When did the language we use to talk about death start to resemble a Pentagon briefing, full of military references and combat analogies?
Maybe it dates to 1971, when Richard Nixon declared a "war on cancer." Or much earlier, in the late 1800s, when doctors began using the word "armamentarium" to describe all the techniques, materials and equipment available to treat disease.
Certainly these metaphors have since become pervasive, among patients and physicians, the public and the news media. Family members seek aggressive treatment for an ailing relative, saying, "He's a fighter," or "She's a survivor." We talk about whether people with terminal diseases want "heroic measures" or not.
And when people die, we portray them not as having succumbed to disease, but as having struggled to the very end before being vanquished by a superior foe. Recent death notices in The New York Times (which are placed by families, as opposed to the obituaries written by reporters) memorialized a woman in her 90s who died "after a valiant battle against Alzheimer's and Parkinson's" and a 93-year-old man who died "after a long-fought battle with prostate cancer."
The bellicose wording "reflects some of the death-denying and death-defying feelings we find in our culture," said Dr. Daniel Johnson, a palliative-care physician in Denver who directs the Kaiser Permanente Care Management Institute. "Society sees death as the enemy, so it's not surprising we turn to language that references war."
But that can have unhappy real world consequences, Dr. Johnson recently cautioned in a talk at the Association of Health Care Journalists' national conference. Patients have taken him aside to confess that they dread another round of chemotherapy but fear disappointing those who expect them to "fight."
"They're nervous about what their doctors and their families might think," he told me in an interview. What they may actually want to say is that "I've lived a really good life, and now I want to spend time with my family" instead of at a dialysis center or in intensive care.
To spend one's final weeks or months free of that pressure can be "potentially transformative and beautiful," Dr. Johnson said. Often, though, to "give up" has become shameful.
Consider the couple whom Patrice Villars, a gerontological and palliative-care nurse-practitioner, is working with at the VA Medical Center in San Francisco. He's nearly 90, has metastatic lung cancer, can no longer leave his hospital bed, and has lost his appetite — a normal, expected development at the end of life.
But his wife urges him to eat and to "just try harder." His life expectancy is measurable in days or weeks, Ms. Villars said, regardless of what he eats.
Ms. Villars, who complained about the "losing the battle" meme on the GeriPal blog a few years ago, has come to see this language as stemming from the grief of those about to be left behind.
"It's intolerable to think of losing someone they care so deeply about," she told me. "I think it's true for health care providers, too. We feel helpless and sad, and we don't know where to put that."
But, she added, war words make us judgmental. "I worry about the implication that somehow, someone was deficient or a loser or didn't do something right if they died," she told me. "People die."
The idea that sick and old people must wage war is on my mind lately, as well. For some people in some situations, all-out combat against a reversible condition makes sense. In late January, when a beloved cousin of mine, Rae LeRoy, had trouble breathing and went to the hospital, it seemed logical to treat what initially looked like pneumonia. She was a vibrant 93-year-old still living in her house, driving to club meetings, doing water aerobics; perhaps she could regain her strength and continue her active life a while longer.
But one hospitalization followed another, a too-familiar cycle of 911 calls, release to a rehabilitation center and re-admission. She had developed heart failure, not a curable condition. Each hospital stay left her further weakened.
Was it time to shift to comfort care, to call a hospice? Her longtime doctor not only discouraged the idea when Rae's daughter asked that entirely reasonable question, but scoffed at it: "We're not anywhere near that." She wanted Rae to continue The Fight.
But why? Rae had fulfilled every obligation, lived life fully, and now she was weeping with fatigue, saying, "I can't do it anymore, I'm so tired." Is "fighting," which presumably means using everything in the armamentarium, the only way to show courage at the end of life?
A palliative-care physician finally sat down with Rae and her children in late March, explained her options and told her, "You decided how you wanted to live, and now you get to decide how you want to die." Rae chose to stop going to the hospital, enter hospice care, say goodbye to friends and family — a valiant decision in my book, and her children's — and let death come as it would. It came in days.
She didn't want to die, bloodied and exhausted, on a battlefield. She wanted peace.
Others will make different decisions (and I'd like to hear about your families' experiences), but they might feel freer to make them if they were released from the language of war and the expectations that accompany it. If immortality has become the only victory, we're all failures.
Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."
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