'Fighting' disease is the wrong metaphor

When Alex Trebek, the longtime "Jeopardy" host, revealed to the world that he'd been diagnosed with Stage 4 pancreatic cancer this spring, his statement echoed the words of many patients I've treated.

"I'm going to fight this," Trebek promised. "I plan to beat the low survival statistics for this disease."

Though I mourned his diagnosis, I also winced at his use of the familiar language of "fighting" and "beating" cancer. As a palliative-care physician, I know patients can find it empowering to describe their approach to illness as a battle. But others have shown me that the language of "fighting" a disease or "giving up" is a toxic binary. It divides the sick into winners and losers — those who beat cancer and those whom cancer beats.

This militaristic approach to sickness is perhaps rooted in the notion that our personal outlook on disease can change our biological outcomes. But in my experience, these words just as often stand in the way of honest, vulnerable conversations about fear and anxiety, and the peace and dignity most people want as an illness worsens. For some, fighting words are armor that doubles as a veil. What they mask is what interests me.

One of my patients, a woman in her 50s named Janey, recently declared that she wasn't about to "wave the white flag." Diagnosed two years earlier with stomach cancer that had spread to her liver and bones, Janey came to the hospital with severe pneumonia. Once a personal trainer, she had lost so much weight that I could wrap my fingers around her upper arm. Surgery and multiple rounds of chemotherapy hadn't kept her cancer from growing. But knowing this didn't stop Janey from asking about the next surgery or medication she could have.

"I might look weak, but I want to keep fighting," she told me, squeezing her husband's hand. I asked her to help me understand what that meant to her.

Had I met Janey seven years ago, when I was still a medical resident, I wouldn't have had the courage to probe for a deeper explanation. When I didn't know any better, I performed CPR on dying patients because they'd told me they wanted "to fight till the last breath." Using ventilators and dialysis, I prolonged the deaths of patients who told me they wanted "everything" done.

When I sat down next to Janey and asked her to define "fighting," she cried. "I feel like if I don't do every single treatment possible, it'll be like giving up on my family," she said. "But being here in the hospital keeps me away from them."

Getting chemotherapy and going to the hospital had begun to make her increasingly anxious. Blood tests hurt more and more as her veins became harder to find. She hyperventilated during an MRI, fearing the results. When she became dizzy and passed out in the hospital, she'd wanted to ask her oncologist if she was dying, but she couldn't bring herself to project anything other than a positive outlook. "I'm not a quitter," she told me, "but I think fighting this is killing me."

"Keep the faith and we will win," Trebek said in his statement. It's a sentiment that patients and doctors alike cling to when an illness advances despite our best efforts to restrain it. But could it be freeing rather than disempowering to understand that the body — born of nature and subject to its laws — has its limits? That no matter how strong our determination to live, our bodies will eventually die?

If the language we use reflects our cultural attitudes, then our perspective on illness and death, and the metaphors we use to discuss them, must evolve together. Maybe cancer and heart disease and organ failure aren't battles to win or lose, but simply illnesses that we strive to treat. Maybe a patient living with cancer isn't a warrior, but simply a human struggling to live well and survive while contending with her mortality. Our bodies and lives are infinitely more than battlegrounds.

Janey couldn't loosen her grip on the terms "fighting" and "giving up," but she came to realize that her focus on outsmarting cancer had compromised her sources of joy: helping her daughter with her homework, taking drives with her husband along the Pacific Coast Highway, working her way through the stack of books on her nightstand. After two more hospitalizations for pneumonia, Janey enrolled in hospice. She told me that fighting for her comfort — being at home, lucid and free of pain — mattered more to her than pursuing the clinical trial her oncologist had mentioned.

Janey, back at home, sent me a photo of her family gathered around their dinner table, another of her daughter's perfect report card. She e-mailed, wondering whether patients who step away from the fight die sooner than those who soldier on. Her husband called one month later to tell me that she had died in her sleep, alert and clear-minded until the end.

"I think she came to see that letting go and giving up aren't the same thing," he wrote to me. I keep his card taped to my desk.