There are now more female medical students than male in most medical schools across the UK, peaking in 2003 at 61%. [1] But it has not always been easy to be a woman in medicine, and certainly not to lead transformation in healthcare culture.
However, this did not stop Cicely Saunders and Anne Merriman, two women who were driven by their faith, to challenge the way that we view dying and care for those at the end of life.
Dame Cicely Saunders graduated from medical school at 39; her route was unconventional. After giving up philosophy and Economics at Oxford University, she trained as a 'nightingale nurse' at St Thomas' Hospital to help the war effort.
Unfortunately she gave up nursing due to back problems, but returned to Oxford to train as a 'lady almoner' (social worker) so she could continue to be closely involved in patient care.
At 27, Cicely became a Christian and described the change in her life 'as though I suddenly felt the wind behind me rather than in my face'. Following this she became an enthusiastic member of All Souls, Langham Place and was driven by her prayer and desire 'to know how best to serve God'.
She felt that God gave her the answer very quickly when she met a terminally ill polish Jew called David Tasma. She helped him come to terms with his imminent death, given the difficult life he had led. following their discussions about improving care for the dying, he gave her £500 to begin a movement that would better manage pain and also provide better overall care.
She said this felt 'like God tapping me on the shoulder and saying, "You've got to get on with it"'. She began to explore a concept she later described as 'total pain', that dying people have physical, spiritual, psychological, and social pain that must all be addressed in good palliative care.
Through working at St Luke's Hospice for the dying poor she saw the benefits of compassionate nursing care plus good, regular pain control. this was unusual, as doctors were afraid of giving patients access to regular morphine for fear of addiction. Patients would often be begging for pain relief, only to be given small amounts of morphine by injection, which was itself painful. Despite seeing the benefits of giving dying patients regular analgesia, pre-emptive of pain, Saunders saw there was a serious lack of professional medical help, as doctors had given up on these patients. This made her sure that care of the dying needed to be a lot better and was work that she could do.
However, this was not going to be easy and it was a surgeon she had been working with who advised her: 'Well, you've got good ideas, but you won't get anywhere unless you become a doctor. It's the doctors who desert the dying'. Cicely qualified as a doctor at St Thomas' Medical School and went straight into work on pain control for the terminally ill, based at St Joseph's Hospice in London in 1957.
'Commit thy way unto the Lord; trust also in him; and he shall bring it to pass' [2] was the verse that she came across in her daily Bible reading that convinced her to build her own hospice for the dying.
2017 marks the 50th anniversary of St Christopher's Hospice in Sydenham, London. Palliative care was not integrated into the NHS at this point and so the building of the hospice came completely from charitable donations, which was no mean feat! St Christopher's offered individualised patient care, but was also active in research and education as Saunders saw that this would be crucial to advances in end of life care.
Since then, hospice care has spread across the world and there are believed to be 8,000 hospices in over 100 countries. Throughout her life, Cicely was consistently opposed to euthanasia, saying 'anything which says to the ill that they are a burden to their family and that they are better off dead is unacceptable'. She believed that if patients' symptoms, physical,
psychological and spiritual, could be properly managed, there would be no need for euthanasia.
This continues to be a perspective maintained by the Association for Palliative Medicine who released a public briefing outlining serious concerns about the legalisation of assisted suicide. [3]
Cicely died peacefully at St Christopher's in 2005. But this shy girl, who spent a lot of her teenage life feeling like an outsider, [4] completely transformed both our view of dying and made care of the dying a priority in our healthcare system. Her philosophy still drives research and policy to improve end of life care for every patient and their families: 'You matter because you are you, and you matter to the last moment of your life'.
But the story does not end with Cicely Saunders or in the UK…
Wanting to follow in her brother's steps, she had been bitterly disappointed when she discovered that as a woman she could not be a priest. However, little did she know that she would establish the first hospice in Uganda, and be part of the next step in revolutionising end of life care across the world.
She graduated from University college Dublin in 1963, and after a year's internship began her career as a Medical Missionary in Nigeria. However, it was when she had to return to the UK for family reasons that she describes the need for palliative care as part of her work in geriatrics, 'the elderly needed pain and symptom control and a… team to bring them to peace'. She got in touch with Cicely Saunders and began to bring her palliative care teaching to the northern part of the UK.
However, her call to work abroad never went away and in 1981 she embarked on a Masters in International Health that led her to work in India and Singapore. With a growing ageing population, Dr Anne saw a desperate need for holistic palliative care in Singapore. As a result, she went on to not only introduce some of Dr Saunders' principles but in 1989 set up the Hospice care Association of Singapore that continues to offer one of the best palliative care services in South East Asia.
But Anne had not forgotten her first experiences of medicine in the developing world. The invitation to become the first Medical Director of Nairobi Hospice, Kenya, took her back to Africa in 1990. Her work in the hospice made her realise the desperate need not only for good palliative care but also affordable pain relief to enable patients to die peacefully at home with their families. She describes this realisation: 'while working in Nigeria as a hospital doctor, I was one of the many doctors who, when we could do no more, would ask the families to take the patients home. For the first time in Nairobi I was seeing what was happening to the patients who were sent home. And it broke my heart'.
With growing numbers dying from cancer and an exploding AIDS epidemic, need seemed to outstrip the resources available. In addition to coping with death and dying in a culture so far from her own, Anne described days where it felt like she has nothing left to give and prayed 'Oh God I am helpless. Please help my patients'.
But like Cicely before her, Anne was motivated by faith in god's provision, and a 'determined, stubborn' character. [5] This 'fire in my belly' determination that had overcome so many obstacles thus far, made her persevere in the fight against the 'bureaucracy inherited from the British… [that remained] still alive and well in the African health systems' and in the early 1990s
'Hospice Africa' was introduced. The aim would be to initiate a model of affordable palliative care services that was also culturally acceptable.
In 1993 Dr Anne began in Uganda with three months' worth of funding and a team of just three nurses. More than 20 years later, Hospice Africa Uganda has over 130 staff, a budget of 2.8 million and palliative care has been now incorporated into Uganda's Strategic Health plan, making it a national health priority. A big shift in culture was needed in regards to the vital role of nursing staff in palliative care, particularly for prescribing.
With the ratio of doctor to population in Africa varying from 1:4000 to 1:100000 (in the UK it is roughly 1:450), relying on doctors to prescribe morphine left many dying patients with no access to vital analgesia. [6] Dr Merriman made the training of nurse prescribers a priority and it is having a significant impact on access to morphine across particularly rural part of Uganda.
Although Hospital Africa continues to expand, with Anne supporting initiatives in many countries across Africa including Tanzania, Malawi and Sudan, the work of palliative care is nowhere near complete. [7] Currently 100 million people across the world have some form of palliative care need, but only eight million have access to even the most basic service. despite the World Health Organisation stating that access to analgesia is an essential human right, each day six million terminal cancer patients across the world suffer pain needlessly, because they cannot access or afford morphine. [8]
Where other doctors saw failure and the end of the road, Cicely Saunders and Anne Merriman saw people at their most desperate and in their time of greatest need. These women were motivated by their faith in God and love for people and could see there was a better way. Their autobiographies are littered with stories of patients that they learnt something from or people who meant something to them.
To them, patients were so much more than statistics, bodies in beds, numbers on a jobs list. 'How can I understand a figure or a statistic unless I have held the hand that it represents? The people we are talking about are the same as us. By the way we treat them we know just how much like Jesus we have become.' [9]
The challenge for us is this: will we stand on the shoulders of these giants, to continue their work? The issues our palliative patients face today are no less pressing, no less challenging, and they deserve no less an urgent and sustained response.
Alice Gray is a junior doctor in Birmingham
1. General Medical Council. growth in the proportion of female medical students begins to slow. GMC; October 2013 bit.ly/2u0IDqy
2. Psalm 37:5 (KJV)
3 . George R. public briefing on the APM's position on assisted suicide. APM; July 2015 bit.ly/2vpxOyM
4. Cicely Saunders Archive bit.ly/2u3GU3W
5. Anne Merriman Foundation, Biography bit.ly/2uUI8LX
6. Merriman A. Audacity to love. Dublin: Irish Hospice Foundation, 2010
7. Anne Merriman Foundation, Biography bit.ly/2uUI8LX
8. Piana R. Dying Without Morphine. The New York Times 30 September 2014 nyti.ms/2f5z82V
9. Anne Merriman foundation, Biography bit.ly/2uUI8LX
However, this did not stop Cicely Saunders and Anne Merriman, two women who were driven by their faith, to challenge the way that we view dying and care for those at the end of life.
Dame Cicely Saunders
Dame Cicely Saunders graduated from medical school at 39; her route was unconventional. After giving up philosophy and Economics at Oxford University, she trained as a 'nightingale nurse' at St Thomas' Hospital to help the war effort. Unfortunately she gave up nursing due to back problems, but returned to Oxford to train as a 'lady almoner' (social worker) so she could continue to be closely involved in patient care.
At 27, Cicely became a Christian and described the change in her life 'as though I suddenly felt the wind behind me rather than in my face'. Following this she became an enthusiastic member of All Souls, Langham Place and was driven by her prayer and desire 'to know how best to serve God'.
She felt that God gave her the answer very quickly when she met a terminally ill polish Jew called David Tasma. She helped him come to terms with his imminent death, given the difficult life he had led. following their discussions about improving care for the dying, he gave her £500 to begin a movement that would better manage pain and also provide better overall care.
She said this felt 'like God tapping me on the shoulder and saying, "You've got to get on with it"'. She began to explore a concept she later described as 'total pain', that dying people have physical, spiritual, psychological, and social pain that must all be addressed in good palliative care.
Through working at St Luke's Hospice for the dying poor she saw the benefits of compassionate nursing care plus good, regular pain control. this was unusual, as doctors were afraid of giving patients access to regular morphine for fear of addiction. Patients would often be begging for pain relief, only to be given small amounts of morphine by injection, which was itself painful. Despite seeing the benefits of giving dying patients regular analgesia, pre-emptive of pain, Saunders saw there was a serious lack of professional medical help, as doctors had given up on these patients. This made her sure that care of the dying needed to be a lot better and was work that she could do.
However, this was not going to be easy and it was a surgeon she had been working with who advised her: 'Well, you've got good ideas, but you won't get anywhere unless you become a doctor. It's the doctors who desert the dying'. Cicely qualified as a doctor at St Thomas' Medical School and went straight into work on pain control for the terminally ill, based at St Joseph's Hospice in London in 1957.
'Commit thy way unto the Lord; trust also in him; and he shall bring it to pass' [2] was the verse that she came across in her daily Bible reading that convinced her to build her own hospice for the dying.
2017 marks the 50th anniversary of St Christopher's Hospice in Sydenham, London. Palliative care was not integrated into the NHS at this point and so the building of the hospice came completely from charitable donations, which was no mean feat! St Christopher's offered individualised patient care, but was also active in research and education as Saunders saw that this would be crucial to advances in end of life care.
Since then, hospice care has spread across the world and there are believed to be 8,000 hospices in over 100 countries. Throughout her life, Cicely was consistently opposed to euthanasia, saying 'anything which says to the ill that they are a burden to their family and that they are better off dead is unacceptable'. She believed that if patients' symptoms, physical,
psychological and spiritual, could be properly managed, there would be no need for euthanasia.
This continues to be a perspective maintained by the Association for Palliative Medicine who released a public briefing outlining serious concerns about the legalisation of assisted suicide. [3]
Cicely died peacefully at St Christopher's in 2005. But this shy girl, who spent a lot of her teenage life feeling like an outsider, [4] completely transformed both our view of dying and made care of the dying a priority in our healthcare system. Her philosophy still drives research and policy to improve end of life care for every patient and their families: 'You matter because you are you, and you matter to the last moment of your life'.
But the story does not end with Cicely Saunders or in the UK…
Anne Merriman
Dr Anne Merriman was born in Liverpool in 1935 to a devout catholic family. At the age of four she announced to her mother that, 'I want to go and help the suffering of Africa when I grow up'. She was inspired by Jesus' example of showing love to the poor and marginalised, and continued to be inspired by hearing about missionaries travelling across the world, spreading the gospel and showing the love of Jesus to those in need.Wanting to follow in her brother's steps, she had been bitterly disappointed when she discovered that as a woman she could not be a priest. However, little did she know that she would establish the first hospice in Uganda, and be part of the next step in revolutionising end of life care across the world.
She graduated from University college Dublin in 1963, and after a year's internship began her career as a Medical Missionary in Nigeria. However, it was when she had to return to the UK for family reasons that she describes the need for palliative care as part of her work in geriatrics, 'the elderly needed pain and symptom control and a… team to bring them to peace'. She got in touch with Cicely Saunders and began to bring her palliative care teaching to the northern part of the UK.
However, her call to work abroad never went away and in 1981 she embarked on a Masters in International Health that led her to work in India and Singapore. With a growing ageing population, Dr Anne saw a desperate need for holistic palliative care in Singapore. As a result, she went on to not only introduce some of Dr Saunders' principles but in 1989 set up the Hospice care Association of Singapore that continues to offer one of the best palliative care services in South East Asia.
But Anne had not forgotten her first experiences of medicine in the developing world. The invitation to become the first Medical Director of Nairobi Hospice, Kenya, took her back to Africa in 1990. Her work in the hospice made her realise the desperate need not only for good palliative care but also affordable pain relief to enable patients to die peacefully at home with their families. She describes this realisation: 'while working in Nigeria as a hospital doctor, I was one of the many doctors who, when we could do no more, would ask the families to take the patients home. For the first time in Nairobi I was seeing what was happening to the patients who were sent home. And it broke my heart'.
With growing numbers dying from cancer and an exploding AIDS epidemic, need seemed to outstrip the resources available. In addition to coping with death and dying in a culture so far from her own, Anne described days where it felt like she has nothing left to give and prayed 'Oh God I am helpless. Please help my patients'.
But like Cicely before her, Anne was motivated by faith in god's provision, and a 'determined, stubborn' character. [5] This 'fire in my belly' determination that had overcome so many obstacles thus far, made her persevere in the fight against the 'bureaucracy inherited from the British… [that remained] still alive and well in the African health systems' and in the early 1990s
'Hospice Africa' was introduced. The aim would be to initiate a model of affordable palliative care services that was also culturally acceptable.
In 1993 Dr Anne began in Uganda with three months' worth of funding and a team of just three nurses. More than 20 years later, Hospice Africa Uganda has over 130 staff, a budget of 2.8 million and palliative care has been now incorporated into Uganda's Strategic Health plan, making it a national health priority. A big shift in culture was needed in regards to the vital role of nursing staff in palliative care, particularly for prescribing.
With the ratio of doctor to population in Africa varying from 1:4000 to 1:100000 (in the UK it is roughly 1:450), relying on doctors to prescribe morphine left many dying patients with no access to vital analgesia. [6] Dr Merriman made the training of nurse prescribers a priority and it is having a significant impact on access to morphine across particularly rural part of Uganda.
Although Hospital Africa continues to expand, with Anne supporting initiatives in many countries across Africa including Tanzania, Malawi and Sudan, the work of palliative care is nowhere near complete. [7] Currently 100 million people across the world have some form of palliative care need, but only eight million have access to even the most basic service. despite the World Health Organisation stating that access to analgesia is an essential human right, each day six million terminal cancer patients across the world suffer pain needlessly, because they cannot access or afford morphine. [8]
Where other doctors saw failure and the end of the road, Cicely Saunders and Anne Merriman saw people at their most desperate and in their time of greatest need. These women were motivated by their faith in God and love for people and could see there was a better way. Their autobiographies are littered with stories of patients that they learnt something from or people who meant something to them.
To them, patients were so much more than statistics, bodies in beds, numbers on a jobs list. 'How can I understand a figure or a statistic unless I have held the hand that it represents? The people we are talking about are the same as us. By the way we treat them we know just how much like Jesus we have become.' [9]
The challenge for us is this: will we stand on the shoulders of these giants, to continue their work? The issues our palliative patients face today are no less pressing, no less challenging, and they deserve no less an urgent and sustained response.
Alice Gray is a junior doctor in Birmingham
1. General Medical Council. growth in the proportion of female medical students begins to slow. GMC; October 2013 bit.ly/2u0IDqy
2. Psalm 37:5 (KJV)
3 . George R. public briefing on the APM's position on assisted suicide. APM; July 2015 bit.ly/2vpxOyM
4. Cicely Saunders Archive bit.ly/2u3GU3W
5. Anne Merriman Foundation, Biography bit.ly/2uUI8LX
6. Merriman A. Audacity to love. Dublin: Irish Hospice Foundation, 2010
7. Anne Merriman Foundation, Biography bit.ly/2uUI8LX
8. Piana R. Dying Without Morphine. The New York Times 30 September 2014 nyti.ms/2f5z82V
9. Anne Merriman foundation, Biography bit.ly/2uUI8LX
