropriate drugs. …?’. This is a knowledge which may depend as
Accordingly, much more thought and consulta- much upon silences and reassurances as upon infor-
tion is required on the question of euthanasia. In mation given. Again, changes are detected from the
particular, two additional questions need to be earlier period and ‘Perhaps we are becoming more
answered: ‘Do patients ask for euthanasia?’ and confident in the courage and common sense of our
‘What would they do and feel if mercy killing patients’. The piece then continues, as in the origi-
became a legal option?’. nal, with a detailed discussion of the case of ‘Mrs H’,
A discussion of Christian beliefs about suffering followed by sections on ‘what is hope?’ and ‘spiri-
then follows and the case of Captain Oates is tual help’. The discussion of hope returns to the
recounted, drawing on Scott’s journal of his last patient ‘Paula’, described in 1975c. A list of hospices
expedition to the Antarctic. Like Oates’s compan- in the UK is included in the article.
ions, who cared for him throughout and until he left References: 5.
voluntarily, those caring for the dying must convey
the sentiment: ‘You matter because you are you.
You matter to the last moment of your life, and we Saunders C. Care of the dying – 4.
will do all we can to help you not only to die peace- Control of pain in terminal cancer.
fully, but also to live until you die’. Nursing Times, 1976e; 72(29): 1133–35
References: 7. Photographs: 1.
Patients and even some nurses may have a fatalistic
acceptance that cancer must inevitably mean pain.

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Yet, experience over many years at St Luke’s home most about the possibility of communication of all
in Bayswater (Hereford Lodge at the time of writing kinds that is knit into skilled and affectionate bed-
in 1976) had shown that constant pain can be over- side nursing’. There follow sections on: anorexia,
come, ‘with an equally constant control’. Subse- intractable vomiting and/or nausea; dysphagia;
quently, the regime was introduced into St Joseph’s insomnia; urinary complications; bowels; fungating
Hospice, Hackney, where ‘the improvement in the growths; and pressure sores.
patients’ total well-being as well as in the control of No references.
their pain was so obvious that there could have been
no going back’. The work was then developed further
at St Christopher’s Hospice in the Department of Saunders C. Care of the dying – 7. The
Clinical Pharmacology. The article then continues, as last achievement. Nursing Times,
in the original, with a discussion of the case of ‘Mrs 1976h; 72(32): 1247–49
W’. The use of amiphenazole as a partial morphine
antagonist which might counteract problems of Entitled ‘When a patient is dying’ in the original
sedation, which had been reported optimistically in series, this article follows a similar structure to the
1959, is now regarded as unsubstantiated. Work in first but begins with an example from St Christo-
progress on assessing the key ingredients of the pher’s. In this particular example, the case of a fam-
‘Brompton Mixture’ is also reported: ‘So far in a ily man: ‘The good hours were the best of the
series of controlled clinical trials no observable clin- family’s life together; the bad ones are remembered
ical difference has been found between morphine by them with pride’. Elsewhere it is noted ‘I can
and diamorphine when given with Stemetil …’. quote no figures but I have seen many patients who
However, when injection is the favoured route, then seemed only just ready when the end finally came,
the solubility of diamorphine is preferred. and countless others who have continued to grow in
References: 6. Photographs: 1. patience and courage right up to their last
moments’. Following one page of new material by
way of discussion, the article moves into the 1959
Saunders C. Care of the dying – 5. format, with further sections on: when a patient is
Mental distress in the dying. Nursing dying; confidence gained; observant care; and a ser-
Times, 1976f; 72(30): 1172–74 vice that is shared. A prayer in use at the Continu-
ing Care Unit, Royal Victoria Hospital, Montreal is
This is a largely unrevised version of the original included in the final section of the article.
1959 article, although it does contain a discussion References: 1. Photographs: 1.
of psychotropic drugs developed over the intervening
20 years, and describes recent improvements in the
diagnosis and treatment of confusion. Saunders C. Care of the dying, 2nd
References: 1. edition. London: Macmillan, 1976i: 24
pages

Saunders C. Care of the dying – 6. The The full set of seven articles from Nursing Times,
nursing of patients dying of cancer. 1976, together with a brief editorial section by way
Nursing Times, 1976g; 72(31): of introduction on ‘the hospice movement’, plus a
1203–205 short biographical account of Cicely Saunders and
the formation of St Christopher’s Hospice.
It is emphasized in the introduction to this article
that issues in the nursing care of patients dying from
cancer must be shared between nurse, doctor and Saunders C. Living with dying. Man
family members. A list follows of suggestions and Medicine, 1976j; 1(3): 227–42
‘culled over the years from many people’ and
acknowledgement is made to the auxiliaries at St With minor subsequent amendments, this paper is
Christopher’s from whom the author has ‘learned based on the First Alexander Ming Fisher Lecture

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at the Columbia University College of Physicians Incurable Patient’s Bill). There is now much discus-
and Surgeons, on 5 March 1974. It begins by chal- sion about where such patients should be cared for.
lenging a recent editorial in The New York Times Services in the local community and the involvement
which had argued that ‘agonizing deaths’ from can- of the family doctor should be given priority. Find-
cer should be avoided by the use of drugs aimed to ings from a recent study by Murray Parkes are pre-
produce ‘the illusion of painless pleasure’. The work sented; the increased teaching available to GP
of the New York organization Cancer Care is cited trainees and medical students is noted; and the par-
as an example of an alternative approach and the ticular role of nurses in this developing field is
article draws on the author’s 25 years of experience acknowledged. The concern that the increasing
in caring for people with terminal cancer. number of hospices may draw patients away from
Part of the problem is that the ‘treatment of per- their own doctors is raised, along with the idea that
sistent cancer is too often concerned with the disease hospices may acquire a negative image in the popu-
alone’. There is a failure to view the patient as a lar imagination. This can be avoided by including dif-
‘whole person’. There may also be a danger of ‘treat- ferent kinds of patients, by adopting flexible
ing the doctor rather than the patient’ through admission and discharge policies, and by home care
overzealous interventions which are unlikely to be of programmes. ‘But no Hospice will be satisfied until
benefit. Conversely, the suggestion that ‘there is it knows that it has been accepted and included in the
nothing more to be done’ is equally unhelpful. The local community, that its resources are recognised
article goes on to chart ‘a middle road between these and drawn on by the family doctors when needed and
extremes’. This is one in which ‘doctor and patient that its very existence in the background will help
can work together to alter the character of this stage, towards the giving of better care for the dying in their
so that the process of dying is experienced not as a homes and in other hospitals in the area.’
defeat, but as a positive achievement’. References: 18.
Chronic pain in these patients is described as ‘a
complex situation affecting the whole person’.
Nonanalgesic measures for the relief of pain are dis- Saunders C. On dying and dying well
cussed, together with the appropriate use of pain [Letter]. Proceedings of the Royal
relieving drugs of varying strengths. ‘Spiritual pain’ is Society of Medicine 1977a; 70(4):
also considered, particularly the sense of meaning- 290–91
lessness that can occur in the face of terminal disease.
Above all, ‘if we are ready to “be there” as another Written in February of 1977, this letter was stimu-
person, as well as to “be there” as a skilled and under- lated by the Archbishop of Canterbury’s Edwin
standing professional, we will experience something Stevens Lecture, which dealt with the question of
of the human spirit and what it can achieve’. euthanasia and incurable illness. Cicely Saunders
References: 4. Figures and photographs: 11. seeks to clarify a misunderstanding which has
arisen from the lecture that the elderly are being
cared for at the expense of other members of soci-
Saunders C. Care for the dying. Patient ety. Similarly, another concern to older people,
Care, 1976k; 3(6): [page numbers not highlighted by the 1976 Incurable Patients Bill, is
known] that for some the ‘right’ to die might be interpret-
ed as a duty to do so. However, the Archbishop’s let-
‘It seems that we first learn how to do things and only ter ‘has opened up the subject in a useful way’ and
later when to do them.’ The statement captures the he has spoken favourably about the work of the hos-
opening theme of a short article which draws atten- pices. It is important to note also that teaching in
tion to the problem of deciding when concern for a terminal care has applications in a wide range of set-
patient should turn into ‘an acceptance of and an eas- tings: home and hospital among them. By passing
ing of dying’. This is not a new problem. Alfred on the available knowledge it may be possible to
Worcester was an early commentator on this and it ensure that appropriate and competent treatment
was the subject of ‘a long and interesting debate’ in is available to everyone.
the House of Commons in 1976 (Baroness Wootton’s No references.

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The publications of Cicely Saunders – 2: 1968–77 501

Saunders C. Palliative care for the which provided St Christopher’s with one of its most
terminally ill [Letter]. Canadian important metaphors. The talk, however, is princi-
Medical Association Journal, 1977b; pally concerned with Cicely Saunders’ relationship
117(1): 15 with Antoni, who died in St Joseph’s Hospice in
1960. Both men were Polish émigrés. It describes the
Following Balfour Mount, to whose 1976 Montreal love forged in the shadow of mortal illness and in
conference reference is made, this letter uses the the public space of a hospice ward. ‘We had no past,
term ‘palliative care’ to describe the field of caring no ordinary things to remember but somehow the
for dying people. It highlights how the principles of strength of being together at the end of his hard life,
this palliative care can be developed in other set- of being kept in a kind of solitude in the midst of a
tings, as demonstrated by Balfour Mount at the busy ward and the joy of finding each other in the
Royal Victoria Hospital in Montreal, which has very time of parting, belong to all I aim to do now.’
shown ‘how transferable our work has become’. No references.

Acknowledgements
Saunders C. A window in your home. Thanks are expressed to those who have offered
In The light of experience. London: encouragement following the first instalment of the
British Broadcasting Corporation, bibliography. This work forms part of the Hospice
1977c: 100–105 History Project, based within the Sheffield Palliative
Care Studies Group at the University of Sheffield.
In the BBC television broadcasts entitled The light Financial support is gratefully acknowledged from
of experience one person talks straight to camera the Wellcome Trust (Grant No. 043877/Z/952), the
about some personal crisis or watershed and why it Sir Halley Stewart Trust and the Royal Society. Con-
has such significance for them. The idea is to tinuing thanks also to Margaret Jane for her
explore an inner territory. The series was produced detailed assistance with the preparation of the
by Shirley du Boulay, later Cicely Saunders’ biog- bibliography.
rapher. In this volume 20 contributions to the tele-
vision series are brought together. Other
contributors include Bel Mooney, Maeve Binchy, Reference
Sheila Cassidy, Erin Pizzey, Rabbi Lionel Blue and
Colin Cowdrey. 1 Clark D. An annotated bibliography of the
The title of this piece refers to David Tasma’s publications of Cicely Saunders – 1: 1958–67. Palliat
famous phrase of 1948, shortly before his death, Med 1998; 12: 181–93

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