Modern activists in palliative and end of life care work increasingly in a global context, where international links and collaborations have been become a regular feature of day to day activity. But it was not always the case. The early pioneers lived in an era before the internet and instant electronic communication. It is interesting to note therefore just how international connections were made: before email, e-journals and Skype – and alsothe tangible benefits that resulted from them. In this context, a striking feature of Cicely Saunders’ practice during the formative years of St Christopher’s Hospice in the first half of the 1960s was the way in which she forged links with and drew strength from colleagues in America. This came through extensive correspondence by letter, through the exchange of precious ‘reprints’ of publications and also by direct visits. In particular there were three key extended visits which Cicely Saunders made to the United States that yielded a huge amount in terms of knowledge, insight and collaboration.
The first of these, in the spring of 1963, was a tour de force, covering the east and west coasts and making connections with individuals from a spread of disciplines – people would soon become influential in forging modern ideas about ‘hospice’ across the United States. Afterwards she compiled a detailed report of her experience and went to considerable trouble in sending copies to many of those she had met. Indeed she soon ran out of copies, as demand outstripped supply and she underestimated the level of interest the report would attract. Three of those she encountered on the trip were asked to become Vice-Presidents of St Christopher’s Hospice. Professor Gordon Allport, was a contact through her brother, Christopher; he was Chair of Psychology at Harvard University and Executive Secretary of the Ella Lyman Cabot Trust, which supported the visit to the United States. Theodate Soule was a Consultant to the Hospital Social Service Fund, in New York. The Rev Almon Pepper was Director of the Department of Christian Social Relations, at the Protestant Episcopal Church, New York and subsequently attended the laying of the foundation stone for St Christopher’s in 1965.
For a lone Englishwoman who had never before travelled to the USA it was a remarkable tour, lasting eight weeks. Taking in New York, Yale, Boston, Washington, Los Angeles, San Francisco and Vancouver, she visited 18 different hospitals of varying types and also went to the National Institutes of Health, Maryland. Along the way she met with doctors, psychiatrists, nurses, social workers, social scientists and hospital chaplains. As she noted in the introduction to the report of the visit: ‘I found it a great asset that I was able to go in my threefold capacity of nurse, social worker and doctor. It made my own approach a broad one and also made me “one of them” when I discussed problems with each of the different professions’[i]. There are sections in the report dealing with pain in terminal cancer; with the mental pain and distress of dying patients; with relatives and their problems; with home care programmes; with nursing homes; and with the work of chaplains.
Several of those she met on this visit became longstanding colleagues and friends and over time an elaborate network of individuals concerned with the care of the dying began to develop. In the early 1960s the letter was their main means of communication, coupled frequently with the diligent and enthusiastic exchange of reprints from recent publications. In these years Cicely Saunders was a prolific letter writer and her correspondence gives a remarkable insight into the energy with which she pursued her links with the United States and the benefits that flowed from them. Her personal papers contain no less than 15 archive boxes of correspondence with colleagues in the USA, much of it covering the period up to 1967 [ii].
On the west coast the psychologist Dr Herman Feifel, Chief Psychologist at the Veterans Administration in Los Angeles and author of key early work on aspects of death and dying [iii] as well as Esther Lucille Brown were met for the first time and soon became became regular correspondents. The latter, a social anthropologist working with the Russell Sage Foundation, was a frequent source of letters and ideas, with specific interests in improving the quality of nursing care. On the east coast Florence Wald (then Dean of Nursing at Yale) as well as Gordon Allport and Carleton Sweetser (Chaplain at Memorial Hospital, New York) all became close colleagues.
The link with Yale was to be particularly significant. Cicely Saunders’ first visit had been at the invitation of Dr Bernard Lytton, a former surgeon at the London Hospital, from where he had visited St Joseph’s Hospice once a week. On moving to Yale and learning of Cicely Saunders planned visit to the USA he invited her to lecture at the University and it was he who met her when she arrived at the airport in New York. At Yale she spoke first to the students’ council in the School of Medicine and then, by special request, the following day repeated the talk to the Faculty of Postgraduate Nursing. The second lecture sparked an enormously positive reaction. It was there that she met Florence Wald, who the report of the tour states, remarked afterwards: ‘This is what we have lost, and this is what we need’.
As the historian of American nursing Joy Buck has noted, Wald was at a critical point in her own life in 1963. She was an advocate for major reforms in nursing education and the clinical role of the nurse and like Cicely Saunders, she believed that professional nurses should eschew non-nursing tasks in order to give more focus to care at the bedside. She was also deeply sceptical of the drive within medicine to privilege technology and cure over an emphasis on care of the person. Wald believed the hospice concept offered the perfect vehicle by which she and other reformers could achieve a ‘brave new world’ in healthcare with nursing and medicine working together as equals at the helm [iv]. She soon set about developing ‘St Christopher’s in the field’ – which became the first hospice programme in the United States, established at New Haven, in 1974.
The second visit by Cicely Saunders to the USA began on 10 May 1965 in New York with a lecture a few days later at the Postgraduate Center for Mental Health, followed by speaking engagements at Yale and meetings at the Massachusetts General Hospital with Professor Lindemann (a psychiatrist at Massachusetts General Hospital and early bereavement researcher, who developed the concept of ‘anticipatory grief’). On this occasion, as before, financial assistance from the Ella Lyman Cabot Trust was made available, mediated through the good offices of Gordon Allport. She observed to Esther Lucille Brown ‘I cannot be too grateful to them, for not only did they help me very substantially on my last trip but they also sent me a most generous gift as “seed money” for St Christopher’s . I am most undeservedly fortunate in the people who support us’[v]. In the case of Gordon Allport there was also an emotional and intellectual debt, for it was he who in 1963 had first introduced her to the writings of the Austrian psychiatrist and concentration camp survivor Viktor Frankl, in particular Man’s Search for Meaning[vi], which was to prove so influential upon her thinking in the coming years[vii].
During the second visit and capturing somewhat the mood of the times, Saunders discussed with colleagues at Stanford the possibility of using LSD with terminally ill patients, later followed up with a reading of Dr Sidney Cohen’s September 1965 Harper’s Magazine article on the subject of ‘LSD and the anguish of dying’. She also was featured in a San Francisco newspaper piece.
American colleagues also proved a useful sounding board about events and developments taking place back in London. After writing to Esther Lucille Brown on the subject of her feelings about leaving St Joseph’s in the autumn of 1965, her friend wrote back this ringing endorsement: ‘It must have been a wrench to leave St Joseph’s after seven years there. I believe, however, that this is a most auspicious moment for you to sever ties and prepare yourself psychologically for initiating your new program in your own new hospital’[viii]. Or on another occasion when the finances of St Christopher’s had taken an upturn: ‘Isn’t it marvellous how financial sustenance at this very trying moment has been coming to your rescue. I do hope that it will continue …’ [ix]
Regular correspondents all received a newsletter which contained details of the development of the St Christopher’s project; this was clearly an important channel of communication and often featured in the exchange of information and the words of encouragement which were such a feature of the letters to and from American colleagues. Perhaps more so than in the United Kingdom, and maybe also resulting from the cultural disposition of the Americans with whom she made contact, there was a tendency for her to receive from across the Atlantic a greater recognition of the wider import of her work than that found at home. In due course therefore the traffic between the UK and the USA came to be two-way and American visitors were arriving in London with increasing regularity to visit St Joseph’s and the still to be opened St Christopher’s – Anselm Strauss for example, sociologist and pioneering researcher on awareness contexts in dying[x] and based in San Francisco, visited her in the autumn of 1965 and many others followed.
By late 1965 Cicely Saunders’ reputation in the USA was growing rapidly and increasing media attention led to her being the subject of an article in the 12 November issue of Time magazine. Requests for her help and guidance, as well as for her to write for other publications began to increase. In May 1966 she took part in a series of five lectures (later published [xi]) at Western Reserve University, Cleveland, Ohio, and in which the other lecturers were Lawrence Leshan (Psychotherapy with the dying patient); Anselm Strauss (Awareness of dying); Robert Kastenbaum (Psychological death) and Richard Kalish (The dying person: impact on family dynamics). By the autumn of 1966, there was a sense of an emerging critical mass of interest not only in her work, but also in the wider field to which she was contributing. By now what Robert Kastenbaum referred to as ‘our little death newsletter’19, Omega, which been established and was reproducing her article ‘A medical director’s view’, which had appeared first in the journal Psychiatric Opinion[xii] These early publications in the USA spanned several key disciplines and audiences: the church; nursing; medicine and psychiatry. America was learning about the work of Cicely Saunders and she was learning from America.
The third sojourn in North America included Canada. It began on 19 April 1966 with six weeks in Yale before moving on to Cleveland and then to Vancouver. She began her lecture at the Yale School of Nursing on 28 April 1966 thus:
‘This is the third time I’ve been at Yale, and like St Thomas’s Hospital, I think you must begin to feel that every time you get rid of me, I come back in another capacity. This time I’ve chosen the title, “The Moment of Truth”, not because I just want to discuss the perennial question, “Should you tell the dying patient the truth?” (which is not really the right question anyway), but because meeting dying patients and facing the fact of death does concern all of us, whether we’re nurses, doctors, social workers, psychologists, or of any other discipline; I think perhaps almost most of all, when we’re just members of the family. This moment is, or should be, a moment of truth, not just a matter of words, who says what and when, but something much more deep and far-reaching than that in its implications, implications which, I think, are relevant to the whole of life’.[xiii]
Also at Yale was a meeting with two major figures in the emerging psychiatry of dying and bereavement. Elisabeth Kübler-Ross was visiting from Chicago, and Dr Colin Murray Parkes was spending a year in Harvard. Their first encounter brought together a remarkable triad of names which were to become synonymous with the modern care of the dying and bereaved. Dr Elisabeth Kubler Ross was at that time working as a psychiatrist at the Billings Hospital and University of Chicago, where she had begun to embark on a series of important and widely acclaimed works on death and dying [xiv]. Murray Parkes was later to work closely with Saunders at St Christopher’s where he brought his psychiatric perspective not only to the care of patients and families, and also to research and to the support of the staff.
She was to go on returning to Yale, not least in June 1969 when she was awarded the Degree of Doctor of Science; and her friendship with Florence Wald was to grow and thrive over many years, particularly as developments for the New Haven Hospice got underway.
A special relationship
Perhaps more than anything it was the opportunities which America afforded for access to a range of disciplines and perspectives which was so important to Cicely Saunders in these years as she, in her own words, picked up ideas like a sponge. Here she could meet chaplains, such as Carleton Sweetser struggling with the care of the dying in a modern hospital setting and also social workers like Theodate Soule, at the United Hospital Fund of New York. In addition there were psychologists, sociologists and anthropologists who, unlike most of their contemporaries in Britain, were also contributing to developments in the field of care for the dying. There was also the new cadre of pain specialists, such as Stanley Wallenstein and Ray Houde, at Memorial Hospital, New York and Henry Beecher at Massachusetts General Hospital, from whom she received encouragement and inspiration in her own studies. It was indeed a rich mixture of influences and skills, and one that was later to become such an important aspect of the modern multi-disciplinary specialty of hospice and palliative care. There was a sense of forces coming together, of new possibilities.
A special relationship was forged between Cicely Saunders and her American friends and colleagues during the middle years of the 1960s. The relationship was part of an extraordinary groundswell of interest in the care of the dying and the bereaved out of which new social movements and professional specialties were quickly to emerge, not only in Britain and the United States, but worldwide.
For more on the whole of this particular topic see: Clark D (2001) A special relationship: Cicely Saunders, the United States, and the early foundations of the modern hospice movement, Illness, Crisis and Loss 9(1): 15-30
[i] Cicely M Saunders Report of Tour in the United States of America, Spring 1963, unpublished.
[ii] http://www.kingscollections.org/catalogues/kclca/collection/s/10sa88-1, accessed 7 July 2014.
[iii] Feifel H ed (1959) The Meaning of Death. New York: McGraw-Hill.
[iv] Buck, J (2009) ‘I am willing to take the risk’: politics, policy and translation of the hospice ideal. Journal of Clinical Nursing 18(19): 2700-2709.
[v] Cicely Saunders letter to Esther Lucille Brown 16 February 1965.
[vi] Frankl.V. 1962. Man’s Search for Meaning. Beacon: Boston.
[viii] Esther Lucille Brown letter to CS 30 November 1965.
[ix] Esther Lucille Brown letter to CS 17 November 1966.
[x] Glaser, B. and Strauss, A. (1965) Awareness of Dying. Chicago: Aldine.
[xi] Saunders C. The moment of truth: care of the dying person. In: Pearson L ed. Death and Dying: current issues in the treatment of the dying person. Cleveland: The Press of Case Western Reserve University, 1969: 49-78
[xii] Saunders, C. 1966. A Medical Director’s View. Psychiatric Opinion 3 (4):28-34.
[xiii] Text of Cicely Saunders’ lecture at Yale School of Nursing, 28 April 1966.
[xiv]Kübler-Ross, E. (1969) On Death and Dying. London: Routledge.