Reweaving a tapestry of care: Religion, nursing, and the meaning of hospice, 1945-1978

Nursing History Review

Volumn 15, Issue , 2006, Pages 113-145

  Buck, Joy ^a  

^a UNIVERSITY OF PENNSYLVANIA SCHOOL OF NURSING   (United States)

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[No Author keywords available]

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EID: 77349085772     PISSN: 10628061     EISSN: None     Source Type: Journal    
DOI: 10.1891/1062-8061.15.113     Document Type: Article

References (157)

1. David Clark, ed., Cicely Saunders: Founder of the Hospice Movement, Selected Letters 1959-1999 (London: Oxford University Press, 2002), 12-13.
2. Paul DuBois, TheHospiceWay of Death (New York: Human Sciences Press, 1980).
3. Sandol Stoddard, The Hospice Movement: A Better Way of Caring for the Dying (New York: Stein andDay, 1978).
4. Lenora Finn Paradis, The Hospice Handbook: A Guide for Managers and Planners (Rockville, MD: Aspen Corporation, 1985).
5. Cathy Seibold, The Hospice Movement: Easing Death's Pains (New York: Twayne, 1992)
6. David Clark, "Originating a Movement: Cicely Saunders and the Development of St. Christopher's Hospice, 1957-1967," Mortality, 3, no. 1 (1998): 43-63.
7. Claire Humphreys, "Waiting for the Last Summons: The Establishment of the First Hospices in England 1878-1914," Mortality, 6, no. 2 (2001): 147.
8. Susan L. Smith and Dawn D. Nickel, " From Home to Hospital: Parallels in Birthing and Dying in Twentieth-Century Canada," Canadian Bulletin of Medical History, 16, no. 1 (1999): 49-64.
9. Karen Buhler-Wilkerson,No Place LikeHome: AHistory ofNursing and Home Care in the United States (Baltimore: The JohnsHopkins University Press, 2001).
10. James Walsh, The History of Nursing (New York: P.J. Kennedy, 1929).
11. For additional information, see Humphreys, "Waiting for the Last Summons," 146-165.
12. Alberta Hapenny, A Legacy of Love: A Biography of Rose Hawthorne Lathrop in Three Parts (Pittsburgh: Dorrance 1999).
13. Sister Mary Joseph, Out of Many Hearts: Mother M. Alphonsa Lathrop and Her Work (New York: Servants of Relief for Incurable Cancer, 1965).
14. Derek Kerr, "Mother Mary Aikenhead, the Irish Sisters of Charity, and Our Lady's Hospice for the Dying," American Journal of Hospice & Palliative Care, 10, no. 3 (1993): 13-20.
15. See Kerr, "Mother Mary Aikenhead," and Stoddard, The Hospice Movement, 87. The Irish Sisters of Charity were a nineteenth-century religious order founded to care for the poor and terminally ill. Mother Mary Aikenhead, founder of the order, devoted her life to works of mercy with the poor Irish in Dublin. Roman Catholic archbishop Daniel Murray was a strong supporter of Mother Aikenhead's commitment to the "poorest of poor" and her ability to motivate others to work for the cause. In 1816, he secured papal approval for a new congregation and the Irish Sisters of Charity, an institution of women called to serve the poor and terminally ill was born.
16. Kerr, "Mother Mary Aikenhead," 14.
17. Kerr, "Mother Mary Aikenhead," 15.
18. Kerr, "Mother Mary Aikenhead," 16.
19. Humphreys, "Waiting for the Last Summons," 157.
20. Humphreys, "Waiting for the Last Summons," 159. The rules also disallowed the sisters from entering hospitals or homes of "heretics" unless there was hope of conversion to Catholicism.
21. Shirley du Boulay, Cicely Saunders, Founder of the Modern Hospice Movement (London: Hodder and Stoughton, 1984).
22. Cicely Saunders, "Foreword," in Derek Doyle, Geoffrey W.C. Hanks, and Neil MacDonald, eds., Oxford Textbook of Palliative Medicine (London: Oxford University Press, 1993), v-viii.
23. Humphreys attributes these distinctions to middle-and upper-class morality during the Victorian Era. There were clear distinctions made between poverty and pauperism and the respectable and nonrespectable poor. It was believed that the nonworking or undeserving poor should be cared for in workhouse infirmaries. The conditions in these institutions were deliberately harsh to serve as a deterrent for reliance on them. The stigma of pauperism was used as a social tool to reduce it.
24. Humphreys, "Waiting for the Last Summons," 160-2
25. Methodist theology and the Protestant ethic of dying was in contrast to a traditional Catholic death. Catholic deathbed rituals were intended to prepare believers for death and served as a bridge between life on earth and life in heaven. To the Methodists, dying was part of living, and as such, Protestants could achieve a good death by the art of holy living. See Shai Lavi, "The Modern Art of Dying: The History of Euthanasia in America," PhD dissertation, University of California at Berkeley, 2001.
26. du Boulay, Cicely Saunders, 61.
27. Humphreys, "Waiting for the Last Summons," 61.
28. For more information about the role of Catholic benevolence in health care, see Christopher J. Kauffman, Ministry and Meaning: A Religious History of Catholic Health Care in the United States (New York: Crossroad, 1995).
29. Barbra Mann Wall, Unlikely Entrepreneurs: Catholic Sisters and the Hospital Market place, 1865-1925 (Columbus: The Ohio State University Press, 2005).
30. Katherine Burton, Sorrow Built a Bridge: A Daughter of Hawthorne (1937; New York: Image Books, 1956).
31. See also Patricia Dunlavy Valenti, To Myself a Stranger: A Biography of Rose Hawthorne Lathorp (Baton Rouge: Louisiana State University Press, 1991), 131.
32. Sister Mary Joseph, Out of Many Hearts (New York: The Servants of Relief for Incurable Cancer, 1981), 22.
33. Hawthorne and Huber received permission from the Dominicans to form a religious community. Rose took the religious name SisterMary Alphonsa and Alice became Sister Mary Rose. On December 8, 1900, they professed vows as members of their new community, the Dominican Sisters, Congregation of St. Rose of Lima.
34. Hapenny, A Legacy of Love, 129
35. The "quest for cure" and use of experimental treatments and surgeries in terminally ill cancer patients was of concern to Lathrop and other reformers during the early twentieth century. See, for example, Richard Cabot and Russell Dicks, The Art of Ministering to the Sick (New York: Ferris Printing Company, 1936).
36. The authors discussed problems associated with care for the sick and dying in research and teaching hospitals. They listed common patient complaints about physicians and nurses, including the tendency of physicians to focus too much on research and teaching rather than on the patient.
37. Mother M. Alphonsa to Mother M. Rose, August 15, 1908, Archives of the Servants of Relief for Incurable Cancer, Hawthorne, New York.
38. Valenti, To Myself a Stranger, 170.
39. Walsh, The History of Nursing, 270.
40. Burton, Sorrow Built a Bridge, 253. These words were written in a letter to James Walsh, MD, PhD, a benefactor, supporter, and historian of nursing.
41. The window remains at the entrance of St. Christopher's. Tasma's story has been repeated frequently in books and articles about Saunders and St. Christopher's. The author was told the story by Saunders in person, while looking through the window in May 2003.
42. Brompton's Cocktail was developed in 1896 when a surgeon, Herbert Snow, demonstrated that a combination of morphine and cocaine could relieve pain in cancer patients. This concoction was introduced in the early 1930s at St. Luke's, as was aroundthe-clock dosing. Although there was considerable interest in the mixture in the 1960s and 1970s, physician Robert Twycross asserts it has no place in modern palliative medicine, despite the almost cult-like following who believe in the mixture as a panacea for cancer pain. Although the formulations vary, Brompton's Cocktail typically contains 15 mg morphine hydrochloride and 10 mg cocaine hydrochloride per 10 ml of the cocktail. For more information about early hospice symptom-management guidelines, see Stoddard, The Hospice Movement, 292-305.
43. For more information, see Ronald Melzack, Balfour Mount, and J.M. Gordon, "The BromptonMixture VersusMorphine Solution GivenOrally: Effects on Pain," Canadian Medical Association Journal, 120 (1979): 435-8.
44. Cicely Saunders, "Dying of Cancer," St. Thomas's Hospital Gazette, 56, no. 2 (1958): 37-47.
45. Robert Twycross, "The Brompton Cocktail," in John J. Bonica and Vittorio Ventafridda, eds., International Symposium on Pain of Advanced Cancer, Advances in Pain Research and Therapy 2 (New York: Raven Press, 1979).
46. du Boulay, Cicely Saunders, 60-73
47. Cicely Saunders, "Origins: International Perspectives Then and Now," Hospice Journal, 14, no. 3/4 (1999): 3. Both Clark and du Boulay detail this era of Saunders's life in some detail.
48. Cicely Saunders, "The Treatment of Intractable Pain in Terminal Cancer," Proceedings of the Royal Society of Medicine, 56 (1963): 95-7.
49. There is little documentation of Saunders's research methods or statistical analysis. She often cited anecdotal evidence, patients' stories, and, beginning in 1960, pictures of patients as evidence, which raises questions about the limitations of her research.
50. Saunders, although prolific in her writing and a propagandist for palliative care, spent more time focusing on patient care, fund-raising, and administrative duties at St. Christopher's. Two of the researchers who have played prominent roles in palliative-care research are Robert Twycross and Balfour Mount. In fact, Saunders preferred the use of diamorphine instead of morphine for management of cancer pain. When the actual effectiveness was studied by Twycross, however, there was no clinically observable difference between the two drugs given orally with adjuvant treatment. See Robert Twycross, "Choice of Analygesic in Terminal Cancer Care: Morphine or Diamorphine?" Pain 3 (1977): 93-104.
51. Saunders, "The Treatment of Intractable Pain," 195. Although in Saunders's earlier writings she speaks of the compassion that the Sisters of Charity had for patients, in later descriptions she states that they were more concerned for patients' souls.
52. Saunders, "The Treatment of Intractable Pain," 195.
53. Cicely Saunders, "The Challenges of Terminal Care," in Thomas Symington and R. L. Carter, eds., Scientific Foundations of Oncology (London: Heinemann Medical Books, 1976), 673-9.
54. Cicely Saunders, "The Patient's Response to Treatment: A Photographic Presentation," Proceedings of the Fourth National Symposium, Catastrophic Illness in the Seventies: Critical Issues and Complex Decisions (New York: Cancer Care, 1971).
55. Saunders contacted various experts in cancer care, including Dr. Robert Loberfield of the New York City Cancer Committee, Professor W. Bean of the University of Iowa, and Dr. JohnHeller of the U.S. National Cancer Institute. See Clark, Cicely Saunders: Selected Letters, for more documentation of her correspondence with American scholars.
56. Cicely Saunders, "Report of Tour in the United States of America, Spring 1963," Dame Cicely Saunders Papers, Hospice History Project, Sheffield, England, box 57, folder 2/1/92, 1 (hereinafter CSHHP). Clark reports that Saunders went through a lot of trouble to develop this report and was somewhat pessimistic about how many people would want copies. She was surprised to be contacted by so many people for copies that she ran out of them.
57. Saunders, "Report," 2. There were many people she met who did not receive a copy of the report. Quite a few people requested copies of the report. In response to their queries, Saunders explained that she had sent reports to those who had given her money. It is also interesting to note that Saunders was cautioned to downplay the role of religion in hospice, although for her it was the basis of her work.
58. Other homes are in Philadelphia; Atlanta; Fall River, Massachusetts; St. Paul, Minnesota; and Parma, Ohio. To date, these homes have cared for some 92,000 patients of all creeds and races over the years - all of it free. To this day, the sisters do not accept contributions from patients or families, nor do they take government funding or insurance payments. Bills are paid from an endowment fund, investments, and public and private donations.
59. Saunders, "Report," 24.
60. Saunders, "Report," 24.
61. There were quite a few institutions in the United States, predominantly operated by religious and philanthropic groups. For example, Calvary Hospital in New York City and Youville Hospital in Cambridge, Massachusetts, were facilities dedicated solely to the care of terminally ill patients.
62. Saunders uses the word "trained" in her report. There were differences in nursing education in theUnited States and the UK. Saunders expressed some concern about nursing education and the move toward professionalism.
63. This finding is substantiated, at least to some degree, by a study done by Yale-New Haven Hospital by sociologist August Hollingshead and pediatrician Ray Duff, funded by the USPHS Division of Nursing. Based on observations of nurses working with patients, they noted there were discrepancies in the nursing staff's knowledge of patient diagnosis and treatment and their understanding of patients' emotional problems. See Duff and Hollingshead, "Physicians, Nurses, and Patients," in Raymond S. Duff and August B. Hollingshead, eds., Sickness and Society (New York: Harper and Row, 1968), 217-47.
64. Saunders, "Report," 16.
65. Saunders, "Report," 15.
66. This observation reflects the transition of nursing education fromtraining schools to the university. It also reflects the quality of the schools she visited.
67. Hildegarde Peplau, Interpersonal Nursing Theory (NewYork: G.P. Putnam, 1952).
68. This finding reflects the influence of the psychiatric/mental health nursing movement that was flourishing at Yale at this time.Wald trained withHildegarde Peplau atRutgers prior to returning to Yale to creating an MS program in mental health psychiatric nursing in the late 1950s.
69. Saunders was referring to Jeanne Quint's [Benoliel] seminal research on nursing education and care of the dying, Phyllis Verhonick's research on decubitus ulcer care and problem solving, and Harriet Werley's work on the development of nursing research.
70. Saunders, "Report," 24
71. Saunders was particularly impressed with the work of existentialist philosophertheologians Paul Tillich andMartin Buber. For Tillich, see, for example, "Autobiographical Reflections," in CharlesW. Kegley, ed., The Theology of Paul Tillich: A Revised and Updated Classic (New York: Pilgrim Press, 1982)
72. "Being and Love," in Ruth Nanda Anshen, ed., Moral Principles of Action (New York: Harper and Brothers, 1952).
73. Jack Mouw and Robert P. Scharlemann, "Bibliography of the Publications of Paul Tillich," in Kegley, The Theology of Paul Tillich, 395-423.
74. Buber was a renowned scholar of Jewish tradition and literature. To Buber, the basis of religious faith was the relation between man and God, the relation to the eternal Thou. Within the I-Thou relationship, any statement made about God also reflected the nature of man. For example, seeMartin Buber and Judith Buber-Agassi,Martin Buber on Psychology and Psychotherapy: Essays, Letters and Dialogue (Syracuse, NY: Syracuse University Press, 1999).
75. Florence Wald, interview with the author, tape recording, July 21, 2001, Branford, Connecticut
76. Wald has recently won awards for lifetime achievements in hospice/palliative care from the Hospice and Palliative Nurses Association and the American Academy of Hospice and Palliative Physicians and was named a living legend by the Academy ofNursing. "Medicare Hospice Regulations" hearing before Subcommittee on Health of the Committee on Finance, U.S. Senate, 98th Congress, first sess., September 15, 1983 (Washington, DC: U.S. Government Printing Office, 1984), 12-13. Senator Durenberger, chair of the committee, gave the recognition to Wald during a committee hearing on the hospice Medicare benefit.
77. See Florence Wald, "Emerging Nursing Practice," American Journal of Public Health, 56, no. 8 (1966): 1252-60.
78. Wald, "Emerging Nursing Practice," 1259.
79. Wald was not the only American nurse who was concerned about the type of care afforded terminally ill patients. Starting in the 1950s, articles in the nursing literature began calling for a new approach to care of the dying and changes in nursing education. The U.S. Public Health Service Division of Nursing funded several studies on institutional care of the dying. See, for example, Jeanne Quint, The Nurse and the Dying Patient (New York: Macmillan, 1967).
80. David Sudnow, Passing On: The Social Organization of Dying (Englewood Cliffs, NJ: Prentice-Hall, 1967).
81. Barney G. Glaser and Anselm L. Strauss, Awareness of Dying (Chicago: Aldine, 1965).
82. Barney G. Glaser and Anselm L. Strauss, Time for Dying (Chicago: Aldine, 1968).
83. See also Jeanne Benoliel, "Nursing Research on Death, Dying, & Terminal Illness: Development, Present State, & Prospects," Annual Review of Nursing Research, 1 (1983): 101-30.
84. Wald, interview, July 21, 2001
85. Wald, "Emerging Nursing Practice," 1259.
86. Wald, "Emerging Nursing Practice," 1259.
87. Clark, Cicely Saunders: Selected Letters, 87. Although some of Saunders's expenses were covered by travel grants, she was dependent on consultation fees to cover travel expenses and donations that were sent to support St. Christopher's. Issues about money appear quite often in correspondence with Wald and other Americans.
88. Both Saunders andWald wanted the visiting professorship to be longer than six weeks, but there was not enough money in the endowment to allow for this.
89. During Saunders's stay at Yale, she met with Dr. Elisabeth Kübler-Ross and Dr. Colin Murray Parkes. These two psychiatrists would play a significant role in the advancement of terminal-care reform.
90. CSHHP, Box 57, "The Moment of Truth - Some Aspects of Care of the Dying Patient," presented at the Yale School of Nursing, April 28, 1966
91. Wald, interview, July 21, 2001. Saunders was a prolific contributor to both medical and nursing literature during the 1960s, 1970s, and 1980s. Her philosophy was well received in nursing circles, less so in medical circles. See, for example, Cicely Saunders, "Watch with Me," Nursing Times, 61, no. 48 (1965): 1615-17.
92. Cicely Saunders, "Care of the Dying," Nursing Times, 9 (1959): 960-1.
93. Saunders, "The Moment of Truth," 3.
94. Saunders, "The Moment of Truth," 5.
95. Publications based on research funded by the Division include Quint, The Nurse and the Dying Patient.
96. David Sudnow, Passing On: The Social Organization of Dying (Englewood Cliffs, NJ: Prentice-Hall, 1967).
97. Glaser and Strauss, Awareness of Dying.
98. Glaser and Strauss, Time for Dying.
99. See also Benoliel, "Nursing Research on Death, Dying, & Terminal Illness."
100. Duff and Hollingshead, "Physicians, Nurses, and Patients," in Duff and Hollingshead, eds., Sickness and Society, 217-47.
101. Letter from Florence Wald to Cicely Saunders dated October 1968, CSHHP, box 58, folder 2/1/100.
102. Interdisciplinary Study, Research Record, 10-29-1970, 1, Florence and Henry Wald Papers, Manuscripts and Archives, Yale University (hereinafter FHWYU), box 24, folder 60.
103. Interdisciplinary Study, 2-5.Many of the nurses at St. Christopher's were Anglican nuns, and the Christian religious symbols incorporated into the structure are unmistakable, even if there was not overt discussion of a particular religious paradigm.Non-Christians might well interpret this differently than Saunders.
104. Interdisciplinary Study, 3
105. The differences in approach were immediately apparent to Dobihal, who served as director of the chaplaincy program at Yale-New Haven Hospital. Although he met with some success in changing the culture of the hospital, it was an uphill battle.
106. Edward Dobihal, "Progress Report: First Observation and Impressions of St. Christopher's Hospice" (1970), 10, Edward Dobihal Papers, Manuscripts and Archives, Yale University, box 1, folder 14 (hereinafter EDYU).
107. Dobihal, "Progress Report," 13.
108. Dobihal, "Progress Report," 15.
109. Wald, interview, July 21, 2001.
110. Edward Dobihal, interview with the author, July 20, 2001. See also Florence Wald, "Development of an Interdisciplinary Team to Care for Dying Patients and Their Families," ANA Clinical Conferences (1969): 47-55.
111. Florence Wald, "Terminal Care and Nursing Education," American Journal of Nursing, 67 (1979): 1762-4.
112. Steering Committee Minutes, 3/3/1971, FHWYU. Israel used social science frameworks and methods to create "meaningful communities." Her area of interest was small-group dynamics and social communication.
113. Steering Committee Minutes, 3.
114. Steering Committee Minutes, 3.
115. Steering Committee Minutes, 1-5.
116. Steering Committee Minutes, 2. In this assertion, Saunders is similar to the approach taken to spiritual care at St. Luke's Hospice. In this context, Christianity was the unifying framework rather than any specific denominational orthodoxy.
117. Steering Committee Minutes, 5.
118. Steering Committee Minutes, 4-7.
119. St. Christopher's Hospice: Discussion Group on Religious Foundation 6, September 22, 1971, EDYU, box 1, folder 3, 1-12.
120. Hospice Planning Group Steering Committee Minutes, Philosophy Statement, April 7, 1971, EDYU, box 1, folder 5.
121. Lawrence Altman, "LSD and Heroin Found Helpful in Treatment of Terminally Ill," New York Times, November 13, 1971, 1. LSD is one of the major drugs making up the hallucinogen class.
122. For more information on hallucinogens see http://www.nida.nih.gov/Infofax/lsd.html. The modern antidrugmovement or "war against drugs" officially began with the Nixon administration. For more on the history of the drug wars in the United States.
123. see David F.Musto, American Disease: Origins of Narcotic Control (London: Oxford University Press, 1999).
124. For information on the counterculture during the 1960s, see Terry Anderson, The Movement and the Sixties: Protest in American from Greensboro to Wounded Knee (New York: Oxford University Press, 1995).
125. These concerns were well founded. There was a significant antidrug sentiment during this time, and in some areas, criminal charges were brought against physicians who ordered narcotics for patients.
126. Edward Dobihal, "Letter to Mr. C. Pierce Taylor, Executive Director, Connecticut Hospital Planning Commission" (1971), 1-3, EDYU, box 1, folder 3.
127. Wald, interview, 2001. Dobihal, interview, 2001.
128. Yo-Li Chan, "Thoughts on Facility Planning," n.d., FHWYU, 2001-M-041, box 6.
129. Yo-Li Chan, "Thoughts," 2; Hospice, Inc., "To Honor All Life: A National Demonstration Center to Protect the Rights of the Terminally Ill," appendix D, 1-2, FHWYU, Series I, box 3, folder 23.
130. Wald, interview, 2001; Dobihal, interview, 2001
131. Hospice, Inc., "Hospice: A Vision," October 1973, 2, EDYU, box 1, folder 4.
132. Wald, interview, 2001; Dobihal, interview, 2001; Donna Diers, interview by author, tape recording, December 19, 2000, New Haven, Connecticut.
133. Florence Wald, "First Annual Hospice Staff Report," January 14, 1974, FHWYU, box 5, folder 56.
134. Joy Buck, "Rights of Passage: Reforming Care of the Dying, 1965-1986," PhD dissertation, University of Virginia, Charlottesville, 2005.
135. Wald, "Staff Report," 3.
136. Hospice, Inc., Progress Report and Program Plan Regional Hospice Development Program, January 29, 1973, 10, FHWYU, box 22, folder 11.
137. Hospice, Inc., Progress Report, 10.
138. Elisabeth Kübler-Ross, On Death and Dying (New York: Macmillan, 1969).
139. Elisabeth Kübler-Ross, On Death and Dying (New York: Macmillan, 1969).
140. Kübler-Ross, On Death and Dying.
141. Kübler-Ross's work has been criticized by some for describing the grieving process as being linear. K̈ubler-Ross asserts, however, that the process is neither linear nor predictable. The stages were meant to provide a framework to help professionals and lay people normalize rather than pathologize death and grief.
142. The euthanasiamovement clearly had a more grassroots foundation and focused on the individual. The death-and-dying movement remained predominantly in the world of academia among philosophers, theologians, and psychologists.
143. Peter Filene, In the Arms of Others: A Cultural History of the Right-to-Die in America (Chicago: Ivan Dee, 1998).
144. Derek Gill, Quest: The Life of Elisabeth Kübler-Ross (New York: Harper and Row, 1980).
145. Hospice, Inc., Annual Report to National Institutes of Health Contract No. N01-CN-55053, September 1, 1975, 55, EDYU, box 1, folder 4.
146. For more on the development of hospice during this time frame, see Buck, "Rights of Passage," 148-223.
147. Joy Buck, "Home Hospice Versus Home Health: Cooperation, Competition, and Co-optation," Nursing History Review, 12 (2004): 25-46.
148. "The Hospice Movement," Washington Post, February 18, 1978, A16.
149. Florence Wald, interview with author, December 18, 2000, New Haven, Connecticut.
150. Last Acts, Means to a Better End: A Report on Dying in America Today (New Jersey: Robert Wood Johnson Foundation, 2002).
151. SUPPORT Study Investigators, "A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients," Journal of the American Medical Association, 274, no. 20 (1995): 1591-9.
152. Last Acts, Means to a Better End
153. See for example, Hugh Heclo, "The Sixties False Dawn: Awakenings, Movements, & Postmodern Decision Making," in Brian Balogh, ed., Integrating the Sixties: The Origins, Structure, and Legitimacy of Public Policy in a Turbulent Decade (University Park: Pennsylvania University Press, 1996).
154. James T. Patterson, "A Great Society and the Rise of Rights-Consciousness," in Grand Expectations: The United States, 1945-1974 (New York: Oxford University Press, 1996), 562-93.
155. W.J. Rorabaugh, "Challenging Authority, Seeking Community, & Empowerment in the New Left, Black Power, & Feminism," in Balogh, Integrating the Sixties, 106-43.
156. Florence Wald, "Terminal Care and Nursing Education," American Journal of Nursing, 67 (1979): 1762-4.
157. Clark, Cicely Saunders, 12-13