"I loved David. David died. I knew I had to do something for the Davids of this world."
-- Cicely Saunders
Love usually flourishes in more romantic places than a cancer ward, but there are few places where love is more needed. Here is a true love story from such a place. It began in 1947, in England, when the world was still topsy-turvy from the dislocations of the war, bringing people into contact who had never touched before. In a ward at St. Thomas' Hospital in London, David Tasma, a 40-year-old Polish-Jewish refugee and survivor of the Warsaw Ghetto, was nursed by medical social worker Cicely Saunders, a 29-year-old, Oxford-educated Evangelical Christian who was the daughter of a well-to-do businessman.
When Tasma was discharged into an outpatient program and allowed back to work, Saunders maintained contact. She knew that he had terminal cancer. Tasma did not. When the disease recurred, she arranged for him to be admitted to another hospital. He asked her if he was going to die. She said yes.
Saunders became his visitor, his friend, his family and his executor. They fell in love.
During their visits they spoke about pain. They spoke about faith. They spoke about his sense of not having done anything with his life. They spoke about what could be done to help people who were dying, establishing a place, a home, where the terminally ill could receive special care.
Tasma died five months after meeting Saunders. The Evangelical Christian arranged an Orthodox funeral for the Jew. Tasma left her 500 pounds, saying, "I'll be a window in your home."
It took 19 years to build that home. During that time Saunders went back to school, studied medicine and became a doctor at the age of 39. She became an expert on pain control and fund-raising.
The home she built, St. Christopher's Hospice, has become a center for a movement, and Cicely Saunders, Dame of the British Empire, a leader in this worldwide effort to improve the quality of life remaining for the dying and to change attitudes in the medical profession about their care.
The movement is called hospice.
St. Christopher's occupies three buildings on a quiet street in Sydenham, one of the endless cement suburbs sprawling south from central London. David Tasma's window is in the reception area.
One of the striking things about St. Christopher's is the quiet. In most health care facilities there is a constant clatter of carts, buzzers, intercom calls and frenetic background hum. The hospice exudes a quiet -- not sepulchral silence, but calm.
St. Christopher's has four wards devoted to the care of people suffering from advanced cancer and neurological disorders such as Lou Gehrig's disease (amyotropic lateral sclerosis, ALS). Three of the wards are set up in bays of four beds, the other has single rooms for patients who need privacy. There is also a wing for the frail elderly.
The windows of the wards run the length of the building, facing west. When the English sun makes its occasional visits they are flooded with light.
Visiting hours are extensive, and the open ward is typically full of families. Those who have no visitors are not left on their own during visiting times. By policy, a hospice nurse sits on their beds with them if they wish.
There is also a garden with a pond, a day care unit for staff children (who mingle with hospice residents) and the chapel.
Dr. Saunders, now 67, performs administrative and teaching duties and is still on call one weekend a month. The oil paintings that adorn the building were done by her husband, Marian Bohusz -- a Polish emigre.
Between 750 and 800 patients a year are admitted to St. Christopher's. Two thirds of the people are over 65. Their physicians send them to the hospice for a variety of medical reasons related to the diseases they harbor: weakness, weight loss and pain. Some stay a week, others live in the hospice for more than a month. Not all who come to St. Christopher's die there, Saunders says.
There is also a home visiting service which treats approximately 200 people a year.
These services are provided on an annual budget of roughly $2.4 million. Saunders says that nearly half of the cost is paid through the National Health Service. The rest comes from donations. Insured patients pay approximately $75,000 of the annual operating budget. Saunders says no one ever is turned away from St. Christopher's for lack of money.
In addition to patient care, the hospice is a center for research and education in the care of the terminally ill. Studies done there include research on the control of pain and the social aspects of cancer care -- bereavement and informing the patient of the terminal nature of the disease.
Saunders believes that there comes a time when the best medical recourse is to accept the nature of the disease and accept mortality, then take medical measures to provide as high a quality of life as possible in the time remaining.
"My concern is the health of my patients," says Saunders. "There are times when the healthy thing to do is die. It is unhealthy to prolong dying."
The main medical task of hospice care is to control the pain of advanced cancer, she says. Each patient's pain medication at St. Christopher's is prepared individually. The patients are given their medicine every four hours or five times a day.
Spirituality is another component in the treatment of the terminally ill. An incurable disease brings a person face to face with mortality, forcing reflection on it and on the feeling of life ending.
Saunders has moved mainstream to the Church of England, and St. Christopher's remains a place of Christian practice. "You can't take the Christianity out any more than you can take the medicine out and still have St. Christopher's," she says.
She has created an institution where, she says, "science and religion lie creatively together." She emphasizes the nondenominational mix of patients. Prayers are conducted on the wards daily, but the television always remains on during devotions (patients listen through earphones) for those who don't wish to take part.
And for those without religious beliefs, "I tell them, ' Look to your own foundations or you'll find this hard work to do.' "
Saunders has strong opinions on the ethics of dying. Accepting that a disease is terminal doesn't mean giving up hope. She expresses abhorrence for euthanasia. "I am against any active step to end life.
"Suicide is the most difficult bereavement for those left behind. There is no way of taking one's life without taking some of the life away from one's family."
Most patients and their families, she says, make "tremendous use of the time remaining," often sorting out family problems and giving the family a chance to prepare to live on.
Saunders' effect as a proselytizer for hospice care has been global. In 1963 she gave two lectures at Yale University Medical School that galvanized a group of medical students and nurses to begin planning a hospice of their own.
The Connecticut Hospice started treating patients in their homes in 1974. Home treatment is a hallmark of the U.S. hospice movement, as is the fact that it has been organized at the grass roots level.
There are several reasons for this. The U.S. hospice movement lacked a medically and socially connected charismatic leader like Saunders. The start-up expense is greater here, and the source of payment for hospice service was unclear.
There was also skepticism on the part of the medical establishment. "A kind of 'We're-from-Missouri-show-us attitude,' " says Rosemary Hurzeler, one of the founders and chief executive officer of the Connecticut Hospice.
"It was serendipity," Hurzeler says, "that home care turned out to be so effective. It was also a tremendous thing for grass roots organizers, since they discovered that they didn't need to be based institutionally."
Home care is also cheaper, a fact that does not displease insurers. It also allows continuity of care since patients remain with their families and other physicians.
The basic components of the hospice team are the same in the United States as in Britain, but it was nurses, not doctors, who have provided the impetus for organizing hospice care in America. There is also a strong emphasis on volunteer help in the community.
Many hospice organizations are hospital based, but most care is still given at home. There are small hospice units within some hospitals, but they lack the institutional independence of St. Christopher's.
In 1980, Connecticut Hospice opened a 44-bed building, the first of its kind in this country. The building's $3.2 million cost was shared in thirds by federal and state governments and philanthropy. Hurzeler believes that the creation of an independent hospice marks the beginning of the hospice movement's adolescence in this country.
"There is a better understanding of cancer and its prognosis in individual cases, there is a clearer sense of what the limits of aggressive care are," she explains. "It is easier to make the transition to palliative measures."
Hurzeler's opinion is not universal. Mary Cook, director of New York's Cabrini Hospice, says some physicians still have a "mania for preserving life at any cost." She argues passionately that part of hospice care is "helping people to find meaning in the life they have lived and the suffering they now have."
Both women speak with religious fervor and compassion about their work and the people they serve. Faith is another aspect of the Saunders model that made it across the Atlantic.
It is a part of the model that Hurzeler wants to preserve. As hospice becomes more accepted by the medical community she fears that enterpreneurs whose primary aim is profit will enter the field.
Some 1,200 organizations call themselves hospices in this country, but only 161 meet Medicare standards for reimbursement. Thirteen states now have licensing procedures for hospices. That's a trend of which Hurzeler approves.
"There is a certain standard that must be maintained," she says. "We must keep entrepreneurs out and quality assured."
Cicely Saunders expects the need for hospices to grow in the future, regardless of advances in medical technology. More people living longer means more people will die of malignancies. In hospices they will find care grounded in a principle that Saunders frequently quotes, "to cure sometimes, to relieve often and comfort always."
Michael Goldfarb, a New York-based writer, met Dr. Cicely Saunders during his recent travels in Europe.