'We Will Help You Live Until You Die'
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GrandRound ‘We will help you live until you die’ ➜ Joanna Lyall Cicely Saunders touched the lives of millions of terminally ill patients through her promotion of hospices and palliative care. Though she died this summer at the London hospice she founded in 1967, her fight for all patients to have the right to live well and die pain free and in dignity goes on. hortly before her death in the medical profession had an equal Robert Twycross, who worked as a St Christopher’s Hospice responsibility to help their dying research fellow at St Christopher’s, this summer, Cicely patients live as full and pain-free lives from 1971 to 1976, says “When Saunders took part in a tel- as possible for as long as possible. Cicely first became involved, doctors evision programme that It was a hard battle to win, and, as largely neglected the dying. There Scalled for better access to good pallia- is clear from her correspondence, was no systematic approach to pain tive care in the UK. Few who knew published in paperback earlier this and symptom management and the her would be surprised that at 87, and year, Saunders recognised the mes- idea that patients had to ‘earn’ their only weeks away from her own death sage of palliative care is one that analgesia was still prevalent.” from cancer, she still accepted the needs constant reinforcement. Twycross, now emeritus clinical opportunity to speak out on the issue In a letter written in 1972, she reader in palliative medicine at to which she had dedicated her life. warned that, “Unless we teach stu- Oxford University, says that as well as Born in 1918, months before the dents even more widely than we are being “an excellent physician and a end of the First World War, Saunders doing and continue battling away charismatic figure with a superb is widely recognised as a pioneer of with those already trained, patients brain… she was extremely effective at the modern hospice movement, will simply not get the quality of care engaging powerful allies and spread- founding the trail-blazing St they should receive.” ing the knowledge she had gained.” Christopher’s hospice in south It was due to her work that pallia- Saunders, he says, saw the bene- London in 1967. Though the concept tive medicine was first recognised as fits of pain relieving drugs being given of offering a place of support and a specialty by the Royal College of regularly, pre-empting pain. She initi- comfort for the dying was not new, Physicians in 1987, 20 years after she ated research which showed the such hospices as existed at that time started St Christopher’s hospice as a effectiveness of morphine and spread were mainly run by nuns. Saunders’ centre for treatment, teaching and what she had learned. unique contribution was to insist that research. “She was a visionary and also a 12 ■ CANCER WORLD ■ NOVEMBER-DECEMBER 2005 GrandRound ST CHRISTOPHER’S HOSPICE She was a great advocate for research and made the case that morphine is the gold standard propagandist and disseminator of relieving pain as the mixture of practice was not widespread, and she knowledge. She always said she didn’t diamorphine, cocaine and anti-emetic saw that part of her task was to act as found the hospice, it found her, and in chloroform water, then known as a catalyst to promote better care both certainly it was an idea whose time ‘the Brompton cocktail’. Importantly, in the UK and beyond. had come. But without her in the it also showed that there were no Her background gave her a special background there would not have problems of addiction when mor- perspective from which to do this. been a recognition of palliative medi- phine was given for pain relief. Forced to give up nursing because of a cine as a specialty. “In the 1970s we killed the back problem, she trained as a hospi- “She was also a gifted teacher. Her Brompton cocktail and were essen- tal almoner (medical social worker) concept of ‘total pain’, introduced in tially using morphine in tap water and worked at St Thomas’s hospital an article in 1964, encouraged stu- and an anti-emetic in selected (south London), on a cancer ward, dents and health professionals to con- patients,” recalls Twycross. This had before starting medical school at the sider the mental, spiritual and social considerable implications for pain age of 33, qualifying in 1957, at the dimensions of the patient’s feelings. control in countries where diamor- age of 38. “Cicely was never just a sympto- phine could not be prescribed. Some of her first articles, written matologist,” he says. Saunders had already seen the well before the opening of St benefits of pre-empting pain by giving Christopher’s, were for the nursing PAIN AND PALLIATION drugs regularly when she worked as a press in the 1950s, and her writings Twycross’ research at St Christopher’s volunteer nurse in the evenings at St stressed the role of nurses in hospice in the 1970s showed that morphine Luke’s hospital, in central London care. She believed it was the nurses at was as effective in preventing and between 1948 and 1955. But the St Luke’s who came up with the idea CANCER WORLD ■ NOVEMBER-DECEMBER 2005 ■ 13 GrandRound ST CHRISTOPHER’S HOSPICE “You matter because you are you, and you matter until the last moment of your life” of giving drugs regularly to patients research and made the case that mor- and with relatively little expense, with advanced cancer to prevent pain. phine is the gold standard,” he says, excessive and unnecessary regulation It was Saunders’ concept of ‘total adding that some doctors still need to of opioids still prevents its use where pain’ that sparked the modern pallia- be reminded that prevention is better it is most needed.” tive care movement, according to Phil than trying to treat pain when it has Geoffrey Hanks, professor of pal- Larkin, lecturer in palliative care at already occurred. liative medicine at the University of the National University of Ireland in Bristol, and honorary president of the Galway and vice-president of the PAIN IS STILL A PROBLEM EAPC, agrees that many patients with European Association of Palliative However, regulation is still hamper- cancer pain still do not benefit from Care (EAPC). ing effective palliative care in many the advances made many years ago. “She could speak to a number of parts of the world, he says. “Despite “We have the knowledge to relieve levels, and as a nurse she hugely vali- clear evidence that morphine pain in about 80–90% of patients with dated the role of nurses in palliative remains the gold standard for pain cancer. But the prevalence of unre- care. She was also a great advocate for relief and may be administered safely lieved cancer pain is 50%.” 14 ■ CANCER WORLD ■ NOVEMBER-DECEMBER 2005 GrandRound He argues that pain relief is still poor- widely as possible, Saunders always this work in whatever way is most ly understood by many, and that some stressed that the pattern of services, suited to their circumstances.” patients are wary of taking morphine. should be determined at a local level. Later in her career, reviewing glob- “Our problem is still the inadequate She lectured widely and fostered al developments in hospice care, use of powerful drugs by non-special- international networks and received Saunders said: “a worldwide spread has ists. And the reluctance of patients to thousands of visitors to St Christo- shown that the basic principles can be take these drugs.” pher’s, but did not want it to be taken interpreted in widely differing cultures But while it may be depressing to as a global template, saying her main and with few resources other than the see how little has changed for some aim was “to encourage people to do family values of the developing world.” cancer patients since Saunders started her campaign, a head of steam is CICELY SAUNDERS clearly building up to force a change of attitudes at the highest level. A Cicely Saunders was born in London on 22 June 1918, the eldest child of a suc- group of pain specialists from 16 cessful estate agent. Educated at Roedean, a girls’ private boarding school, she went countries, known as the Opioids and to Oxford to read philosophy, politics and economics, but left when war broke to train Pain European Network of Minds as a nurse at St Thomas’s Hospital, South London, qualifying in 1944. Forced to give (OPENMinds), is calling for “a posi- up nursing because of a back problem, she trained as an almoner (medical social tive educational programme to change worker) and it was while working at St Thomas’s in 1948 that she met David Tasma, attitudes on the medical use of opi- a 40-year-old agnostic Polish Jew who was dying of cancer. In the months before his oids, extending from the core curricu- death, she fell in love with him. They discussed the needs of the dying and he left her lum of medical students to patients £500 and said “I’ll be a window in your home.” taking opioids and their families.” Soon afterwards she went to work as a volunteer in the evenings at St Luke’s hospi- In a report to the European tal, in central London. It was at St Luke’s, which had been founded as the Home for Parliament in June, the group pointed the Dying Poor in 1839, that she saw the benefits of pain relieving drugs being given out that many European countries regularly.