“Better”

Her son and daughters sighed in collective relief. Mrs. J’s breathing and blood pressure were “better.” In that single word, “better,” her family heard the promise of betterment on the scale of the whole person: the healing of their loving, generous, and gregarious mom. 

But Mrs. J wasn’t really “better.” Yes, she was now on 70% FiO2, down from 100%, but still on volume control failing spontaneous breathing trials. Her vasopressin was down from the maximum dose today, but her nurses couldn’t pull back on her norepinephrine. After 20 days on the ventilator in the ICU, Mrs. J was in multiorgan failure secondary to septic shock, with worsening oliguria. Even real improvements in respiratory or hemodynamic status were unlikely to lead this beloved mother toward “better.”  

Hospitalized patients’ conditions often change from one day to the next. Especially for loved ones of critically ill patients, improvements in objective data can represent steady hope amidst chaotic uncertainty. But when clinicians highlight quantitative clinical improvements in the context of debilitating illness without clearly describing a tenuous big picture, we create false expectations for a positive linear trajectory where none exists. 

It makes sense that medical professionals would view clinical trends towards “better” as just that: better. But I suspect many people carry an implicit understanding of “better” that conjures a return to normalcy, a step toward a familiar quality of life. 

Choosing words intentionally can help us partner with patients in hoping for the best, without causing confusion. I find the following helpful, and hope you do too: 

1. Be precise. What, specifically, appears to be on the right track?  
 

2. Use a comparator. Compared to what benchmark are you interpreting progress?

3. Situate within context. Given the patient’s own goals, what does the road ahead look like?

Hoping or praying for the best is supported, not hindered, by using this sort of specific language. Nonspecific language like “better” can cause dismay when even the most probable setbacks occur. For families like Mrs. J’s, this heartbreak can fracture trust and add to decisional distress. 

We can always do better than “better.” 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.