“Fighting the Ventilator”: Abandoning Exclusionary Violence Metaphors in the Intensive Care Unit

Language used by clinicians can motivate, discourage, align, and alienate patients, families, and other clinicians (1, 2). It influences patient–clinician and clinician–clinician relationships, shapes organizational thinking, and can insidiously stigmatize patients and harm therapeutic relationships (3). Violence metaphors are prevalent in clinician–clinician communication in the intensive care unit (ICU) and are often used to describe patients who are reacting to invasive medical interventions (“bucking the vent,” “fighting staff,” “struggling against restraints”), but the consequences of their use are poorly described. Here, we characterize the use of violence metaphors in the ICU to describe patients who are experiencing challenges with medical interventions. We argue that violence metaphors that are specifically related to patients interacting with medical interventions should be abandoned, as they provide little practical clinical value and perpetuate negative and harmful stereotypes and stigma.

Metaphors in Clinical Settings

A metaphor is defined as the understanding and direct mapping of one domain of experience, which is usually more abstract, in terms of another, which is usually more concrete (4). Metaphors thus have a “framing” effect (5) in how they help “select some aspects of a perceived reality and make them more salient” through these mappings (6, p. 52). According to conceptual metaphor theory, metaphors represent conceptual tools for structuring and creating realities that affect our cognitive processes and the way we interact with the world (7). In a classic example, “winning” or “defending” an argument places argumentation in a war or combat frame and actors in combatant roles (4). Alternatively, if one considers argument as a dance, then the actors are performers, and the goal of argumentation is one of balance instead of conflict. Metaphors alter one’s cognitive framework and can directly impact the approaches, goals, and strategies related to argumentation. In clinical settings, and particularly in the ICU, patients and clinicians often rely on conceptual metaphors for mutual understanding of physiology, pathophysiology, and complex medical interventions. This places metaphors in a critical position to shape patient and clinician understanding of disease states and influence medical decisions (8).

Inappropriately Imposing Blame and Moral Responsibility on Patients

Combat and war metaphors have been highlighted in oncology (i.e., “war” against cancer) (9) and pandemics (i.e., coronavirus disease; COVID-19) to foster community and mobilize resources to confront a common enemy (10). Despite the intention to use them to galvanize, combat metaphors have both motivating and disempowering effects (9). Similar to the example of argument as war, violence metaphors relating to patient responses to interventions (i.e., “resisting restraints”) place the patient in a combatant—often enemy combatant—role within a physical combat frame. These metaphors impose certain expectations of agency and volition on the patient, despite many patients lacking decisional capacity in the ICU because of an altered mental status from their critical illness or sedation. For example, delirium often compromises the patient’s decisional capacity and is prevalent in the ICU. It is estimated to occur in 50–75% of patients and can be attributed to underlying critical illness and uncomfortable ICU interventions such as arterial line placement, tracheal suctioning, and intubation (11). Patients can experience confusion and fear in this altered state, and their reactions may be self-preserving and instinctual (i.e., survival instinct), even if they are interfering with treatments that are intended to be beneficial.

Thus, violence metaphors are problematic when they inappropriately attribute challenges with medical interventions to a patient’s intentional refusal to participate in care. When volition is implied by violence metaphors, clinicians impose moral responsibility on patients for their behaviors or actions. Blame cultivates agency in the patient, but it also generates negative emotions and reactions in the clinician, which can lead to destructive attitudes and behaviors that are counter to this morality (12). Placing blame on patients in the ICU, for example, may bias clinicians to restrain and sedate patients as retribution for their behavior rather than critically evaluate for acute changes in their medical condition or for sources of discomfort that may have prompted these instinctual reactions.

Creating an Oppositional Relationship and Reinforcing Hierarchies of Power

Violence metaphors also promote an oppositional and subjugative relationship between the patient and the healthcare system. For example, the phrase “bucking the ventilator” is often used when referring to patient–ventilator dyssynchrony, which occurs when the patient’s respiratory cycle does not coincide with the ventilator’s delivery times. Ventilator dyssynchrony may be due to potentially harmful processes, such as delayed triggering or insufficient flow delivery that can be improved with ventilator setting changes. It can also be due to acute life-threatening situations, such as airway obstruction, pneumothorax, or endotracheal tube dislodgement, requiring more emergent interventions (13). Terms such as “bucking” or “fighting” the ventilator provide minimal explanation for these potentially injurious patient–ventilator interactions and reinforce problematic cognitive frameworks of patient–clinician relationships.

Framing the interaction as a “fight” between two opposing sides encourages clinicians to cognitively position patients in opposition to the ventilator and creates an “us versus them” mentality rather than promoting collaboration with the healthcare team. Furthermore, a “fight” implies that there must be a “winner” and a “loser” from the interaction and generates motivation to “defeat” or “triumph” over the patient. This framing suggests that clinicians may unconsciously exercise their systemic and positional power to overcome their “opponent” (the patient)—often by means of chemical sedation or neuromuscular blockade—rather than change the ventilator or care process. The coupling of “fight” with “ventilator” may contribute to the overuse of interventions to subdue patients, such as the use of restraints, which have been shown to be overutilized in the ICU and are associated with psychological sequelae in ICU survivors (14).

Mediating Systemic Inequities and Racism through Power Dynamics and “Exclusionary Othering”

Differences in outcomes across socially disadvantaged groups and across individual races and ethnicities are well described in the critical care setting (15). Black patients in ICUs in the United States are less likely to receive timely antibiotics for pneumonia (16). In one Canadian meta-analysis, it was found that Indigenous populations are rarely considered in the design, methodology, or interpretations of critical care studies (17). By applying the conceptual framework established by Kilbourne and colleagues to understand the mechanisms underlying healthcare disparities, we may identify the language utilized in the ICU as a clinician factor that contributes to stereotyping and biasing patients from different racial and ethnic groups and may mediate these inequities (18).

One study on stigmatizing language in the electronic health record demonstrated that non-Hispanic Black patients are more likely to be referred to as “nonadherent,” “belligerent,” “argumentative,” or “difficult” (19). Such stigmatizing language influences clinician treatment behavior, for example, with less aggressive management of pain in Black versus White patients (20). Furthermore, metaphors have been identified as a tool to engender stigma and influence thoughts and behavior through public discourse, as in the use of metaphors around schizophrenia in British press that potentially contribute to the stigmatization of mental health (21).

Violence metaphors exacerbate healthcare inequities by augmenting the relational power between the clinician and the patient. We propose that inappropriately blaming patients and creating oppositional and subjugative frames around medical interventions imply physical and moral power over patients. This is exclusionary and perpetuates power dynamics that may magnify or contribute to structural inequities, some of which already exist (e.g., the racial and ethnic disparities described earlier). The power dynamics in health care that result in the domination and subordination of another marginalizes the patient, mirroring notions of “exclusionary othering” that have been described in nursing literature (22). “Othering” has been conceptualized “as the process which serves to mark and name those thought to be different from oneself” (23, p. 18), and this process can impose complex power dynamics between the self (clinician, in our case) and the other (the patient or family). The use of violence metaphors to describe patient behavior toward medical interventions also contributes to the negative or exclusionary othering of the patient, which uses power within relationships (between the self and the other) to dominate and oppress. Although othering is not always considered negative (22), the exclusionary focus is dependent on the intent of different parties and the choices and agency of the patient. The “othering” when using “fighting,” “bucking,” “struggling against,” or “resisting” specifically with regard to medical interventions is inherently exclusionary and cannot enhance connectedness and shared power. This “exclusionary othering” promotes the perpetuation of stigma and stereotyping of marginalized groups, and this can lead to the exacerbation of healthcare inequities in the ICU setting, as outlined in Figure 1.

Figure 1.

Mechanism by which violence metaphors lead to “exclusionary othering” of the patient and exacerbation of healthcare inequities.

Recommendations

Violence metaphors that reference interactions with medical interventions do not provide actionable clinical information. They are nonspecific metaphors that position patients within a combat frame that implies volition and blames patients, creates an oppositional and subjugative relationship between the patient and the medical team, and mediates healthcare inequities within our healthcare system. These effects may result in harms such as antagonism between the patient and the medical team and a lack of critical problem solving on the part of the medical team. This may further lead to undertreatment of symptoms; oversedation; and less individualized, patient-centered care (Figure 2).

Figure 2.

Potential impacts and harms of violence metaphors for patients who are experiencing challenges with medical interventions.

Rather than using nonspecific phrases such as “resisting restraints,” clinicians should present objective data or use language that more clearly describes the patient’s behavior to help the medical team troubleshoot and improve interventions so that they may be better tolerated by the patient (Table 1).

Table 1.

Suggested replacements for violence metaphors used for patient behavior toward medical interventions

Violence Metaphor	Suggested Replacements
“Bucking the ventilator”	Patient’s respirations are dyssynchronous with the ventilator settings (with further details about the cause of dyssynchrony (e.g., “reverse triggering”)
	Patient is biting the endotracheal tube
	Patient appears uncomfortable and is grimacing while connected to the ventilator
“Fighting BIPAP”	Patient is trying to remove the BIPAP mask
	Patient shakes head whenever staff tries to place BIPAP mask
“Struggling with restraints”	Patient is trying to remove restraints
	Patient has hyperactive delirium and is in restraints
	Patient is trying to leave his or her bed
“Resisting staff”	Patient is declining staff requests for medical interventions (i.e., lab draw, medications, i.v. placement)
	Patient is asking staff to leave his or her room

Definition of abbreviation: BIPAP = bilevel positive airway pressure.

Furthermore, clinicians should strive to use patient-centered and inclusive medical language that emphasizes a partnership between patients and their medical team. Instead of utilizing violence metaphors and oppositional language in clinical settings, we challenge clinicians to find alternative metaphors that may foster more collaborative approaches and cognitive frameworks around healing and recovery. Metaphors rooted in dance or music may provide an alternate way to communicate within a frame that is communal, supportive, and aligned toward a common goal of achieving balance and harmony. Examples of phrasing include “we need to achieve synchronicity/synchrony with the ventilator” and “we need to take the patient’s lead.” Globally discussing patient-ventilator strategies as a “dance,” whereby sometimes the clinicians lead (e.g., lung-protective ventilation) and sometimes the patients lead (e.g., spontaneous breathing trials), is more inclusive. These emphasize collaboration and partnership between the patient and the healthcare team in troubleshooting challenges with medical interventions.

Future Directions for Investigation

To be sure, not all violence or combat metaphors may be disempowering. Some metaphors such as “the patient is a fighter” and “battling cancer” may be motivating in certain contexts and patient populations (e.g., veterans). Frameworks and ontologies around metaphors should be developed that explore the additional uses of violence metaphors beyond patients who are experiencing difficulties with medical interventions. Furthermore, quantitative studies examining the association of violence metaphor use and sedation practices, for example, could reveal the material implications of language choice in clinical practice. By critically assessing the use of violent metaphors, we may better understand how we can alter our language culture to promote more equitable and patient-centered care in the ICU.