Author: David Clark
This biography eloquently portrays the life of a visionary doctor whose passion, reasoned logic, forensic research and effective collaboration enabled her to establish the principles that revolutionised palliative care. The book describes how, by clearly delineating and then forcefully pushing through her ideas on the management of chronic diseases and terminally illnesses, she laid the foundations on which a whole new medical specialty evolved. The book also showed how her foresight enabled her to build palliative care on a strong multidisciplinary and cross-specialty platform. The narrative stressed how her unique and fascinating background as a social worker, a nurse and then a doctor, made her well-suited to recognise and marshal the divergent qualities, outlooks, and skills that symbolise the specialty. In exploring this multifaceted framework – what he characterised as ‘a powerful and rare combination’ – the author demonstrated how it enabled her to ‘more clearly’ elucidate the ‘nursing, social, and medical needs‘ of palliative patients. The overall picture the book paints is of a dynamic pioneer whose character and competence appropriately inspired what emerged as a profoundly empathetic and effective medical specialty (pages 81-82).
In charting the journey Cicely Saunders took towards palliative care, the biography traced her earliest steps to her nursing training when she witnessed the pain and suffering of children with cancer. The book described how, unable to pursue a nursing career because of chronic back pain, she explored ‘other areas of work that would afford her a similar level of human contact with people…who were suffering and who needed care‘. This yearning, the author noted, led her to train as an almoner in hospital social work, a calling that fulfilled her impulse to relieve the burden of those who suffer. The author depicted this work as ‘a fertile context for Cicely to sharpen her social awareness…and get close to the ordinary lives of working-class people’. He added that it also provided her an insight into the wider context of caring because she also took part in ‘organising aftercare and convalescence, and in mitigating the effects of poverty, poor housing, and over-crowding‘. These activities, the author explained, enabled her to ‘see not only the physical consequences of serious illness, but also its social and emotional sequelae’. It was also as an almoner that Saunders experienced the different facets of hospice practice and realised that ‘she would get more involved in terminal care‘ because she became ‘more and more drawn to the needs and care of dying people‘ (pages 39-40, 44, 50-51 and 64-65).
In identifying the drivers for Saunders becoming a medical doctor, the book pointed to her insistent quest to do more for those suffering with chronic and terminal diseases. This zeal, the author said, was recognised by the surgeon Norman Barrett, who worked closely with her looking after terminally ill cancer patients, and who provided the impetus for her to enrol as a medical student. The author narrated how medical school enabled her to see the problems of cancer and palliative care ‘close up and in graphic detail‘, and to appreciate that ‘there was a complexity there which needed deep reflection, clear thinking, and confidence in the approach’, qualities which the author maintained ‘were often lacking and rarely found in combination’. The book also painted a vivid picture of the deplorable state of palliative care at that time, cancer being viewed then as a ‘death sentence‘ which either went untreated, or was treated with ‘damaging surgery‘, ‘unsophisticated radiotherapy‘, or ‘pessimistic’ chemotherapy. This portrait also captured the ‘nervousness‘ by which clinicians approached people with cancer; the ‘widespread public silence about the disease’; and the ‘resignation, and often despair‘ of the 1950’s cancer patient. It is remarkable that it was also as a medical student in 1958 that the author said Saunders wrote ‘her first publication on terminal care’; this was a case-based paper which ‘proved to be a remarkably complete statement about the issue of terminal care in Britain at that time’, and which would become ‘a manifesto for future action’ (pages 71-72, 83-84 and 91- 95).
The single-minded commitment Saunders made to palliative care is perhaps best reflected in her career trajectory after she qualified as a doctor. Proceeding to work in several religious-based hospices, the author remarked that this pioneering phase of her profession offered her the opportunity ‘to develop a wider view of pain in the context of the whole person’s suffering‘, and to start implementing better methods of relieving cancer pain. It is also illuminating that she started advancing the field of palliative care at this early stage, the author saying that this was when she ‘formed her own key ideas and specific approach to clinical practice’, ‘built up a network of international contacts to strengthen her endeavours’, and started researching, teaching, publishing, and performing public advocacy work on palliative care practices. Her full philosophy of palliative care however only got full expression at St Christopher’s, the hospice the author said she set up because she wanted to overcome the ‘tide of indifference to the needs of terminally ill people which existed in the care system’. Thus becoming ‘the first-ever modern doctor to devote her entire professional career to caring for those at the end of life’, the book provided an exhaustive account of how she developed her modern palliative care principles to mitigate ‘the twin undesirables’ of the ‘terminal neglect of the dying’ and ‘the medicalisation of death‘. Perhaps her most profound palliative care insight which the book highlighted is her idea of total pain – a concept that would become ‘emblematic of the whole principle of care’ in palliative medicine. The author also explored how she introduced ‘a research-based approach to improving care at the end of life’, defined ‘a new knowledge base about the care of those dying from malignant disease’, and introduced a truly multidisciplinary approach to palliative care (pages 105-111, 125-128, 132-133, 140-176, 187 and 237).
The character portrait the book painted of Saunders highlighted several qualities which defined her personality and determined her career. In this regard, her leadership skill was perhaps the most prominent and most influential attribute she demonstrated throughout her life. The book supported this by noting that she had held such positions as house head, school prefect, and secretary of school mission whilst in college, and that as a trainee nurse at St Thomas’s Hospital she was elected the set representative and became ‘a good overseer of others’. The author also described her effective administrative skills, depicting her as a ‘detail terrier for whom no issue was too small’ – a laudable quality which nevertheless brought her into conflict with colleagues. And whilst her management style was productive, the author noted that this was tainted by such traits as ‘her tendency sometimes to trample over established boundaries, protocols, and norms‘, and her ‘boundary-hopping and close intertwining of the personal and the professional’. Her other skills, which the author said she developed during her nursing training, included strict discipline, ‘scrupulous’ attention to detail‘, and ‘an ethical stance to others’ (pages 13-15, 30-44, 49-50, 88-90, 121, 188 and 315).
A crucial element of Saunders’ personality was her religious faith, a life-long trait that rang loud throughout the book; the author traced its onset to her college days, and he described how she rekindled it at university where she pursued ‘an accelerating spiritual path‘. The book described how she became enthused by the views and writings of such evangelists as Billy Graham and John Stott, and how she adopted an ‘evangelical culture‘ that was ‘variously intense, literal, high-minded, and not at all hedonistic’. The author nevertheless pointed out that she later remodelled her religious attitude ‘in a shedding that revealed something altogether deeper and more profound’, and that her religious revival ‘would eventually temper and…open out into a richer, more nuanced and multi-faceted religious worldview‘. Perhaps associated with her spiritual leaning were the curious spiritual encounters she experienced with two terminally ill patients. The most influential in this regard was with David Tasma, a Polish man with inoperable bowel cancer who Saunders met whilst working as an almoner. The author cited her relationship with Tasma as the reason she wanted to ‘find a way to work with the dying‘, and as the fountain of her concept of palliative care which was based on ‘the application of the knowledge and wisdom of the mind, sitting alongside the care and vulnerable friendship of the heart’. The second patient was Antoni Michniewicz, a patient with bone cancer Saunders met whilst practicing as a hospice doctor, and ‘with whom she formed a deep personal relationship‘ (pages 13-15, 30-44, 49-63, 88-90, 188, and 315).
This is a very well-written and brilliantly organised book, a fitting tribute to its subject – the doctor who put palliative care on solid footing and established its future direction. The narrative, detailed and focused, conveys the sense of a compassionate doctor determined to ease the pain and suffering of a group of patients that healthcare profoundly undeserved. Her ability very early on to pull the disparate threads of palliative care together into a cohesive whole marked her genius. Whilst some of the narrative appeared dragged out, such as the details of setting up St Christopher’s, this nevertheless provided a grainy view of the hard work and commitment, as well as the hurdles and obstacles, that typify any worthy venture.
The book’s strengths lie in the author’s overwhelmingly objective assessment of his subject, striking a balance between highlighting her laudable qualities and criticising her faults and failings. The book is also strengthened by the cultural, social, political, and historical contexts in which it set its subject’s life. The life of Saunders portrayed in this book powerfully highlights the values of passionate and long-term commitment to objectives, and of the hard work and detailed research required to attain them. The biography also illustrates how these values are fundamental to the ethos of medical progress, and I recommend it to all doctors.
Publisher, Place, Year: Oxford University Press, Oxford, 2018
Number of chapters: 6
Number of pages: 333
Star rating: 5