Cicely Saunders and Elizabeth Kübler Ross are two fundamental authors who marked a before and after in the conception of death and in the care of the dying. They are pioneers in what they promulgate and both have enormous relevance in the changes that occur in the care of the dying, both their novel approach of it that continues to guide our performance today; These authors made contributions that form a guide in the care for professionals and continue to evolve today, marking a turning point on the concept of death and its care. We summarised the important contributions of Dra Saunders and Dra Kübler Ross into what we know today as Palliative care /end-of-life care.

Keywords: care of the dying, end-of-life care, palliative care, cicely saunders, elisabeth kübler ross

In the 1960s, medicine made enormous technological progress with the development of organ transplants, 1963 hepatic, 1967 cardiac, 1968 cardiopulmonary... Healing was the most important objective of medicine, resuscitation techniques were developed, intensive care medicine (ICU), multidisciplinary work and specialization with the emergence of the coronary intensive care units and the first pediatric intensive care units.¹

In this context, death represented a failure, and physicians avoided referring to it. In large hospitals the dying patients were left aside, they were placed in the farthest rooms, they could not receive visitors outside the indicated hours and they died alone.^2-5

Drs. Saunders and Kübler Ross dedicated their lives to changing the situation. The two observed the neglect, loneliness and suffering of dying patients in hospitals and reformed end-of-life care, humanizing the dying process and initiating the worldwide Palliative Care Movement.^{6, 7}

We highlight how Dr. Cicely Saunders and Dr. Elisabeth Kübler-Ross, two contemporary and extraordinary women, created what we know today as Palliative Care to humanize the care of terminally ill patients and alleviate suffering.

Cicely and Elisabeth, for different reasons, in distant parts of the world and with different approaches, were the initiators of this medical discipline, considered as a specialty in more and more countries.

They began their journey in the observation of the need for care of the terminally ill, the concern to alleviate suffering and help them to face death in peace and serenity.⁸ They began in the observation and research though different paths, Cicely did it for friendship and commitment to a terminally ill patient⁹ while she was practicing at that time as a social worker.¹⁰ Elisabeth, as a psychiatrist,  she decided to investigate following the demand for information^11,12 from university students who could not find publication on death.

Cicely Saunders' religious conviction would mark her life and work. Already as a physician, in 1958, she received a research fellowship at St. Mary's Hospital, worked and researched at St. Joseph's on pain control for seven years.¹³ She found that there were few medical records and that medications were administered on demand, patients, could only receive morphine if they had previously experienced significant pain. Dr. Saunders introduced the pain management system she had observed at St. Luke's ^14,15 with patients taking opioids regularly every four hours. She introduced this practice at St. Joseph's and helped the nuns to be more effective in the care of these patients.¹⁶

She described "total pain" in 1964, which includes physical, emotional, social and spiritual aspects; the Protestant sisters of St. Luke’s¹⁷ were already paying attention to “Total Pain” although they had not named it as such.¹⁸

During her stay at St. Luke's, Cicely Saunders as a nurse devoted special attention to reading the annual Memoirs of its founder, Dr. Barret, which would influence her St. Christopher's Hospice project ^{16, 19}  Its Founding Charter states "that it is based on Christian faith in God through Christ.” ¹⁶

Dr. Cicely Saunders is the creator of the first modern Hospice.¹ In 2000 she inaugurated the Cicely Saunders Foundation (now Cicely Saunders International), a key objective was to create the Cicely Saunders Institute to promote research, training and treatment in palliative care, and it was inaugurated in 2010.²⁰

Dr. Kübler Ross worked as a psychiatrist in several hospitals in the USA and she observed the distant treatment that the terminally ill patients received, they were not sincere with them, if they asked if they were going to die, the doctor answered "Oh, no! Don't talk nonsense". During her visits to the sick she would sit at their bedsides listening to their needs, their complaints, their fears, their unfinished business and helped them face death in peace and serenity; talking to them she learned that there is not a single dying person who does not yearn for affection, contact or communication. He watched them struggle to accept their fate. Listening to them, he came to know that all dying people know that they are dying.¹¹

Elisabeth Kübler Ross gave her first talk at the Denver Medical School on death in 1964. She taught to see the dying not only as clinical cases, but as human beings; she interviewed more than five hundred terminally ill patients,⁵ conducted the interviews in the presence of the students, devised a system of interviews that preserved the patient's privacy and collected data.^11,21

She described the best known model of the patient's psychological reactions of adjustment to terminal illness through a series of phases, described in many texts as the stages of grief: denial, anger, bargaining, depression and acceptance.^12,22

The prestigious “Life” magazine in 1969 published an article about her seminars and from then on her work became widely known. That same year he published her first book: “On Death and Dying” which became a bestseller and was recognized as an important book by almost all the medical institutions in the USA.¹¹ In the early 1970s, a patient related to Dr. Kübler-Ross, constituted what would be the first Near Death Experience (NDE), and what she designated as death threshold experiences work. This case was the beginning of a research that would last for decades. With an assistant they studied some 20,000 cases around the world of people who had been declared clinically dead.^11,23 She was a pioneer in the investigation of life after death.²⁴ In 1974, she published the first book on NDEs, Death: A Dawning, where she also describes the four phases of life after death.^11,23 However, Dr. Raymond Moody in 1975 published Life After Life, coining the term Near-Death Experiences, the foreword to which was written by Dr. Kübler-Ross.²⁵

Dr. Kübler-Ross was highly criticized for these investigations on (NDE), however, today prestigious physicians from all over the world continue to investigate these cases.^11,23 In 1990 the Elisabeth Kübler-Ross Center was opened in Head Waters, Virginia. In 1994, she suffered a fire on her property that destroyed her possessions. Her son established the Elisabeth Kübler-Ross Foundation in 2006 to disseminate her work and continue her legacy.

"The 2004 New York Times obituary to Kübler-Ross's death summed up the way official medicine dealt with death before the publication in 1969 of the doctor's celebrated book “On Death and Dying”. "Terminally ill patients were often left to face death surrounded by loneliness and fear, because doctors, nurses, and patients were often ill-prepared to deal with death." "Dr. Kübler-Ross's work helped to end the taboos that existed in many Western cultures against openly discussing and studying death. It also contributed to reforming the way in which terminally ill patients were cared for." ²⁵

Officer of the Order of the British Empire, 1965. She was awarded an honorary doctorate by the Archbishop of Canterbury in Lambeth in 1977. Dame of the Order of St. Gregory the Great (awarded by the Pope). Dame of the British Empire, 1979. Templeton Award for Progress in Religion, 1981. The Order of Merit, 1989. Conrad Hilton Award, for St. Christopher's Hospice, 2001.Gold Medal of the British Medical Association. She was a member of the Royal Colleges of Physicians, Nurses and Surgeons.

1. -Care of Terminal Malignant Disease, edited by Saunders, first published in London in the late 1970s ¹⁶
2. -Living with Death: A Guide to Palliative Care (Oxford Medical...1995).By: Mary Bainés, Robert Dunlop and Cicely Saunders.
3. -Watch with Me is a selection of lectures by C. Saunders compiled by David Clark 2003. Pia Aguirreche Foundation 2023.

Dr. Saunders published articles in peer-reviewed journals and gave numerons lectures.

She died in 2005, at the age of 86, in London at the Hospice she created.

Both graduated in medicine in 1957, Saunders in London and Kübler-Ross in Zürich.

She received 28 honorary doctorates.Time magazine referred to her as "one of the hundred most important thinkers of the 20th century".She was named "Woman of the Decade" in the field of science in the 1970s and "Woman of the Year" in 1977²⁶ Nominated for the Nobel Peace Prize in 1983.^27,31

Author of more than twenty books published and translated into more than 45 languages, some of them bestsellers, among them:²⁶

On death and the dying or (on death and dying).

On life after death

Death a dawn

Children and death

Remember the secret

Is there life after death?

Letter to a child with cancer

A light that goes out 

Life lessons

Living until we say goodbye

Every end is a luminous beginning 

A full life       

Conferences: Dying is of vital importance

Questions and answers about death and dying

Learning to die-learning to live

AIDS: the great challenge

The Wheel of Life (biography)

On bereavement and grief. By Elisabeth Kübler-Ross and David Kessler He died in 2004, in Scottsdale, Arizona, at the age of 78.

Both Dr. Cicely Saunders and Dr. Elisabeth Kübler-Ross are the initiators of Palliative Care, bringing a new approach to end-of-life care.

The term Palliative Care is due to Dr. Balfour Mount of Canada, who, motivated by reading the books of E. Kübler-Ross, and subsequent visit to St. Christopher's Hospice, Cicely Saunders in London, created the first Palliative Care unit at the Royal Victoria Hospital in Montreal, in 1974.²⁸

We perceive that Palliative Care Associations and Societies do not cite Dr. Kübler-Ross, or if anything, only mention the five phases of grief, or the interviews she conducted with the dying, giving all the merit only to Dr. Cicely Saunders. However, different authors consider Dr. Elisabeth Kübler-Ross as one of the founders of the palliative care movement.^29-31 

"Saunders and Kübler-Ross raised awareness of the patient's suffering, needs and hopes and advocated for their rights to a dignified life to the end", "however their personal influences on the development of pediatric palliative care were quite different.^10,29,30

Cicely Saunders is the creator of the Hospice Movement. "In parallel to this development, the Swiss psychiatrist, Elisabeth Kübler-Ross, through the study of different clinical cases of dying people in the United States, developed a model that would lay the foundations of current palliative care, whose objective is for the patient to face death with dignity and peace of mind.²¹ 

“The Kübler-Ross archive is housed in the Special Collections Department at Stanford University, and her works serve to establish the goals of Stanford's palliative care programs”.³¹  "Elisabeth Kübler-Ross laid the foundation for modern palliative care, which aims to enable the sick person to face death with dignity and peace of mind. She fought to humanize the treatment of health personnel in hospitals and is one of the greatest experts in death and palliative care; she has dedicated more than three decades to researching death and life after death. She was, and is, the inspiration and driving force behind the palliative care movement".⁸

Cicely Saunders and Elisabeth Kübler Ross dedicated their lives to change the situation of neglect and loneliness suffered by terminally ill patients in hospitals, to humanize the dying process, seeing people with all their physical, emotional and spiritual needs, instead of clinical cases, initiating the Palliative Care Movement that continues to divulgo nowadays.

They investigated terminally ill patients, relieving pain and emotional suffering, supporting families, conducting research and training.

Dr. Cicely Saunders researched pain in patients at the end of life and created the Hospice Movement. Dr. Elisabeth Kübler Ross investigated death and the dying process, teaching that death is a natural part of life. She was a pioneer in research on life after death.

Today's palliative care would be more complete if Elisabeth Kübler-Ross's insights on dying were taken more into consideration.

Our gratitude to all the people who research in the field of human values for their time and dedication, for presenting us through their publications a path that can inspire others.

There isn´t conflicts of interest.

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