“My Mom Is a Fighter”

Abstract

Background

A metaphor conceptualizes one, typically abstract, experience in terms of another, more concrete, experience with the goal of making it easier to understand. Although combat metaphors have been well described in some health contexts, they have not been well characterized in the setting of critical illness.

Research Question

How do clinicians use combat metaphors when describing critically ill patients and families in the electronic health record?

Study Design and Methods

We included notes written about patients aged 18 years or older admitted to ICUs within a large hospital system from 2012 through 2020. We developed a lexicon of combat words and isolated note segments that contained any combat mentions. Combat mentions were defined systematically as a metaphor or not across two coders. Among combat metaphors, we used a grounded theory approach to construct a conceptual framework around their use.

Results

Across 6,404 combat-related mentions, 5,970 were defined as metaphors (Cohen κ, 0.84). The most common metaphors were “bout” (26.2% of isolated segments), “combat” (18.5%), “confront” (17.8%), and “struggle” (17.5%). We present a conceptual framework highlighting how combat metaphors can present as identity (“mom is a fighter”) and process constructs (“struggling to breathe”). Identity constructs usually were framed around: (1) hope, (2) internal strength, (3) contextualization of current illness based on prior experiences, or (4) a combination thereof. Process constructs were used to describe: (1) “fighting for” (eg, working toward) a goal, (2) “fighting against” an unwanted force, or (3) experiencing internal turmoil.

Interpretation

We provide a novel conceptual framework around the use of combat metaphors in the ICU. Further studies are needed to understand intentionality behind their use and how they impact clinician behaviors and patient and caregiver emotional responses.

Take-home Points.

Study Question: How are combat metaphors (eg, “my mom is a fighter”) used in notes on critically ill patients in the ICU?

Results: Combat metaphors often present as identity and process constructs whereby identity constructs are framed around hope, internal strength, contextualization of a current illness relative to prior experiences, or a combination thereof. Process constructs related to combat metaphors described fighting for different goals, fighting against unwanted forces, or the experience of internal turmoil.

Interpretation: We present a novel conceptual framework around the use of combat metaphors in the ICU.

Although metaphors represent linguistic tools often used to facilitate understanding of abstract health concepts, they also affect our cognitive frameworks. People often think in metaphors, and these can frame our understanding and behaviors.¹ A metaphor conceptualizes one, typically abstract, experience in terms of another, more concrete, experience.^2,3 According to conceptual metaphor theory, metaphors are not simply linguistic embellishments, but rather, they directly influence the way we think about and interact with the world, acting as conceptual tools for structuring and restructuring problems.^3,4 Frame semantic theory improved metaphor conceptualization by describing how metaphors also place ideas or individuals within a frame, or perceived reality, by carrying out roles evoked by certain words and language.5, 6, 7 Multiple field experiments in cognitive science demonstrated that framing events as metaphors can impact individuals’ actions directly.⁸ Considering crime as a virus leads to more support for social reforms,⁹ cancer described as a journey instead of a battle leads to more acceptance of difficult outcomes,¹⁰ and framing federal budgets metaphorically affects individual voting intentions.¹¹ In medicine, patients and clinicians often rely on metaphors to communicate complex ideas relating to health,¹² placing metaphors in a crucial position to shape understanding of disease states and influence medical decision-making.¹³

Combat metaphors (metaphors for hostile encounters like warfare and battle) have been well characterized in oncology,^14,15 media campaigns against HIV¹⁶ and COVID-19,¹⁷ and social causes like so-called wars on crime and poverty.^17,18 Prior studies have described that such metaphors can be disempowering, because they objectify and dehumanize patients (eg, characterizing the body as a battleground).^1,10,19 Writer Susan Sontag critiqued metaphors characterizing cancer as a hostile enemy that must be defeated,²⁰ which places a psychological burden on patients to overcome disease. These could lead to feelings of vulnerability, passivity, or personal failure if a disease remains out of their control.⁶ Our group previously argued that specific combat metaphors describing patient interactions with health interventions (eg, “fighting the ventilator”) provide minimal actionable clinical information and could be disempowering.²¹ Although combat metaphors have been well described in some health contexts, they have not been well characterized in the ICU. Phrases like “my mom is a fighter” or “the patient is struggling to breathe” are used frequently in the ICU, but to our knowledge, their use has not been characterized or explored rigorously. To study the clinical relevance and psychological impact of combat metaphors in the ICU as communication tools,^22,23 a conceptual framework is needed first to understand the landscape of their use.

In this study, we aimed to develop a conceptual framework to characterize the use of combat metaphors in ICU notes from the electronic health record (EHR). We analyzed EHR notes written about adults admitted to any of six ICUs from a large academic hospital system. We present a conceptual framework for the documentation of combat metaphors in notes that may be used as a foundation for future studies. We hope this will guide future research on implications of combat metaphor use in the ICU and the emotional responses around their use.

Study Design and Methods

Study Design

This study was conducted using a constructivist grounded theory approach²⁴ by which analysis progressed through an iterative and comparative process principally grounded in the raw data itself. We chose this approach because it acknowledges researchers’ own subject matter expertise in critical care as informative and interacting with the interpretative process. The primary researchers regularly author notes about critically ill patients. The study followed the Consolidated Criteria for Reporting Qualitative Research guidelines (e-Table 1).²⁵ This study was approved by the University of California, San Francisco (UCSF), institutional review board (Identifier: 19-29429).

Sample

We included notes from adult patients (≥ 18 years of age) admitted to one of six ICUs within the UCSF health system between 2012 and 2020 using the UCSF de-identified notes data set²⁶ (e-Appendix 1). Notes written by any clinical team member (registered nurses, physicians, house staff, respiratory therapists, social workers, physical therapists, occupational therapists, chaplains, or case managers) were included.

Data Collection and Management

We derived our lexicon of combat-related terms from the FrameNet database, an online lexical database for English based in frame semantics, maintained by the University of California, Berkeley.²⁷ In concert with a linguist (D. B.) on our team, we included all words evoking the hostile encounter frame on FrameNet in our lexicon. We treated the hostile encounter frame as analogous to the combat frame, given the overlap with other published lexicons. FrameNet defines such words as those describing a hostile encounter between opposing forces over a disputed issue, to reach a specific purpose, or both. Further detail on FrameNet and frame semantics is found in e-Appendix 1. Our final lexicon is presented in Table 1.²⁸

Table 1.

List of Combat-Related Words With Number of Unique Instances of Word in EHR Notes

Combat-Related Worda	No. of Unique Instances of Combat-Related Mentions in Clinician EHR Notes	No. of Unique Instances Characterized as Metaphorsb	Cohen κ Valuec
Altercation	77	0	N/A
Battle	0	0	N/A
Bout	1,583	1,563	0.83
Brawl	0	0	N/A
Clash	0	0	N/A
Combat	1,130	1,104	1
Conflict	423	281	0.83
Confront	1,076	1,065	0.64
Duel	0	0	N/A
Dust-up	0	0	N/A
Fight	877	808	0.88
Firefight	12	0	N/A
Fistfight	0	0	N/A
Gunfight	0	0	N/A
Hostile	108	100	0.04
Infight	1	0	N/A
Scuffle	0	0	N/A
Shootout	0	0	N/A
Showdown	0	0	N/A
Skirmish	0	0	N/A
Spat	7	0	0
Squabble	0	0	N/A
Stalemate	0	0	N/A
Standoff	0	0	N/A
Strife	0	0	N/A
Struggle	1,052	1,047	1
Tiff	0	0	N/A
Tussle	0	0	N/A
War	58	2	1
Warfare	0	0	N/A
Wrangle	0	0	N/A
Totals	6,404	5,970	0.84

EHR = electronic health record; N/A = instances in which either no instances were found or the hypothetical probability of chance agreement was 1 and thus led to a Cohen κ with 0 in denominator. This occurred only with terms in lexicon that had low prevalence.

^aCounts include all parts of speech (eg, fight, fights, fighting, fought, fighter).

^bCombat mentions were evaluated independently by two coders using the Metaphor Identification Procedure.²⁸

^cCohen κ value measured interrater reliability for metaphor identification using the Metaphor Identification Procedure between two coders for all words included in the lexicon.

We identified note segments containing combat-related terms or their derivatives (eg, parts of speech). We first tokenized notes, then expanded terms from our lexicon using lemmatization and part-of-speech tagging. This allowed for different parts of speech and tense words to be included. Words from our lexicon were queried using the regular expression package in Python (Python Software Foundation), resulting in a data set of isolated segments. Each segment represented the unit of analysis for our grounded theory analyses. All natural language processing tasks were performed using the Natural Language Toolkit in Python (Python version 3.8 software).

We next determined whether sentences containing combat-related mentions were true metaphors or nonmetaphors (eg, the “patient was a fighter pilot”), using the Metaphor Identification Procedure (MIP) described elsewhere.²⁸ Segments were identified as containing a metaphor if the basic meaning and contextual meaning of a phrase did not match. Detail on the MIP can be found in e-Appendix 1.

We assumed a certain level of agency when individuals were placed in the combatant role in keeping with FrameNet. Roles are evoked by metaphors even if they are not directly present in a sentence. When determining metaphors vs nonmetaphors, we assumed that two sides were evoked by the hostile or combat frame (eg, the patient and the entity they were fighting). The MIP was performed independently by two coders (S. K., J. C.) on all terms extracted. Cohen’s κ was used to measure interrater agreement. Disagreements were included for qualitative analysis to allow for more expansive analyses.

Grounded Theory Analysis

We applied a constructivist grounded theory approach for qualitative analysis.²⁴ This included initial coding, focused coding, memo writing, and finally conceptual framework development. This iterative process occurred across serial meetings between S. K. and J. C. We continued memo writing until we constructed a framework around combat metaphor use. The coding and memoing remained stable after analyzing approximately 45% of segments. We analyzed an additional 10% to be confident that we had reached theoretical saturation, leading to a total of 3,229 note segments (54%) analyzed before reaching saturation. A Consolidated Standards of Reporting Trials diagram for the analysis is included (Fig 1). An example memo is found in e-Figure 1. Additional details of the grounded theory analysis are in e-Appendix 1.

Figure 1.

Consolidated Standards of Reporting Trials diagram for segment analysis. A total of 226,731 electronic health record notes were assessed for eligibility. Six thousand four hundred four notes contained combat-related words including all parts of speech (eg, fight, fights, fighting, fought, fighter), 5,970 note segments contained combat-related metaphors that were included in analysis, and 3,229 total segments were analyzed before reaching theoretical saturation.

Results

Across 226,731 notes from 5,603 adults admitted to any of six ICUs across the UCSF health system, we identified 6,404 unique note segments among 2,084 unique patients containing combat-related words. Of these, 5,970 segments were considered metaphors after MIP. Substantial interrater agreement was found regarding whether segments containing combat words represented actual metaphors (Cohen’s κ, 0.84). Cohen’s κ values for individual terms are included in the Table 1. Sociodemographic data are shown in Table 2 and e-Table 2. The most common metaphors were “bout” (26.2% of isolated segments), “combat” (18.5%), “confront” (17.8%), and “struggle” (17.5%) (Table 1).

Table 2.

Patient Characteristics

Characteristic	No. of Unique Instances at the Patient Levela
No. of patients	2,084
Age range, y
18-60	1,001 (48.0)
61-80	735 (35.3)
> 81	170 (8.2)
Unknown	178 (8.5)
Female sexb	817 (39.2)
Language
English	1,600 (76.8)
Chinese dialects	81 (3.9)
Spanish	108 (5.2)
Unknown or declined to answer	206 (9.9)
Otherc	89 (4.3)
Religion
Christian denominations	806 (38.7)
Buddhist	42 (2.0)
Muslim	24 (1.2)
Jewish	45 (2.2)
Atheist, no faith, or none	503 (24.1)
Unspecified or unknown	569 (27.3)
Other	95 (4.6)
Race
American Indian, Alaska Native, Native Hawaiian, or other Pacific Islander	55 (2.6)
Asian	196 (9.4)
Black or African American	139 (6.7)
Latinx	246 (11.8)
Multiracial or multiple ethnicities	55 (2.6)
Otherd	85 (4.1)
Unknown or declined to answer	439 (21.1)
White or Caucasian	869 (41.7)

Data are presented as No. (%) unless otherwise indicated.

^aCounts were analyzed at the level of 2,084 unique patients in the data set. Instances that were left blank in the data set were included in the unknown count.

^bMost nonfemale individuals were male. However, given low number of nonbinary individuals, we suppressed this characteristic in the table to maintain anonymity.

^cRefers to less prevalent languages including: Amharic, Arabic, Cambodian, Farsi, German, Hindi, Hmong, Japanese, Korean, Laotian, Mon-Khmer, Mongolian, Polish, Punjabi, Sign Language, Tagalog, Vietnamese, other, and unspecified.

^dGiven the small sample of patients (< 20) per individual race or ethnicity group not listed in this table, for privacy (and cell suppression) purposes, all other races and ethnicities were grouped within an "Other" category. This also includes a self-reported "Other" category at UCSF when an individual's self-reported race was not included on the pre-defined categories presented at hospital or ICU admission.

Voice

We observed different narrative voices using combat metaphors. Sometimes metaphors were quoted by the author directly from the patient (“[the patient stated] I am a fighter”) or the family (“[adult child stated] my mother is a fighter”). Elsewhere, metaphors were voiced by authors themselves (“I struggle to come up with a diagnosis”). Other times it was difficult to identify the individual using the metaphor (“she would then need to fight to recover”) from the note segment. Notes were analyzed in aggregate, making it challenging to identify the narrative source of each metaphor used. We believed it noteworthy that the author chose to place such metaphors in notes at all and considered this a conscious choice by authors.

Capacity

Coders assumed conscious decision-making was required in the setting of hostility in accordance with the FrameNet conceptualization. However, capacity was difficult to assess. Sometimes it was evident when patients were making decisions consciously on their own behalf (“patient verbalized wanting to fight through his cancer”). Elsewhere, patients were less aware of their surroundings and likely lacking decision-making capacity (“patient is agitated, combative, and delirious requiring versed and restraints”) or had unclear capacity (“he is mildly hostile”). As described in Methods, both instances were included in our analysis.

Conceptual Framework

We present a conceptual framework for the use of combat metaphors in EHR notes within the ICU (Fig 2). We provide a brief overview of the conceptual framework, followed by descriptions of each category and subcategory, as well as additional considerations and implications. Exemplar quotations are outlined in Table 3.

Figure 2.

Conceptual framework for the use of combat metaphors in clinician electronic health record notes in the ICU. Combat metaphors were found to fall within two broad construct categories: (1) identity constructs and (2) process constructs. Within the process construct, the patient is described as “fighting for” a goal, “fighting against” an unwanted force, or experiencing internal turmoil.

Table 3.

Exemplar Quotations

Construct Categories and Subcategories	Exemplar Quotation
Category 1: Identity construct
1.1 Hope	“He knows his wife is very sick but she is a fighter and that he continues to hope she will get better”
1.2 Internal strength	Mental/emotional strength •“Upon extubation pt could not answer mental health the patients son reports that the pts has a fighting [redacted] and can be arrogant and cocky’ in a way that will help pt recover from a liver transplant” •“Her son talked about feeling encouraged by how resilient his mom has been in the face of all her recent complications which he sees as proof of what a fighter she is” Physical strength •“[Redacted] indicated that pt has been very independent at home and is a fighter” •“He is agitated aggressive and combative” •“Patient intermittently hostile aggressive toward RNs”
1.3 Contextualization based on prior experiences	“He also reflected on Mr. [redacted]s previous serious hospitalization 3 years ago and how he recovered because he is a fighter and that he feels that it is possible this may again happen in [redacted]”
Category 2: Process construct
Subcategory 1: Fight for
2.1.1 Societal context	Religious beliefs •“[Redacted] and patient spoke about her faith and her illness please note patient faith is expressed by not giving up the fight for life” Limited resource •“Her family members confirmed her motivation to pursue retransplantation expressing that she expressed willingness to try and fight for it”
2.1.2 Personal context	Family •“The patient and her husband are fighting for the children” Functional recovery •“Patient and husband note changes in her speech for several weeks where she will struggle to get words out or find herself stuttering” •“She struggles to abduct her arm out significantly and has had issues with fine motor skills”
Subcategory 2: Fight against
2.2.1 Physiologic forces	Illness •“This makes it hard for the body to fight infection and disease” •“Antibiotic coverage broadened to include pseudomonas coverage given long hospital course with multiple bouts of ventilator associated PNA” •“He wasn’t sure what to do as patient’s organs are failing but she is . . . a fighter and seems to still be fighting” Symptoms •“[Redacted] like she couldn’t get enough air and was struggling to breathe” •“Pt has had multiple bouts of chest pain since yesterday” •“Patient shared that since his accident 12 years ago that he has struggled w symptoms of depression and anxiety but endorses hopefulness that his current surgical intervention will improve his physical condition thereby improving his mood” Death •“On my prior discussions with him he remained clear that he was not yet ready to die and wanted to keep fighting and keep living” •“I’m fighting and I’m going to survive” •“The patient actually communicated via writing and gestures in the 24 hours before his death that he was done fighting and wanted god and nature to take his course”
2.2.2 Structural forces and interventions	Staff •“Visual fields were full to confrontation” •“On re-evaluation today while extubated and off sedation he was moving all extremities vigorously and fighting the staff despite restraints” Treatments or procedures •“Patient has started responding to pain and fighting the vent versed sedation given” •“Patient continues to fight to take off bilevel pressure ventilation” Sociocultural forces •“Pt noted how stressful it is to have to fight for proper care being so disabled”
Subcategory 3: Internal turmoil
2.3.1 Cognitive challenge	•“I struggle to come up with a diagnosis that [redacted] her hemoptysis with her severe refractory anemia” •“She struggles to provide a history of how acute her vision loss was but right ptosis was known in June 5” •“This patient appears to be in shock with perhaps some component of cardiogenic shock given suspected pulmonary edema however the bedside echo is conflicting as it shows no grossly reduced EF”
2.3.2 Emotional distress	“It seems likely that his wife and sister would struggle with being responsible for a decision to withdraw notably because of their perception that family members who have been less involved in [redacted]’s care would not understand and because he had been less willing to contemplate the circumstance in which he now finds himself”
2.3.3 Spiritual distress	“Struggling with decision because it [redacted] with his personal religious beliefs and he feels strongly that [redacted] would mean that he were killing her”
2.3.4 Existential distress	•“Pt very understandably does not feel ready for his life to be over and vows to keep the fight going” •“She had just heard an estimation of a 5-5 chance of recovering and expressed in a very insightful way feelings related to confronting her own mortality”

EF = ejection fraction; pt = patient; “[redacted]” = machine redactions using Philter algorithm and are considered protected health information (eg, names, birth dates, geographical data); PNA = pneumonia; RN = registered nurse.

Combat metaphors fell within two broad construct categories: (1) identity constructs and (2) process constructs. Within the identity construct, metaphors were used by clinician authors to describe the patient’s conceptualization as a combatant. In the following sample segment—“patient appears to have an appropriate understanding of the challenges he faces and identifies strongly as a fighter”—the clinician author cites the patient’s self-identification as a “fighter,” an essential nature of the individual, serving as a source of meaning and reference for the patient or family.

The other primary use of combat metaphors described a metaphorical act of combat, rather than the self-identification as a combatant, which we termed process constructs. Although these categories and subcategories partition the conceptual space, many metaphor instances belonged to multiple categories at once. For example, “he is a fighter and is fighting for his life” represented both an identity (being a fighter) and a process (the act of fighting) construct.

Identity Construct

In this context, combat metaphors co-occurred with characteristics describing the identity of the combatant, drawn from hope, strength, and prior experience. Patients often were positioned as the actor (or fighter) within the described interactions. The combatant identity often was invoked to maintain hope for a favorable outcome, despite illness severity (Table 3, subcategory 1.1). Confidence, stubbornness, persistence, and resilience were personality traits often highlighted in reference to the patient’s identity as a combatant (Table 3, subcategory 1.2). Sometimes, these qualities were cited by patients and families as characteristics that potentially could increase the chances of a successful outcome. Patients and families presented these personality traits as qualities that could influence physical trajectories directly. Additionally, physical strength and aggression were key characteristics in the patient’s combatant role (Table 3, subcategory 1.2). This physicality was highlighted by families in the patient’s fighter identity against disease. It was highlighted by clinicians when describing the patient’s behavior toward staff, as well.

Prior personal experiences played an important role in this identity construct. Past challenges were within medical (eg, hospitalizations) or social (eg, war, persecution, immigration) contexts and were cited as proof by patients and families that the patient could persist, endure, and recover from hardship and severe illness (Table 3, subcategory 1.3). Families cited instances in which the patient defied doctors’ expectations and drew hope from prior experiences that the patient could recover from the current illness.

Process Construct

Distinct from the personal identity of combatant, many combat metaphors were used as a verb describing an act of combat. This process construct refers to a lived experience in which the actor is fighting for (eg, working toward) a goal, struggling against an unwanted force, or experiencing internal turmoil.

Combat metaphors were used in a so-called fight for context referring to motivating factors for the patient. These factors fell within societal or personal contexts and often were presented as a source of motivation for persisting and fighting, usually in the context of continuing treatment or preventing death for as long as possible. Societal factors included religious beliefs in which giving up hope and not fighting would be counter to one’s faith identity (Table 3, subtheme 2.1.1). Other societal factors included the desire for a limited resource, like a future transplantation (Table 3, subtheme 2.1.1). Within the personal context, family often was cited as a strong motivating factor for recovery (Table 3, subtheme 2.1.2). Patients also were described as working toward a personal goal, particularly functional recovery (Table 3, subtheme 2.1.2).

We distinguish between physiologic and structural forces when metaphors were used to describe fighting against an unwanted force. Physiologic forces included illness (eg, “fight infection,” “bouts of pneumonia”), symptoms (eg, “struggling to breathe,” “struggle with depression”) and death (eg, “I’m fighting and I’m going to survive”) (Table 3, subcategory 2.2.1). Structural forces included staff, either directly (eg, “fighting staff”) or through examination maneuvers (eg, “visual fields were full to confrontation”), treatments and procedures (eg, “fighting the vent”), as well as sociocultural forces such as stigma in the health care system (eg, “fight for proper care being disabled”) (Table 3, subcategory 2.2.2).

Within the process construct, combat metaphors described instances of internal turmoil. These included clinicians experiencing cognitive challenges (eg, “struggle to come up with a diagnosis”) or patients having difficulty processing historical facts (eg, “struggles to provide a history”) (Table 3, subcategory 2.3.1). Metaphors also described emotional distress around difficult decisions (eg, “struggle with being responsible for a decision to withdraw care”) and spiritual distress (eg, “struggling with decision because it [redacted] with personal religious beliefs”) (Table 3, subcategories 2.3.2, 2.3.3). One notable internal challenge was existential distress whereby patients faced their mortality (eg, “patient . . . does not feel ready for his life to be over and vows to keep the fight going”) (Table 3, subcategory 2.3.4). For these patients, death was the implicit enemy that they were facing, and patients and families wanted to do everything possible to prevent death. Pursuing full treatment was exerting intentional effort to survive, and not doing so might represent succumbing to death.

Discussion

This study used a grounded theory approach to develop a conceptual framework around the use of combat metaphors in ICU notes. We identified two core interrelated concepts describing how combat metaphors are used: (1) as identity constructs and (2) as process constructs. We further described subcategories and subthemes emerging from the data, acknowledging that any one instance of metaphor can belong to > 1 category or subcategory. Our findings suggest that combat metaphors are used commonly, but important nuances around their use determine their impacts and implications.

Our study adds to existing non-ICU literature demonstrating how combat metaphors can be used to promote individual agency. Semino et al²⁹ defined empowerment and disempowerment as “an increase or decrease in the degree of agency that the patient has, or perceives him/herself to have, as manifest in the metaphors and their co-text.” This involves the (perceived) ability to control or react to events for one’s own benefit, whereby this ability is desired by the patient and not imposed externally.²⁹ Despite not interviewing authors, when adopting the Semino et al²⁹ definition for empowerment, we observed that in some instances, patients maintained an empowered position within combat metaphors. We found examples of combat metaphors in EHR notes that seemed to enhance individual agency, even at the end of life, providing them with a sense of active engagement with the illness and an ability to control medical outcomes through their actions, (eg, “I’m fighting and I’m going to survive” and “he was done fighting and wanted god and nature to take his course”). Our results seemed to disagree somewhat with those of Semino et al,²⁹ who characterized empowering and disempowering scenarios based on the outcome and success of the so-called fight. At times, abandoning fighting might imply more active control in the dying process, despite perhaps being considered an unsuccessful outcome. Further interviews with patients and families are needed to understand better the full impact of these metaphors.

We also observed that metaphors were used to describe discordance between a patient’s internal fighting spirit and their medical reality and bodily fragility (eg, “he wasn’t sure what to do as patient’s organs are failing but she is . . . a fighter and seems to still be fighting”). Largely because of physical limitations, we observed a sense of hopelessness and inability to control or influence medical outcomes, placing patients and families in a disempowered position. Gustafsson et al³⁰ describes this splitting of the body and self as a compartmentalization coping strategy to preserve the self and self-image as the body “fails.” Yet this compartmentalization does not prepare patients for the transition to end-of-life care. When patients or families insist that so-called fighting continue, this aggressive and potentially burdensome care impedes a more comfort-focused death. It is possible that note authors inserted these combat metaphors to comment on this conflict between a patient’s so-called fighting spirit and medical reality, but further studies are required to elucidate how these metaphors are being used and interpreted.

Strengths of this study include its systematic approach using grounded theory with two independent coders and a progressive, iterative coding process to develop a conceptual framework. This study used a large corpus of notes at UCSF and leveraged natural language processing to identify notes containing combat words and their derivatives, which may not otherwise be easily identifiable through prospective or traditional (random) collection of EHR notes. Although prior studies focused largely on diaries by patients themselves,^29,30,31 and one study examined online writing by health professionals,²⁹ to our knowledge, this is the first study to examine the use of metaphors in medical record documentation.

Our study has limitations. Some terms, like struggle [to breathe], may not seem like metaphors, given their pervasive use. However, linguistically, they do evoke a hostile encounter frame between two sides and place an individual as a combatant against a force (in this case dyspnea). Thus, we included them in our study, but recognize this nuance as a potential limitation. Our results are limited to how clinicians use metaphors textually. This is similar to Southall’s review that found most studies were about clinician use and not patient use of metaphors.³² Note writers and patients were not interviewed, so discordance may exist between the intended meaning of note writers and patients and the interpreted meaning of the study researchers. We acknowledge that our lexicon may capture incompletely all possible instances of combat metaphors that may be more contextual. Future studies should explore intended and perceived meanings of these metaphors across multiple ICU stakeholders and context around when and how these metaphors are used.

Interpretation

We present a novel conceptual framework for the use of combat metaphors in the ICU. This conceptual framework may serve as the foundation for future computational and qualitative studies that should explore the underlying motivation and impact of combat metaphor use in the ICU. The characterization of combat metaphors in the ICU may help us begin to understand how metaphors can enhance disease understanding and strengthen therapeutic relationships between patients and their care team.

Funding/Support

J. C. was supported by the SCCM-Weil grant, the UCSF Noyce Initiative for Digital Transformation in Computational Biology & Health, the Hellman Fellows Foundation, and the UCSF Anesthesia Department Seed Grant. S. L. was supported by the National Institute on Aging [Grants K24AG066998 and R01AG057751]. A. K. S. was supported by the National Institute on Aging [Grants R01AG057751 and K24AG068312].

Financial/Nonfinancial Disclosures

None declared.