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Investigating Language of Fear and Failure in Cancer Care

Kagan, Sarah H. PhD, RN

doi: 10.1097/NCC.0000000000000536
DEPARTMENTS: Insights
Free

Author Affiliation: School of Nursing, University of Pennsylvania, Philadelphia.

The author has no funding or conflicts of interest to disclose.

Correspondence: Sarah H. Kagan, PhD, RN, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104 (skagan@nursing.upenn.edu).

Accepted for publication June 21, 2017.

Investigation to optimize cancer communication is “hot” these days. Clinicians wish to improve patient satisfaction and clinical outcomes with evidence-based conversations, often scripted for timely “big topic” talks with patients and families. Many nurses and other scientists are thus studying means to achieve ideal communication regarding diagnoses, prognosis, and decision making. Nonetheless, a fatal flaw threatens this research. Language, so common nurses and other cancer care clinicians are often oblivious to it, may undermine the most carefully designed studies.

“I understand you've just been told some bad news.” “So, as you've failed first-line therapy, your oncologist is recommending….” “There's nothing more that we, here in the oncology clinic, can offer you, so I think you'll benefit from meeting our palliative care team.” Stated as fact, these words are actually judgments pronounced for patients by clinicians. The words are laden with unspoken meanings, all of them negatively cast. Use of this language persists despite interest in evidence-based communication and research designed to ensure that conversations go according to plan—our plan, that is.

Efforts to improve cancer communication often aim to direct decisions toward choices that clinicians deem best given the clinical situation. Research frequently intends to reduce clinician distress and improve patient and family adherence to recommended treatment. Although these aims are valuable, they are incomplete. The focus is on the clinician, neglecting to explore the perspective of the person living with cancer and relationships within which the communication targeted for improvement occurs. Moreover, the language used to achieve them is typically dreadful.

Listen carefully to the words of cancer care. News of a diagnosis or prognosis is deemed bad or good. Phrases divide responsibility unequally. The phrase “you failed” connotes both volition, “Your choice not ours,” and accountability, “You are the one responsible here.” We rarely, if ever, hear “I'm so sorry. Our therapies have clearly failed you. I'd like to offer something better,” said in clinical practice. Communication research today largely focuses on clinicians, even in the guise of being patient centered, and not on the relationship at the heart of good communication. Think of the patients who find a voice to express abandonment at the introduction of hospice care. Now, consider the burden many must feel having heard they failed treatment. The English-language examples here are from American cancer care. Nevertheless, other languages and societies are certainly replete with similar phrases and consequences.

The language of cancer, used by clinicians and adopted by many patients, is pessimistic and isolating. It underscores outdated notions, implying that any cancer diagnosis is negative and connoting a proximate death. Furthermore, our language privileges the prerogative of clinicians to evaluate information about cancer for patients and their families, not with them. Words and phrases remain emotionally provocative, bearing a presumption that clinicians are better able to interpret the import of cancer than are patients who live with it. Thus, the daily language in cancer care risks underscoring fear and powerlessness in reality. It relays inferences of failure and responsibility more often ascribed to patients when things go wrong and to clinicians when they turn out right. Failure is ultimately death, whereas success is survival beyond cancer.

In our aging world, chances of cancer diagnoses, and even perhaps more than one in a lifetime, and of surviving those cancers to live long enough to experience frailty and multimorbidity are ever greater. With advancing age, the truth of inevitable human mortality becomes a personal reality. It is not death itself but how we live until we die that should concern us all. Accordingly, the population aim of preventing premature death, and not preventing death as outdated language held, translates clinically to timely death in circumstances congruent with personal preferences and desires. Language that impugns our mortality by evoking fear and prompting reliance on biomedical directives is insupportable. Thus, the commonplace words and phrases of cancer care are illogical.

Nurses are familiar auditors and translators of healthcare communications. In that role within cancer care, they frequently manage the language of fear and failure. Whether nurses use this language themselves or interpret in response to words and phrases used by a colleague, the need for better research is the same. Studies of the real language of cancer care and the clinical relationships in which it occurs match long-standing cancer nursing research priorities and well-honed scientific skill sets. Nurses are the acknowledged educators and communicators of the interdisciplinary cancer care team. With those roles and our science, definitive inquiry into real cancer communication and delineation of resulting clinical discourse will drive deeper understandings of meaning for patients and their families, uncovering fresh means to replace fear and failure with greater realism, kindness, and respect.

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