“My Mom Is a Fighter”: A Qualitative Analysis of the Use of Combat Metaphors in ICU Clinician Notes

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BackgroundA metaphor conceptualizes one, typically abstract, experience in terms of another, more concrete, experience with the goal of making it easier to understand. Even though combat metaphors have been well-described in some health contexts, they have not been well-characterized in the setting of critical illness. Research QuestionHow do clinicians use combat metaphors when describing critically ill patients and families in the electronic health record? Study Design and MethodsWe included notes written about patients >=18 years admitted to ICUs within a large hospital system from 2012-2020. We developed a lexicon of combat words, and isolated note segments that contained any combat mentions. Combat mentions were systematically defined 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. ResultsAcross 6,404 combat-related mentions, 5,970 were defined as metaphors (Cohen’s kappa 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 were usually framed around: (1) hope, (2) internal strength, and/or (3) contextualization of current illness based on prior experiences. Process constructs were used to describe: (1) “fighting for” (e.g. working toward) a goal, (2) “fighting against” an unwanted force, or (3) experiencing internal turmoil. InterpretationWe 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/caregiver emotional responses.