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JAMA 25 Years Ago Section Editor: Jennifer
Reiling, Editorial Assistant.
THE IMPACT of Cicely Saunders, OBE, FRCP, director of St Christopher's
Hospice, London (Sydenham), on the care of the dying patient is persuasive.
After Dr Saunders had lectured at St Luke's Hospital Center, a Hospice
Committee was established at St Luke's to consider the introduction of similar
concepts within the framework of a university general hospital. Two members
of the committee and I were invited to St Christopher's for an in-depth site
visit in order to assist the committee in its deliberations.
I believe this report is factually correct, although it reflects my
own intense positive involvement with a committee hospice staff.
Although I arrived with an initial resistance to continual contact with
the dying patient, the actual experience was quite different from what I had
expected. Instead of a terminal care or "death house" environment with cachectic,
narcotized, bedridden, depressed patients, I found an active community of
patients, staff, families, and children of staff and patients. . . .
The key personnel are full-time with many part-time and retired professionals,
as well as volunteers, trainees, medical graduates, and young house doctors
There are mainly wards, with few private rooms. Each bed has a colorful
curtain around it, and there are some transparent, partial panels. Personal
touches, such as flowers, paintings, comfortable lounge chairs, and wood,
give a feeling of warmth. In addition to the wards, there are family rooms
for visits and a large room for group activities.
On arrival, the patient is met at the ambulance by one of the staff.
There is close face-to-face and bodily contact between the staff member and
the arriving patient. The Hospice is designed so that the patient's bed is
brought to the ambulance. From that moment, the bed remains the property of
the patient. If the patient is bedridden, that bed becomes as mobile as a
wheelchair. Once the patient is given a location in the ward, it remains his
regardless of the deaths of surrounding roommates. . . .
"Polypharmacy" is the term coined by Dr Saunders and staff. The symptom
manifestation, rather than the underlying pathologic characteristic, of the
dying patient is paramount. Although emphasis is on pain alleviation, extensive
drug therapy for a wide range of symptoms is also used. . . .
The object of polypharmacy is to maintain an integrated functioning
individual who is neither in pain, nor symptomatic in any other area and who,
if able, is alert to his surroundings and to the people about. . . .
Admissions come from many sources, but the Hospice prefers to select
patients who have families or friends within commuting distance, to avoid
the psychological difficulties inherent in isolating patients from their home
ties. . . .
The median length of stay is two to three weeks; 16% of the patients
die within hours or 24 to 48 hours after admission. Some patients, despite
prognosis, survive beyond six months, and some even survive for a number of
years. . . . Long-term survivors are important for the morale of the staff
and patients, dulling the impact of immediate or early deaths. . . .
Dignity of Death
Since the establishment of the Hospice in 1967, over 2,500 patients
have been admitted, with eight to ten deaths occurring each week. There is
24-hour staff coverage (including physician and chaplain) at the time of the
The actual event of death is managed with dignity. The dying patient
is not isolated behind curtains. All patients in the ward area are aware of
what is transpiring. The lack of suffering, in fact the absolute absence of
patient distress, is the unique factor permitting the staff and other patients
to overcome their fear of death. This applies equally to families and children
who, on visits the next day, note the passing of a previous patient whom they
had befriended. The curtain is drawn around the patient's bed at the very
moment of death only, rarely before. The impending death of the patient concerns
and absorbs the immediate staff on duty. The patient does not die alone and
abandoned. . . .
The Hospice teaches a new attitude toward dying and death, with the
realization and conscious acceptance of dying and death as part of being born
and part of the struggle of life. . . .
JAMA . 1975;234:1047-1048
Liegner LM. St Christopher's Hospice, 1974. JAMA. 2000;284(19):2426. doi:10.1001/jama.284.19.2426
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