The Palliator’s Diaries
(Heard during attending rounds)
MD: “Mr. T, how did it go last night?“
Mr. T: “Not so good doc. Lots of pain. Couldn’t sleep. But you know me. I took some pain medicine and soldiered on.
MD: “Yeah! That’s what I admire about you. You are a real fighter.“
Mr. T: “Right on doc!” sounding pleased. “I am no quitter. So did you get my bone scan results back?“
MD: “Yes, I did. It was positive.“
Mr. T: “Positive?” sounding hopeful. “That is good, right?“
MD: “Unfortunately, it means that the cancer has spread to your bones. In fact, your bone scan lit up like a Christmas tree.“
Mr. T: “Oh. . . . So what comes next? More chemotherapy?“
MD: “Not yet. Your albumin is only 2.2. . . . your marrow is wiped out. The cancer has spread to your liver as well.“
Mr. T: “So what happens next? Do I need a liver transplant?” looking both worried and confused.
MD: “I am talking to some other specialists to see if we can zap the bone mets first. Once you rally around we can probably restart chemo therapy again.“
Mr. T: (doubtfully) “Doc, give it to me straight. How am I doing?“
MD: “Well, you are a real trooper, Mr. T and I think that given the circumstances, you are doing great. So . . . what do you think? Should I call the radiation oncology docs?“
Mr. T: (Cheering up) “You go for it doc! There is still some more fight left in this old body of mine. Let’s give them a run for their money.“
The language of medicine can be as clear as mud. A key reason for this is clinical medicine is not an exact science but more of a blended art form of science (the evidence-based medicine aficionados may not agree with this point of view, but reality cannot be denied) set in a quagmire of human emotions and influenced by numerous abstract variables.
Emotional experiences are notoriously difficult or impossible to convey by literal language.1 By using a metaphor to connect the relational pattern of a new experience with that of a familiar, emotion-laden one, we can create a contextual roadmap to understand and process a complex pattern of feelings. So in an attempt to find clarity and simplicity, patients and clinicians indulge in “medspeak” and metaphors when communicating about grave illnesses.
Common Metaphors in Medicine
Of all the serious life-limiting illnesses, cancer lends itself the most to use of metaphors. The three common types of metaphors often used to describe cancer and cancer therapy include the following.
Commonly used phrases like “fighting a valiant battle with cancer” create an artificial win–lose dichotomy2 thereby obligating the soldier/patient to fight to the end. More importantly, opting to refuse futile or harmful treatment options now becomes equivalent to a cowardly retreat from the “battleground” that may be seen as a shameful act by the patient.
Sports metaphors invoke all the sports-related axioms and polarize outcomes as a win or lose. They also perpetuate the myth that the patient and the illness are playing on opposing teams and that the illness plays by the rule book. In order to be a true sportsman, the patient has to play it out until the end as “quitting the game” is associated with loss of face.
Machine metaphors are derived from Descartes’ theory of mind and body duality by which the human body is seen as a machine with faulty parts that can removed and replaced. Going by this theory, all liver metastasis should be treatable with a liver transplant and all respiratory failures with ventilators.
Why use Metaphors
As Anatole Broyard3 describes so eloquently, “Metaphors may be as necessary to illness as they are to literature, as comforting to the patient as his own bathrobe and slippers. At the very least, they are a relief from medical terminology. . . . Perhaps only metaphor can express the bafflement, the panic combined with beatitude, of the threatened person.“
Metaphors foster clarity and transfer meaning effectively and economically.
A metaphor (from the Greek root metaphora, to transfer) is a powerful linguistic tool that is used to directly compare seemingly unrelated subjects in an effort to clarify the contextual meaning of a complex and novel situation. It helps us raise the subtext to the text and convert closed awareness to open awareness in a nonthreatening manner. It is a tool to relate to and understand the unknown and the uncertain future by drawing upon past experiences and present knowledge. This is beautifully demonstrated by the following ancient Egyptian poem4 used to relate to death in a positive manner:
Death is before me today
Like the sky when it clears
Like a man’s wish to see home after numberless years of captivity
Metaphors foster safety through ambiguity.
Metaphors are often used euphemistically to discuss and relate to complex and risky situations in a nonthreatening and indirect manner (it is easier to talk about death and dying in terms of war or sports).
The challenge with this type of usage is that when the metaphors freeze5 and become part of the language system to which the terms making up the metaphor originally belong resulting in ambiguity and errors of inference. For example, when cancer therapy is described using a war metaphor and the metaphor freezes in the war context, and then all the facts and knowledge related to warfare are thought to apply entirely to cancer therapy as well thereby resulting in errors in inference and the resultant desire to “fight to the bitter end.” It is to be noted that ambiguity is not always bad and that skillful use of ambiguity can help to transmit meaning in indirect and nonthreatening ways.
A Framework to Use/Respond to Metaphors in Clinic Practice
Responding to patient-initiated metaphors
This involves the standard communication skills framework of responses including naming, mirroring, validating, and exploring. It is important to identify and vocalize the possible discrepancies, i.e., the ways in which the metaphor does not fit the illness concept, so that we can clarify those discrepancies as we respond to our patients’ metaphors.
This involves entering into the patient’s metaphor and giving them new information within the context of and through the metaphor as well gently correcting misperceptions and redirecting them to reality based decision making. This strategy is very effective but requires considerable communication skills.
Two commons uses are:
1. To introduce unfamiliar material:
Through the careful use of metaphor, clinicians can help patients and families connect new information (about the illness and coping) with something they already know or have experienced and attaching it to existing “schema” in the mind.5
2. To break preexisting mind sets:
The second essential step in using metaphors is “making the familiar strange.” In this situation, clinicians help patients and families break known connections and pre-existing mind-sets in order to discover something new about the illness. “Breaking connections” 6 to form new metaphors is an effective way to engage patients and families actively with new and complex changes related to the illness process and facilitating crucial conversations and difficult decisions.
1. Holyoak KJ, Gentner D, Kokinov BN: The place of analogy in cognition. reference www.psych.northwestern.edu/psych/ people/faculty/gentner/papers/HolyoakGentnerKokinov01. pdf (Last accessed May 10, 2008).
2. Storey P: A winding career path. J Palliat Med 2008;11: 845–847.
3. Broyard A: Intoxicated by his Illness and Other Writings on Life and Death. New York: Ballantine Books, 1992.
4. Merwin WS: Selected Translations 1948–1968. New York: Atheneum, 1968.