Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

The “D” Word


To give excellent care to patients we must become comfortable using direct language, including words like “death” and “dying.” 

“I think your mom is dying.” 


The patient’s three daughters crowded into the tiny exam room, hovering anxiously around their mom’s bed. One was crying, one was stoic, and the third seemed angry and agitated. “What’s the plan? What are you doing for my mom? Does she need a scan or an antibiotic? It doesn’t seem like anyone is doing anything!” 


The patient had been clear about her wishes to avoid aggressive interventions at end of life, so no transfer to the ICU was scheduled. Her cancer was advanced, and the medical team agreed that her continued decline was inevitable. But no one had used “the D word.” This lack of clarity increased her daughters’ suffering because it allowed them to focus their attention on unhelpful treatments rather than on saying goodbye to their mom.  


Some healthcare professionals avoid saying “dying” or “death.” Instead, we say, “Things aren’t looking good,” or, “Her blood pressure is unstable, but her potassium is better,” so that we don’t have to say, “I think your mom is dying.” 


We should communicate as clearly and accurately as possible so that the family has time to prepare for the loss of their loved one. Also, be sure to emphasize what you will do, not what you won’t. Here are some ideas: 


What to say:

1. “I believe that your father is dying.”

2. “We’ll aggressively treat her pain and other symptoms so she’s as comfortable as possible.”

3. “It’s ok to be in her room when she dies, and it is also ok not to be in the room.”


What not to say:

1. “He’s not doing as well as we’d like.” (Too vague)

2. “We’re withdrawing care.” (We never withdraw care, we change from disease-focused care to symptom-focused care)

3. He’s on “comfort care” now, so we don’t need to treat his fever.” (The term “comfort care” can be distressing to families, and treating fever helps to reduce suffering)


Death is part of life, and we owe it to our patients to become skilled at talking about this often difficult, but inevitable, reality.  








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