The Role of Euphemisms in Healthcare Communication

A euphemism is defined as a “A mild or indirect word or expression substituted for one considered to be too harsh or blunt when referring to something unpleasant or embarrassing” [1]. The word is derived from the Greek – eu “well” and phenai “to speak” and was first used in the English language in the late 16th century. In the context of healthcare, the use of euphemisms is often discouraged, as they may distort the meaning of sensitive issues that require discussion. There are clear situations, where use of a euphemism, such as equating sleep with death, will cause significant confusion and not be helpful. However, a euphemism can be used at times to communicate with a patient such that their understanding of their condition increases, and their experience is less stressful. The latter is more likely to occur in a situation where the patient has a longer time to come to terms with the information relating to their diagnosis, and decisions in relation to management. When choosing the language for a sensitive healthcare conversation, a healthcare professional (HCP) will need to balance their openness and clarity in communication, with consideration of the patient’s experience and level of distress.


Editorial
A euphemism is defined as a "A mild or indirect word or expression substituted for one considered to be too harsh or blunt when referring to something unpleasant or embarrassing" [1].The word is derived from the Greek -eu "well" and phenai "to speak" and was first used in the English language in the late 16th century.In the context of healthcare, the use of euphemisms is often discouraged, as they may distort the meaning of sensitive issues that require discussion.There are clear situations, where use of a euphemism, such as equating sleep with death, will cause significant confusion and not be helpful.However, a euphemism can be used at times to communicate with a patient such that their understanding of their condition increases, and their experience is less stressful.The latter is more likely to occur in a situation where the patient has a longer time to come to terms with the information relating to their diagnosis, and decisions in relation to management.When choosing the language for a sensitive healthcare conversation, a healthcare professional (HCP) will need to balance their openness and clarity in communication, with consideration of the patient's experience and level of distress.
A survey performed in the United Kingdom found the public did try and avoid using the words death or dying because they were confronting [2].Instead the following euphemisms were used.
• Danish; Stille traeskoene -to leave one's clogs behind • Dutch; De pijp uitgaan-to go out of the pipe • French; Avaler son extrait de naissance -to swallow one's birth certificate • Freek; τίναξε τα πέταλα -to cast the petals Culture can have a large impact on what language is used to describe serious illness.People from a Greek background can be extremely sensitive to issues relating to death, dying and cancer [3].There can be a desire to protect the sick person from receiving bad news.This is related to the notion that the bad news itself would exacerbate the suffering.There is also concern that the patient may lose hope.In this context, in the Greek culture, many people prefer to use euphemisms such as "that terrible sickness" or "the situation".The role of the Greek Orthodox church is also very important within the Greek culture in determining the behaviour of people as they grieve [3].Another example includes Aboriginal Australians, who may use the term "finish up" as a euphemism for dying [4].
Best practice generally suggests that euphemisms should be avoided in palliative care.It is suggested that vague words may impair the patient's ability to think clearly about their illness [5,6].Vague terms and medical jargon need to be minimized.If technical language does need to be used, a HCP should be careful to explain such terms fully to the family in accessible language.The use of a euphemism may also suggest to the patient that the health professional considers the issue being discussed a taboo topic themselves.Certainly, HCPs need to be clear, open and direct in their communication.Caution must especially be exercised when using euphemisms with children.Children are more likely to be concrete thinkers, and less likely to pick up on the nuances of a euphemism [7].For example, if a HCP or parent tells a sibling of a child who has died that they are sleeping, the child may expect them to wake up.Further, when they experience that their sibling did not wake from "sleep" after dying, they may themselves become fearful of going to sleep.
However, there may be occasions when it is appropriate to use a euphemism.For example, some parents who have experienced a stillbirth will choose to use the term that their baby was "born sleeping" [8].Parents choose to use this language and it can provide meaning to the family and also allow them to sensitively relay the gravity of what they have experienced to their family and friends.When a HCP first meets a patient and their family, they may want to develop rapport with a patient [9,10].It is also important to foster realistic hope which involves being honest without being blunt or insensitive [6,9].In such a context, a euphemism may be appropriate.This would especially be the case if the patient first used the term.This would be an example of a HCP soliciting a patient or carer's perspective, and then using this to inform subsequent communication with them.The HCP can than build on the mutual understanding of such a term, through dialogue, and ultimately impart the key information on diagnosis and management that they were planning [11].This can allow delivery of bad news to be done within the perspective of the patient and their family.
Patients will respond differently when their diagnosis is given as medical terminology compared to as lay language [12].In one study, use of the term "tonsillitis" made the patient feel they were be taken seriously and this resulted in greater confidence in the doctor.The lay term "sore throat" resulted in patients taking ownership of the problem.However, this was also associated with feelings of guilt.A study of General Practitioner's (GPs) in the United Kingdom found the GPs preferred to use euphemisms, such as "fluid on your lings as your heart is not pumping hard enough" compared to the term "heart failure" [13].A large number of patients were then surveyed in relation to their understandings and perceptions these terms.Patients who received the condition described as "heart failure" believed that the illness would have more serious consequences for their life and that the problem would last for longer.They reported feeling more anxious and depressed than those who received the condition described using the euphemism.
The choice of language therefore presents a dilemma for a HCP.The term "heart failure" may give a clear understanding of the serious nature of the condition, but also a more negative response from the patient.The euphemism may be not as clear but can be more gentle and protective of the patient's experience.At times, there may be more urgency to impart the diagnosis, or make decisions about management.This would particularly be the case for life threatening illnesses.Assessing the patient's comprehension of the situation at this time is also important.In such a context, using terminology that is clear and illustrates the serious nature of the condition e.g."heart failure" may be preferable to using the more vague term "fluid on the lungs".If direct language is to be used, and euphemisms avoided, then appropriate psychosocial support needs to be provided to the patient and their family during, and after such a consultation.
The following is a real life example of where the use of a euphemism allowed compassionate communication to parents who were finding out about the suicide of their daughter [14].
Two policemen came round and they handled it with great sensitivity, I was very impressed.They came round and it was pretty clear to us that it related to Alice and we assumed instantly that she had in fact killed herself, so when they came a few minutes later it was no great surprise at that moment in what they said, they chose their words very carefully, I was impressed by the consideration that they showed us, they used the phrase that, "Alice is no longer with us".As a euphemism it was very well, well judged by them.So altogether, you know, they were very courteous, they obviously waited long enough to see whether we needed them to stay on or needed any further help, but we didn't.So off they went after I imagine a quarter of an hour or twenty minutes or so.
While euphemisms are potentially problematic in healthcare communication, and need to be used carefully, there are situations where they can facilitate communication.This is particularly when the patient first uses the term in a consultation and the goal of the healthcare encounter is to develop rapport.The concerns around the use of euphemisms in the medical literature are justified.However, this should not mean they euphemisms are to be avoided at all times.Factors such as the intent or goal of the health care consultation (e.g.building rapport or relaying the gravity of a situation), the stage of an illness (e.g.diagnosis or end stage), culture, religion and age of the patient will all be important to consider in choosing the correct terminology to use with a patient and their family during a consultation.