Dame Cicely Saunders

Founder of the modern hospice movement
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Cicely Mary Strode Saunders, nurse and physician: born Barnet, Hertfordshire 22 June 1918; Medical Director, St Christopher's Hospice 1967-85, Chairman 1985-2000; OBE 1967, DBE 1980; OM 1989; married 1980 Marian Bohusz-Szyszko (died 1995); died London 14 July 2005.

Cicely Saunders was the founder of Britain's first modern hospice for the dying, and, from this - such was her capacity to inspire others - founder of a worldwide hospice movement. The founding - and funding - of St Christopher's Hospice in Sydenham in 1967 was her personal achievement and has been imitated all over the world. She was the first modern doctor to devote herself to the care of the dying, and St Christopher's was the first modern hospice, though there were already a few homes in existence for the dying, mostly run by religious orders.

She was, initially, a nurse; and then, when a back injury forced her to change career, a hospital almoner. During this time she became so aware of the poor emotional and practical care given to the dying that she devoted her life to putting this right.

Cicely Saunders was born, the eldest of three children, into a prosperous but unhappy family, and sent to Roedean School when she was 10. Here she was taller than the other girls and was shy; she felt she never fitted in, and this, she said, gave her a feeling for people who were outsiders. She also suffered from a painful and slightly crooked spine, and had been made to lie flat on the floor for 40 minutes a day. She wanted to be a nurse but her family discouraged her, so she went to the Society of Oxford Home Students, the future St Anne's College, Oxford, where she read Politics, Philosophy and Economics with a view to becoming secretary to an MP.

When war broke out she disregarded her parents' advice and in 1944 enrolled as a student nurse at St Thomas's Hospital, London. It was good training in palliative care as there was a war on and no penicillin until D-Day. Here she was recognised as a high-flyer. However, because her back was still painful despite an operation, her surgeon advised her to quit nursing. She returned to Oxford for a year, gaining a "war degree", and then trained as a social worker, or what was then called a lady almoner, gaining the Diploma in Public and Social Administration, qualifying in 1947. During this time she had been searching for faith without success, and then, while on holiday in Cornwall, she discovered she really believed in God. She said it was "as if a switch had flipped".

In the course of her almoner's work, at Archway Hospital in 1948, 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 - it was probably what amounted to a spiritual love affair - they discussed the idea that she might one day found a home where the dying could find peace in their final days. He left her £500, a substantial figure then, 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 a plain window, with an unremarkable view of the car park.

After his death Saunders felt that, at last, she knew what God had called her to do, which was to build a home for the dying, where scientific knowledge should be combined with care and love. In hospitals, the prevailing ethic was that patients should be cured, and those who could not be cured were seen as a sign of failure. It was normal policy not to tell them their diagnosis, and the dying were treated with evasion and embarrassment. After Tasma's death she continued her work as an almoner and was also a volunteer sister at St Luke's Hospital, a home for the dying in Bayswater.

She sought closer contact with patients and asked a surgeon at St Thomas's, a Mr Barratt, if she might work as a night nurse, which might put less strain on her back (most of the lifting work is done by day staff). He said that people wouldn't listen to her as a nurse, and that doctors desert the dying. He suggested that if she really wanted to help dying patients she should become a doctor. She was accepted as a medical student at St Thomas's Hospital, where she had trained as a nurse.

Saunders was 33, and for the second time in her life found herself rather isolated - found that the other students made little effort to accept a fellow student who was much older - but she impressed her teachers with her emotional maturity; one recalled her spending her time off reading to a patient who had recently and suddenly lost her sight. She gave her time to her patients, something that few medical students did.

The most important milestone of her student years was the article she wrote for the St Thomas's Hospital Gazette, published in 1958 shortly after she qualified, 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, 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 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 1,100 patients, introducing a punch-card system, which made good scientific sense. 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. 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, such as bedsores, nausea, depression, constipation, and breathlessness. One 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.

She was a good listener and paid systematic attention to patient narratives.

In 1960, as a newly qualified doctor working 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 (he was dying, and they never had a chance to be alone together). She also became exceptionally close to a Mrs G, whom she wrote about in a moving article in the March 1961 Nursing Times. At about the same time her father died, and her grief was compounded by the harsh terms of his will.

Saunders now 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 Elisabeth Kübler-Ross's view that there are five stages of dying: denial, anger, 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. By the end of the year she had named it after St Christopher, patron saint of travellers.

She initially wanted a Church of England hospice, but several of the major grant-giving organisations required her to make it open to people of all faiths, and she modified the plan accordingly; 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 wanted it to have the atmosphere of a friendly village. She met her architect in 1959, and the St Christopher's charity was registered in 1961. She found a location in 1963 at Sydenham, and liked it because it was in the middle of a populated area (people don't want the remoteness of country locations, but prefer to be near their family and friends) and had good transport nearby. Between 1961 and 1964 she raised £330,000. By 1966 the estimated cost was £400,000 and by the following year - these were inflationary times - they stood at £480,000.

All this time she was working at St Joseph's. She went, too, on a "voyage of discovery" to the United States, where they were ahead in pain research. Building work started in 1965 and money was still not coming in fast enough: at times the builder wasn't paid on time.

She had a huge amount of support, both local and national: local children helped prepare the garden, and the fire brigade hung the curtains. The hospice contained 54 in-patient 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 would return home but needed continuity of care, and plans 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 home care (1969), to research (in the same year) and a study centre. In 1968 Saunders's mother died, having stayed at St Christopher's during her terminal illness. By 1970 the NHS contributed two-thirds of the running costs, and NHS doctors undertook part of their specialist training there.

After her visit to the US in 1963, she regularly crossed the Atlantic, learning from US expertise in pain research and all aspects of care. She and the American psychiatrist Dr Sam Klagsbrun were to reciprocate visits for many years, and Saunders's work took on an international dimension and hospices, based on her concept, now exist in North America and throughout the English-speaking world. By 2000 there were 200 hospices in Britain and Ireland.

Cicely Saunders was the author of many papers on terminal care and of several books, including Care of the Dying (1960) and Living with Dying (1983); the editor of The Management of Terminal Disease (1978), St Christopher's in Celebration (1988) and Beyond the Horizon: a search for meaning in suffering (1990); and joint editor of Hospice: the living idea (1981). She has also been the subject of several books - David Clark edited Cicely Saunders, Founder of the Hospice Movement: selected letters 1959-1999 (2002) and Shirley du Boulay profiled her in Cicely Saunders: founder of the modern hospice movement (1984) and Changing the Face of Death (for children, 1985).

In 1963, three years after the death of Antoni Michniewicz, she met another Polish man who was to become her lifelong partner. Marian Bohusz-Szyszko was a painter with a degree in fine art. She met him at a retrospective exhibition he held in a London gallery. She became his patron, and his work was hung at the hospice. He loved her but was not free to marry as he had a long-estranged wife in Poland, whom he supported; also he was a devout Catholic. The solution came in 1969, when he and Saunders, 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 appointed DBE. Marian died in 1995, spending his last days in St Christopher's.

Cicely Saunders stepped down as Medical Director of St Christopher's in 1985, remaining for 15 years as Chairman. She received numerous honorary doctorates, and awards including the Templeton Foundation Prize (1981), the Gold Medal of the British Medical Association (1987) and the Conrad N. Hilton Humanitarian Prize (2001). In 1989 she was appointed OM.

Saunders was strongly against euthanasia, partly because she was a committed Christian, and also because she argued that effective pain control is always possible (though some would disagree) and that euthanasia is therefore not needed. Her position was that a person who requested euthanasia had been failed in some way by others. She did acknowledge, however, that both sides in the euthanasia debate are against pointless pain and impersonal indignity. On one occasion - and there may well have been others - she invited a distinguished doctor on to a committee, but withdrew the invitation after he told her that he was a member of the Voluntary Euthanasia Society.

A new portrait of her, commissioned from Catherine Goodman, winner of the 2002 BP Portrait Award, and painted when Saunders was ill with inoperable cancer, was unveiled at the National Portrait Gallery in April. Interviewed on the occasion, the artist remarked: "Cicely has said that she doesn't mind dying and how can you not believe her?" She died yesterday, at St Christopher's.

Caroline Richmond

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