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Video still from the end of Fight Club

One of our first GeriPal posts was titled “Rant on Terminology,” by Patrice Villars, NP. In the spirit of looking back over our first 10 years, here is the opening paragraph to that post:

News Headlines read: Sen. Edward Kennedy loses battle with cancer. Really, he lost? I thought he died from a malignant brain tumor, an “aggressive” brain tumor. The median survival is less than a year for people for his particular tumor. Kennedy was diagnosed in May of 2008. He lived over 15 months after diagnosis. What a loser. He must not have fought hard enough. Huh? I thought he spent most of his life battling for social and health care reform in America.

In this week’s GeriPal podcast we take a deeper dive into this issue of language and medicine. We are joined by guests Anna DeForest, MD, MFA, a resident in Neurology at Yale, and Brian Block, MD, a pulmonary critical care fellow at UCSF.

Headshot Of Anna DeForest

Anna recently published a paper in the NEJMdescribing her reaction to hearing terms like, “withdraw of care,” in the intensive care unit. It turns out, as she explains in response to the common counter argument, “those are just words,” that words shape the way we think. We interpret the world through the words we use to describe our experiences, and that shapes our understanding. So when we say, “win the battle against cancer,” “nothing more we can do,” or, “withdraw care,” it actually shapes the way we understand these concepts in a fundamental way in our mind. So we both think to form words, and the words we use influence our thoughts. Anna argues for better words for better deaths.

Headshot Of Brian Block

Brian published a provocative piece in JAMA IM recently that illustrates this problem with a phrase so everyday that we use it without thinking – I just used it in the paragraph above – “intensive care unit.” His thesis is that we have a long way from the meaning of “intensive” as it was originally intended, to mean intensity of nursing and other resources available to patients, to mean a type of highly aggressive type of care. To be sure, this highly aggressive type of care suits some people in the ICU, but it is not as good a fit for others, or for people whose goals shift over time in the ICU. Does the term “intensive care unit” promote aggressive treatment?

Please comment on these ideas and rant on terminology in the comments.



Eric: Welcome to the GeriPal Podcast! This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we have another host in our room today.

Alex: We have a guest host in our room today. We have Brian Block, who’s returning to our podcast. I think you were on one previously.

Brian: I was. It’s great to be back again. Thank you.

Alex: Brian is a pulmonary critical care resident here at UCSF and is doing some research on people who come to the intensive care unit and have not engaged in advanced care planning beforehand.

Eric: And I see someone else on our Skype call.

Alex: And on the Skype call, we have Anna DeForest, who is a resident in neurology at Yale. Welcome to the GeriPal Podcast.

Anna: Hi. Thanks for having me.

Eric: How are these two people connected, Alex?

Alex: These two people are connected because they both wrote papers about the importance of language and the words that we use to describe our experiences, our interventions, the intensive care unit.

Eric: Great. One in JAMA IM and another in New England Journal, two journals I’ve heard before. But maybe before we go into that, Anna, we ask all of our guests, do you have a song request for Alex to sing?

Anna: I do. The song I chose is “Where Is My Mind” by The Pixies.

Alex: And why did you choose this song, Anna?

Anna: Well, I think it’s got a bit of a cognitive science tie-in, and sort of questions what we think and why we think it. Plus, I wanted to see if you could sing like Frank Black.

Alex: The answer to that is no.

Eric: I thought you were a Fight Club fan.

Anna: No, not so much.

Eric: Alex, you want to give us a little?

Alex: Okay [Singing].

Eric: Are you done yet?

Alex: I’m done.

Eric: We’ll do a little bit more after that. I thought it was in relation to like Fight Club end scene, in San Francisco, in one of the tall buildings, and you see all the buildings collapse around you. And Brian’s article about collapsing the structure of the ICU name.

Brian: Can’t say that’s what I was going for.

Eric: No. No.

Alex: You read a lot into that.

Eric: This is your soap making business. Another Fight Club reference. Nobody’s a fight club fan here.

Anna: Sorry.

Alex: What is the phrase?

Brian: What happens in GeriPal, stays in GeriPal.

Alex: That’s a different one, that’s Vegas.

Eric: What’s the first rule of fight club?

Alex: The first rule of fight club.

Eric: Of GeriPal.

Alex: The first rule of GeriPal is …

Eric: Don’t talk about GeriPal.

Brian: That was it, I was close.

Alex: Don’t talk about GeriPal.

Eric: That would be a horrendous motto for a podcast.

Anna: It’s pretty bad.

Eric: No one would ever listen to us.

Alex: So Anna, tell us about your paper in the New England Journal. You wrote about your motivation, in the paper for writing about this. But maybe give our readers a sense of what spurred you to write about this.

Anna: Sure, sure. So I was writing about the phrase, “withdraw of care”. I don’t remember the first time I heard that phrase, and I don’t remember the first time I said it, but I really clearly remember the first time someone told me not to say it. I was a medical student at Columbia, I was in the ICU rotating with the palliative care team. And I was talking about some case, and the phrase kind of fell out of my mouth. I picked it up somewhere and it fell out of my mouth. And the palliative care attending I said it in front of, he-

Eric: Who was it?

Anna: It was Craig Linderman.

Alex: Ah, Craig. We know Craig.

Anna: He was very gentle, but I think he just said something like, “Oh, we don’t say that. We say something else.” But I remember it because I was so embarrassed. Because as soon as I thought about it, I was like, “Well, of course we don’t say that.” You know, you guys had someone on a few weeks ago who was talking about the word intervention, and how to ask, it just means anything basically that a clinician does to a patient. But to patients it very clearly means when your family comes and sits around you in a circle and tells you that you have a hoarding problem.

Alex: Right.

Anna: Withdraw of care, to any regular person, sounds like it could only mean one thing, which is that you stop caring. You stop paying attention and you stop showing up and you leave the patients alone and then they die. This is all pretty straightforward, I think, especially for your audience. But where this essay came from was sort of a point past that, where I started to ask my peers in residency and, in many cases, my attendings to stop saying this phrase. Which is somehow still so ubiquitous. And I got a lot of pushback.

Anna: And I got a lot of people saying to me, “No, these are just words. This is just a useful shorthand for extubation or stopping dialysis.” But I felt in my gut that there’s more to it than that, because in many cases we say this phrase and then we actually do what it sounds like it means. Like we stop paying attention, and we stop showing up, and we leave patients alone to die.

Eric: Mm-hmm (affirmative). It sounds like the argument, so, just to let the audience know, we’re talking about Anna’s New England Journal piece called “Better Words for Better Deaths”, published a couple weeks ago in the New England Journal. We’ll have a link to it on our GeriPal post. It sounds like, over a quick read of it, you can think, “Oh my God, this is just words. Are we just being pedantic when we’re talking about it? Like, now we can’t even say … ” This is coming up a lot. So, Brian’s ICU article in- we had a JAGS article about six months ago, maybe longer than that where, we shouldn’t be using the word “elderly”, it’s “older adults”. Is this just academics doing what academics do? Which is being a little bit pedantic?

Anna: Fair enough, and I certainly heard that argument a bunch of times. I was sort of trying to craft my own counter-argument to that when I came across the research that I reference in my essay. I was listening to a podcast, actually, Shankar Vedantam’s social science podcast, Hidden Brain, and this social psychologist cognitive scientist named Lera Boroditsky was on, and she was talking about a group of people, like an Aboriginal community in Northern Australia called the Kuuk Thaayorre who speak a language that doesn’t use relative directions. They only use cardinal directions, there’s no, like, my left hand or my right hand, it’s always like, your east hand or your west hand. And if you spin around, the directions don’t change, the hands do, so they change the names. When they studied people who speak this language, they found out that they have incredible senses of direction. Not just better than you and me, which they are, but better than we thought people could have.

Anna: When I heard this argument, this was my first introduction to what’s called linguistic relativism, or the idea that the words we use actually shape our cognitive processes, I thought, “Oh yeah! That’s what I’m talking about. That’s what I mean.” And then I started to shape my argument from there.

Alex: So it’s much deeper than, “It’s just some label that we use. It doesn’t really matter.” It’s not just that our thinking shapes the words, but the words shape our thinking.

Anna: Right, right.

Eric: So, I’m wondering, Brian, does this resonate with you? So you wrote a JAMA IM piece about, what was the title again? It was published a couple months ago.

Brian: Back in December, yeah, and it was on whether the term “intensive care unit” might promote decisions toward more aggressive treatment.

Eric: So, another label, another thing that we commonly call the ICU, intensive care unit. Do you get a sense that we’re dealing with the same here, same thing?

Brian: I think we’re talking about very much the same thing. And actually, one piece that I’m reminded of, in hearing you speak, Anna, that didn’t make it into my article is some research out of an economist at UCLA showing how in different languages, even things as simple as how we handle the future, the future tense, can affect behaviors that people have. So for instance, if you speak a language where you have what’s called a strong future tense, in which you describe going, “I will go to the park tomorrow”, as opposed to saying something like, “I go to the park tomorrow”, we can see that people who have that difference are more likely to discount the future to see it as more distant. And then in economics research, it’s been shown that such people follow that with behavior that is they’ll save less for retirement. And so I think that these types of aspects of language absolutely motivate behavior and contribute to differences in the actions that people take.

Alex: And Anna, you had another example in your paper about-

Eric: Colors!

Alex: Russians and colors. Could you talk about that for our listeners?

Anna: Oh, sure. This is one of the things that I thought was just, so cool when I was learning about this research the first time through. And it’s another study from Boroditsky who actually is a native Russian speaker. She was explaining that, in Russian, color is just a spectrum and you can really cut it up any way that you want. And like, we do ROYGBIV or whatever, but you can cut it up however you want. And in Russian they actually cut blue up into two different colors. So they’re not the same color. Light blue and dark blue are not shades of a color, they’re like two colors as distinct as blue and green are to you and me. And, consequently, studies have shown that Russians can discriminate better between different shades of blue than English speakers can. Just because they have this, what’s basically just a nomenclature difference actually leads to a cognitive difference.

Eric: Yeah, and I’d love to know also amongst English speakers, ’cause we often think there’s blue, but you go to a paint store, there’s like 30 billion blues. If you talk to my wife versus you talk to me, me is blue, there’s blue, but she has all these other types of words for blue that I have no idea what they are. Blue-ish. I wonder even amongst English speakers, those people who use different terms, whether or not they actually see things differently. Kind of like, when we use different terms in medicine, do we act or see things or perceive things differently? And I think you’re making a great case in this New England Journal article that we do.

Anna: I think that we do. I haven’t done the study yet, so I can’t prove it, but I strongly strongly suspect that we do and that this will be measurable.

Alex: So it sounds like there are multiple layers here to why language is important. And that one layer has to do with misunderstanding. That when we say to, a family overhears us talking and they hear us say we’re gonna withdraw care, that they may misunderstand and think that we’re gonna stop caring entirely for their loved one, when we never in fact stop caring. We stop certain types of aggressive life sustaining interventions. But then there’s a deeper layer that has to do with the way that the words we use shape our though processes and the sort of, constructions we have around ideas and what a thing is, or isn’t. And how one thing may differ from another, and how, way we view the world

Eric: And I get from Anna’s article, in the New England Journal that, it actually does influence. You say we don’t withdraw care, but maybe those words make us actually withdraw care. Like, in her example.

Anna: We have a tendency to do that.

Alex: Right. So, Brian, do you wanna talk a little bit more about intensive care unit, and that particular phrase, how it came in to being, and whether or not it still applies today to what we do, or should do?

Brian: The interesting thing, when I started out about this, is that I actually had no idea where that term came from. And I started thinking about the piece, thinking about all of the different meetings I’ll have in the intensive care unit, where I’ll introduce myself as the physician in the intensive care unit and then go on to suggest that perhaps we don’t take the most aggressive course with the subsequent treatment. And then thinking about how that must bias, or potentially introduce a bias in the family to think that I’m suggesting something that’s contrary to what they came to the intensive care unit for. And I was thinking about how other aspects of the hospital have names of units that are very much descriptive of what they do. You go to the chemotherapy unit for chemotherapy. You go to the dialysis unit for dialysis. So you must go to the intensive care unit for intensive care.

So then I guess the question is, what is intensive care? So it turns out, having gone to the lower lower level of the UCSF library, where they actually still have books and you have to crank the bookshelves to get them to move with warning signs not to pinch yourself in between them, turns out that this term emerged in the 1950s or so, when there was a move away from the old form of organizing how people would be arranged in the hospital, which was largely based on their ability to pay. So the recognition was that different people had different needs, different levels of support that they might need during their illness. And so there was a reorganization called “the progressive patient care movement”. And under this, they developed terms like “intensive care”, “intermediate care”, “convalescent care”, as ways of organizing patients around the resources they were likely to need.

And so it was very much a nursing term at the beginning, which was who needed to have the most access to nursing staff, people at the bedside. And actually if you look at the original publications about intensive care units, first of all they weren’t called intensive care units in the first couple of publications. They were called special care units. And then those first publications were largely focused on drawings, diagrams, of how these intensive care units should be constructed architecturally so that you would have the resources next to the people that need them. So that’s where the term comes from, but then in thinking about the pieces, I put it together-

Alex: But wait, before we move off the where the term comes from, could you talk about the med students doing the-

Brian: The med students bagging hundreds of people on a volunteer basis?

Alex: It’s just such a great part of the story.

Brian: So, in what might today be called mistreatment of medical students, they conscripted hundreds of medical students really, so there was a horrible polio epidemic going on in Copenhagen in 1953. And so at this time, polio led to death in 80% of patients because they would have respiratory failure from muscle weakness. And, it was actually during that epidemic that what is largely considered the first intensive care unit was created in Copenhagen. They were getting 50 patients a day with paralytic polio and an 80% mortality rate. And these were kids, so losing decades of life.

Alex: Yeah.

Brian: And, what they devised was, this is where they first came up with modes of positive pressure ventilation as opposed to the iron lung or other things that used to be used in the past, as well as tracheostomy, so that you could put in breathing tubes. But they needed to have a way of delivering positive pressure ventilation when they didn’t have ventilators. So they had, literally hundreds of students volunteering in shifts around the clock, providing mechanical ventilation. And if you look back at the original reports, you could see that they didn’t have blood gases for everyone, but they tried doing different things, like telling people to breathe more or less frequently for the patients, and they were seeing differences in the treatment. But what they found was, they cut mortality by half, to 40%.

Alex: Yeah, so ICUs did make a difference then.

Brian: For that population-

Alex: For that population.

Brian: It 100% did.

Alex: It absolutely did make a difference. And then, I’m sorry I interrupted you, you were gonna talk about today, and where are we today, and what are intensive care units organized around today? Is it still around nursing staffing and what term might be most appropriate?

Brian: Yeah, so first of all, obviously the patients are different. This was a special care unit for patients with polio in 1953. There were, by 1960, just a handful of them in the U.S., and then hundreds. And then if you look over the last decade, there’s state to state variability, but the number of intensive care unit beds is increasing dramatically in the United States. And we’re filling them, not with people with polio, we’re filling them with a very different population often with chronic diseases, more life-limiting diagnosis. People where it’s hard to imagine a 50% absolute mortality reduction with decades of life gained. And I think-

Eric: If I remember it right, from a population-based level, one of the strongest risk factors for being admitted to the ICU is being in a location with ICU beds.

Brian: That’s exactly right, yeah.

Alex: If you build it, they will come.

Eric: They will come.

Brian: And in terms of ICU triage decision making, one of the best, the best predictor in a paper last fall was, are there beds available. That’s what determines are people going to the ICU and how many beds are available. And so the term has changed, too. Not only how we’re using them, but intensive over time, became less about the attentiveness of care, and more about the types of treatment modalities being deployed, and a goal of life extension. And so by the 70s, 80s, when you read the introductions to introductory critical care textbooks, as I’m sure everyone does, you’ll see that they’re referring to it as synonymous with life extension. And I don’t think that’s how everyone sees it today, but that’s been how the term has shifted.

Eric: I can just think back to my history as a physician, there have been plenty of times where people don’t get admitted to the ICU, they may need intensive care but they’re DNR DNI, so there’s always a battle of, do they really need the ICU? And they may need intensive care, that doesn’t have to be delivered in the ICU, but the staffing is definitely much higher there.

Brian: Yeah, and I think that’s a related issue of conflating code status with goals and what time of treatments are appropriate for people. And there’s research 10-15 years ago on the umbrella term that people ascribe to that.

Eric: When Anna was talking, it made me think, like withdrawal of care, not that like, he’s DNR or even just labeling somebody as DNR, that’s just an intervention or not doing a particular intervention but it carries with it all these labels and potentially influences how we care for someone. All right, sorry for my interruption now.

Alex: So, what’s a better term and what are the harms of using the term intensive care unit.

Brian: So I think the potential harm, to start with that, is that it communicates a expectation, almost a default that we’re going to advise a system of care that focuses on life extension as the default. So, anything that deviates from that is abnormal. And I think that that is not helpful for all patients. It is helpful for a lot of people. There are people who we certainly help, there are people that benefit from a default approach to care that is on the intervention and aggressive side. But there are times when people do not need that, when that is low value care, when it’s not goal concordant. And by setting that up as the expectation, you risk this harm that people think they’re having to turn away from what is the recommended therapy. And I think that’s the major harm.

There’s also a interesting, I was remembering recently for another reason, this Arthur Kleinman article from the 1970s on explanatory models of illness. And he talks in that article about the disease-focused versus illness-focused ways that people will put things together. And I think that a lot of things that we do in the ICU from this intervention focus to something that Anna, you mention as well in your article, about how we round in a organ system-based manner. This is very disease-focused. It’s not patient experience or illness-focused. And so I think that a term that could flip the table back towards focusing on the patient as a person and rather than on the intervention, would be something like “critical illness unit”, which shifts the focus from the intervention that’s being delivered back to the problem that the person has.

Alex: It’s interesting reflecting, Anna and Brian, on that the terms that you find potentially problematic, both have the word “care”. And in one sense, Anna’s is, she’s concerned about saying “withdraw of care”, and in another, Brian is concerned about the term “intensive care”. And you both draw different conclusions about the potential meanings of those terms. Just, thoughts?

Brian: Yeah, I think, Anna I’ll let you chime in as well, I think my concern is more on the change in what people understand the term “intensive” to mean, and not a concern with the term “care”.

Eric: What do you think, Anna?

Anna: Well, when I was reading Brian’s piece I was so excited and I so much agreed with your thesis, Brian. I thought, “This is the truth,” but I also find it hard to imagine anyone buying into that. And the reason has to do I think with what Eric was saying before about all this pendency and what are these changes about. But also, I find that when people tend to argue the most that those are just words, it’s when they really don’t want the words to change. And I think that in a lot of medicine and maybe particularly in ICU medicine, it actually is still the norm to conceptualize your job as a battle against death. And that’s what’s intensive, is the fight against death and anything else is just extra whatever, like not our job. You know, and that’s crazy because everyone dies, but it’s just the way that it goes.

Eric: I also wondered, what would happened if we changed our hospice unit name to the “intensive hospice care unit”? I think the label “care” does matter, is that we provide intensive- I think we provide more intensive care in our hospice unit around care, than sometimes other places provide in more specialized- or more different care settings.

Brian: Yes, that’s actually a great point. And it’s something that I tried to bring into my piece as well which is that, ICUs are not the only place that are potentially disserved by their name, right? There’s all sorts of things that come along with the terms “hospice”, “palliative care”. People think that you’re de-emphasizing every other type of treatment and just focusing on making someone comfortable. You’re not giving comprehensive care, which is not what you’re trying to communicate. And so in the paper I talk about a couple of changes at different hospitals including at the Brigham, where they renamed their palliative care unit, the intensive palliative care unit.

Alex: Mm-hmm (affirmative). To mirror the idea of intensive care, that we are actually providing intense care to these people, but it’s intense caring. It’s a different sort of … And they also, at Brigham as I recall, were very much opposed to the term “comfort measures only”, CMO.

Eric: CMO.

Alex: Right? Which is ubiquitous in medicine. And is the term defined by what it’s not doing, rather than what it is doing. So they prefer the term “intensive comfort measures”, rather than “comfort measures only”. It’s interesting, so they have appropriated that term, “intensive”, in a sense, for their own purposes within palliative care.

Brian: In a sense, taking it back to where it was sixty years ago when it was focused on access to bedside attentiveness.

Alex: Right, right. Exactly.

Eric: I wanna play devil’s advocate here, again though, when we come up with any short phrase, even like “intensive comfort measures only”, what? Are we not gonna do non-intensive comfort measures? Any phrase, short phrase is gonna have it’s limitations. Are we just shifting one limitation to another limitation? Are they just issues, or … Anna, I love your thoughts with your background, even with the shift from “elderly” to “older adults”, are we just gonna move from one place where we did that shift because there’s potential negative stereotype around elderly and older adults is thought to be more appropriate at this point. Are we just, again, will this just shift again, that we’re gonna have this negative attitude towards older adults? Like are we just gonna have this other viewpoint towards the critical illness unit?

Anna: It changes part of the nature of language. So we do have to keep updating the language to keep up with the baggage that our language acquires by existing in our culture. So when people are like, “Oh, we have to change that again?” It’s the nature of language to just acquire these different kinds of connotations and the need to shed them. It’s no reason to say we should just keep it all the same, you know? I mean, think about the evolution of some old medical terms that are now horrible insults including “dumb”, or “lame”, or “moron”, or “imbecile”. These are medical terms, or were. And now they’re just horribly offensive. And if we change them and then if the new term becomes offensive, then we change that.

Anna: But to say I’m not gonna change it because someone’s offended, or I’m not gonna change it because it’s no longer adequate to our changing needs, well that doesn’t really make sense.

Alex: That’s a good argument. I wonder if there are other terms that grate …

Eric: Should we just go around?

Anna: Oh, yeah. Let’s do this one round robin, that would be fun.

Alex: Let’s do round robin. So, one of our GeriPal posts was from Patrice Villars, who’s a nurse practitioner who works with us, and it was about a rant on the term “terminal”.

Eric: Yeah, she hates the term “terminal”.

Alex: Hates the term “terminal”.

Eric: Yeah.

Alex: Like terminal illness. It’s just so … what is it? Do you remember? I don’t remember her exact argument, but …

Anna: Yeah, what’s the argument? I wanna know.

Eric: I think the argument is, what is … honestly, like we’re all terminal. We’re all gonna die, but I think there’s a coldness to it. And it’s unclear what it actually means, I think that’s part of it, as well. I should actually look back to it. I think other things that come up to my head, do everything, we’ve talked about, it’s been written about a lot.

Alex: We’re doing round robin.

Eric: Ah, okay.

Alex: That’s yours.

Eric: I already used mine? What?

Alex: We can go do multiple rounds.

Eric: All right, multiple rounds.

Brian: I’ll Anna go next.

Anna: Yeah, I think we could go around, I could certainly go around multiple times. Oh, what was I thinking? I really hate when they say, “The patient failed the therapy”. That’s a big one I really hate. That doesn’t make any sense at all. This same research pool has studies about agentive and non-agentive language. Just like, the passive and the active voice, basically. So like, doctors when we chart, everything we write is in this passive voice, like, “Mistakes were made”. But the patients, when they take the medicines that we decide for them and they don’t work, we say the patient failed the treatment. So we have all the power and we live in the passive voice and then the patients are subjects in this agentive language, which, studies have shown, increase the rate at which you blame the actor.

Eric: So we should probably use, “They lost their battle against their disease”, instead.

Alex: No, no, we’re not to you again, we’re not back. It’s not your turn yet, Eric.

Anna: Medications fail patients, patients don’t fail medications.

Eric: That’s right.

Brian: And that gets to the adherence, and non-compliance terminology that comes up also, with non-compliant being problematic.

Alex: Right. Is that your turn? Is that your contribution?

Eric: If you’re gonna count mine, that’s his.

Alex: So I’m up again?

Anna: Yeah.

Alex: So I’m up again. Do everything, you said? Is that the one you said?

Eric: Already taken.

Alex: There’s nothing more we can do.

Eric: There’s nothing more that we can do.

Alex: I still hear that. You know, I feel like we’ve been ranting about that for a long time, but I still hear that. I hear that, not just among colleagues, you know docs talking to each other, but in family meetings, with people talking. Clinicians talking to family members or patients. There’s nothing more we can do. Well does that nothing include hospice? Does that nothing include palliative care? Does that nothing include outstanding symptom control?

Alex: That one grates, that one grates.

Eric: Brian, your turn.

Brian: I think in the same vein, I just lost it…

Alex: Well we were going around, Eric, it’s your turn.

Brian: I think that wasn’t fair because we switched to counter-clockwise.

Alex: Yeah, I don’t know what happened. You did the reverse, there, Eric. I think it’s Eric, and then Anna, and then Brian.

Eric: I said fight the battle too, so any term around battle analogies …

Alex: I think Alex Trebek was just diagnosed-

Eric: Yes, and they used that terminology. Pancreatic cancer.

Alex: Pancreatic cancer, stage four, and he said he’s gonna fight this battle. And he’s gonna overcome the odds. [crosstalk 00:32:50] And what’s wrong with him fighting the battle?

Eric: So here’s my thoughts on this, my quick thoughts. If a patient uses the word “fight my battle”, I use that term with them. If I hear it from a health care provider, or on an ad for a health care institution, I curse inside. Sometimes outside. Because it matters, words matter. And you see it in health care ads all the time, like, I won’t mention any right now. I think we actually have a post on it. But, I think it’s okay if patients use it. I think if that’s the terminology that they wanna use, go for it. If not, it means that if you don’t- if the cancer gets worse and you get worse, that means you lost the battle. If you’re gonna fight it. It just sets us up for future failure.

Alex: Right.

Brian: You just used one of my terms there.

Eric: Failure?

Brian: Provider.

Eric: Provider.

Alex: Oh, provider, is that your next contribution?

Brian: Provider and consumer.

Alex: You’d prefer clinician?

Brian: Clinician.

Eric: Why?

Alex: What’s wrong with provider?

Brian: It makes it overly transactional.

Anna: You people say that, but I always think provider is useful because it covers such a wide array of types of clinicians, even some like, chaplains who wouldn’t necessarily identify themselves as clinicians. And they’re providing something.

Brian: It is convenient, and every time I write something and try not to say provider, it usually ends up using more words to circumvent it.

Alex: I think that’s the argument against all of this. It would require more words to make a more appropriate statement. Right? Like it always requires more words. The reason interns love comfort measures only, three words. It’s three letters that they can write down.

Eric: Intensive comfort measures is the same length, right?

Anna: Yeah. ICM.

Eric: No, it’s one extra word ’cause you said intensive comfort measures only.

Alex: No, no no, I didn’t say only.

Eric: You said only before.

Alex: No. Intensive comfort measures. No only. Only is the problem, that’s why we changed it.

Eric: Yeah, but, the reason that they like only, the reason they like that term, is ’cause it tells them also where the limits are. And intensive comfort measures only, I’m still waiting to hear-

Alex: No only.

Eric: And what?

Alex: Only there’s no only, but yeah.

Eric: So there’s a reason that the system we have is perfectly built for, like there’s [inaudible 00:35:23] and people, like there’s a reason people use it because the short hands help them.

Anna: The results we get in the system are not good enough. Is what I would argue to that. Like our short hand supports our system and reinforces our system and our system isn’t good enough.

Eric: Agreed.

Alex: Yeah. Anna you’re up.

Anna: Let nature take its course. Have you heard this one?

Alex: Oh, yeah.

Anna: Like nature is just something we can resort to when all of our ICU powers have ended. And we’re like, “All right, we’ll just put you behind the shed and let nature take its course”.

Alex: That’s my thought with “allow natural death”, like, I imagine a tiger’s gonna spring up and eat me if I allow a natural death.

Eric: I use those words.

Alex: I do as well.

Eric: You use those words, too?

Alex: Let nature take its course, yeah.

Eric: I find them problematic and yet I use them because I don’t have a better substitute for what to say to people. Anna, what is the alternative when you’re talking to patients about choices and options in the case of serious illness?

Anna: I actually, from the toolbox we have, prefer “allow natural death”. Lately, as a neurology resident I do a lot of really bad code status discussions in the emergency room with stroke patients and with intracranial hemorrhage patients where, the one thing I just wanna make sure that they know is that when I’m talking about code, I’m talking about something that happens to them after they have already died. Which in every case is kind of surprising to them. My language is very imperfect, and I need to work on it, but right now I’m just sort of running through the fire [crosstalk 00:37:08].

Eric: I think that’s the really hard part about all of this. I think language is hard. It’s tricky, ’cause even with- ’cause I’ve heard people talk about, “this is what we do after you die”. That also implies that we have the power over death. We can resurrect you from death. That’s how amazing we are in medicine, is even after you die, we can attempt this thing and you will be resurrected. And I think that’s the power with any of what we use, is that sometimes it’s incredibly helpful, but we also have big blind spots sometimes, of where it could actually damage our relationships or influence people’s decisions in particular ways that we may not expect.

Anna: That’s the truth.

Alex: It’s good. Brian, you got another one?

Brian: I’m not sure I’m up again.

Alex: Oh, okay.

Brian: I think I might be tapped out.

Alex: Oh, you’re tapped out? All right, it’s good. Should we call it?

Eric: Uh, Anna, you got anything else?

Anna: Oh, I could do pet peeves all day, but if you guys are tired I don’t wanna … too pedantic.

Alex: Healthy aging. What about people who have disability? They’ve failed aging.

Eric: Successful aging.

Alex: Successful aging. Right.

Eric: Well, Brian, Anna, I wanna thank you both for joining us. We’ll have links to their both articles. One from the New England Journal, one from JAMA IM, on the post that accompanies this podcast. But before we end this, I just wanna ask Alex-

Alex: Thank you Anna, thank you Brian.

Brian: Thank you.

Eric: Give me a little bit more fight club.

Alex: Little bit more fight club.

Eric: And audience, just picture this. Buildings collapsing around us, ICU nomenclature, collapsing.

Alex: Coming down.

Eric: Coming down. Withdrawal of care columns just falling apart as Alex sings this song.

Alex: All right.

Alex: I was swimming in the Caribbean. Animals were hiding behind the rocks. Except the little fish, they told me, yeah they talked to me. They said, “Where is my mind?” Where is my mind? Where is my mind? Way out in the water. See it swimming.

Eric: And the ICU nomenclature just collapsed.

Eric: With that, I wanna thank again Anna and Brian for joining us, all of our listeners for joining us today. As usual, if you have a second, please rate us on your favorite podcasting service.

Alex: We’ll see you next week, folks. Thanks. Bye.

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