Metaphors pervade everyday life.1 ,2 It is not just that what we say is metaphorical; it has been argued that our thought processes and conceptual systems themselves are metaphoric in nature.1 But what are metaphors? What are their value? And why should we, in healthcare, care?

According to Lakoff and Johnson, metaphor is a way to comprehend or experience one phenomenon in terms of another. Metaphors are valuable because they allow us to ‘comprehend partially what cannot be comprehended totally: our feelings, aesthetic experiences, moral practices, and spiritual awareness’ (p. 193).1 This ability can be attributed to their experiential grounding: the use of particular metaphors articulates a shared experiential basis between objects or ideas, generating a particular type of understanding that could not be conveyed otherwise.3

The abundance of metaphors in medicine is well documented.2 ,4 ,5 Objection to the use of metaphors in medicine has been made. Most notable is Susan Sontag's6 Illness as Metaphor, where she argues that ‘the most truthful way of regarding illness… is one most purified of, most resistant to, metaphoric thinking’ (p. 3). Such objection can be seen to stem from what Lakoff and Johnson1 term the ‘myth of objectivism’—that objectivity is desired as it is rational and the only true pathway to knowledge; subjectivity, on the other hand, can be seen as irrational and obscured by emotion.

The most predominant perspective, however, appears to accept metaphor as a valuable form of ‘imaginative rationality’ (p. 193).1 In this way, metaphors are regarded as a form of creativity that far from obscuring reality and knowledge is a pathway to new understandings and potential solutions.3 ,5 ,7 ,8 Various articles have been published about the ability of metaphors to foster clarity and safety regarding complex or elusive topics such as death.3 ,7 ,9 Southall's7 review of metaphors in the palliative care setting affirms their ability to establish mutual understanding between clinician and patient regarding the end of life (EoL) experience, from which new insights and coping strategies can be developed.

The purpose of this short article is to stress the importance of metaphoric expression, of imaginative rationality, in the context of death conversations outside the palliative context. We argue that death is a significant topic missing from Lakoff and Johnson's1 list of ‘what can only be comprehended partially’, which metaphors serve to illuminate.

The pertinence of metaphors to death conversations became apparent in a recent multidisciplinary inquiry into the perspectives of young older adults (54–65) on the likely time and cause of their own death. Semistructured interviews were held with 21 individuals not receiving palliative care nor expecting to die in the next 12 months, analysis undertaken through an immersion/crystallisation process.10 Throughout the interviews, we observed a repeated recourse to metaphoric expression by participants when posed with a question or existential issue not amenable to direct ‘objective’ description. For example, Olive was able to convey her simultaneous acceptance of and bafflement with death.Olive: It's like being on a conveyor belt… all of a sudden you're on this part of the conveyor belt, and then you're on this bit, and you're looking, seeing your own children where you were, and thinking… how strange it is. Yet, it's right, because that conveyor belt is how everything works. You just hop on, and hop off when it's time to get off.

Similarly, Barry drew on automobile culture to convey his uncertainty how his baby boomer generation was making the transition from middle to older age, and the associated decline in bodily functions and sense of well-being.I'd be really interested in the notion of ‘57 Chevys. I was born in 1957, and ‘57 Chevy were the car. I'd be really interested in my peers who were 57 going into 60 about how they view these things. Because there are two ways to look at it: I'm a ‘57 Chevy and I'll always be a ‘57 Chevy, or I'm a ‘57 Chevy that's become a ‘57 Morris Minor.

The use of machine metaphors by Olive and Barry specifically indicates the Cartesian schema of mind and the body being mechanical in nature, and associated assumptions about suitable therapeutic approaches to simply replace ‘faulty’ parts with new ones.9

Mable used the ‘illness as incarceration’ metaphor to convey her father's decline following the onset of dementia.But watching him gradually being robbed of his ability to… It was awful. It was like he was stuck in a prison and he could only partly communicate or could only partly creep out little bits and the rest of it was just shut up and he couldn't get it out because he felt locked somehow.

Through this metaphor, Mable conveys several ideas; her dismay at her loss of her father, and his loss of himself; the social isolation associated with inability to communicate or to engage with others; and the loss of control and autonomy associated with dementia. On rare occasions, her father is visible within his prison of dementia, and the use of words such as ‘creep’ is also indicative of stealth and furtiveness in the assertion of himself within the prison of his illness.

Other participants used metaphor in a way that sanitised death, where people ‘quietly fall off their perch’ (Steven) or ‘pop their clogs’ (Melissa). Arguably, such use of metaphor obscured the pain and discomfort associated with death such that it could be safely engaged with in conversation, while at the same time connecting them to collective experience through these metaphorical clichés.3 However, the use of metaphor is not necessarily enabling. The distress was palpable as June described her disgust at health professionals use of the orientational metaphor ‘happy is up, sad is down’ to describe her fathers' afternoon episodes of physical and verbal abuse that necessitated physical restraint: ‘And they call it sundowners—well that's a nice pretty little term for what is actually something bloody ugly that's going on inside your head’.

As Casarett et al3 state, clinicians' use of metaphor to obscure the painful reality of death and dying may cause anguish in patients where such language is interpreted as a minimisation of their experience.

Arnold and Lloyd have encouraged us to consider how metaphor may facilitate effective communication in the context of death and dying.2 As Lakoff and Johnson1 acknowledge, metaphors are more than mere words, and can act as self-fulfilling prophesies as the associated perception of reality determines actions taken (p. 244). By becoming aware of the nuances contained within metaphoric expression, clinicians will be better placed to understand the idiosyncratic health frameworks patients bring to the consultation, which influence their interpretation of diagnoses and advice, and openness to particular health interventions. Perhaps physicians could explore patients' ideas by asking, ‘How do you think about or view death? What helps you to view or put words around it, what does it seem like for you?’ Further, by being more aware of their own use of metaphors, clinicians can both enhance patients’ overall healthcare experience and avert unintended miscommunication.3 ,11

We affirm Southall's call for greater research on the use of metaphor with regard to death. However, we wish to extend this exploration outside the realm of EoL care: we believe metaphors have a role to play in fostering clarity and safety on the topic of death for people of all ages and states of health.7 While alive, we can experience death only through others. We can be intimately involved in their long-term and immediate death preparations and bear witness to their final moments. But direct personal experience of the death process occurs, primarily, at a point after which insights can no longer be shared. Skilful use of imaginative rationality in the healthcare setting may sufficiently illumine the topic of death, which is elusive and often eschewed by patients, in a way that fosters clarity and new understandings and pave the way towards a better life, and death.