Letter to the Editor: It Is Time to End “Warning Shots”

Dear Editor:

“Don't forget to give a warning shot,” my attending says. My breath stalls as if a gun went off. I imagine crayons rolling off desks as children use desks to barricade doors. I cringe. In an era fraught with gun violence, why are we in palliative medicine still using this threatening language?

The phrase “warning shot” has violent connotations, even if historically it had different meanings. In the 18th century, ships used “warning shots” as a signal prompting other ships to display their nationality. A “warning shot” now typically refers to harmless gunshots by military and police intended to encourage compliance by threatening more aggressive measures. Warning shots are a demonstration of power: some are an attempt to de-escalate situations such as dispersing crowds, whereas others are given by soldiers under threat before they shoot in defense.

In our field of hospice and palliative medicine, a “warning shot” has become standard language in communication skills training. In a landmark article, Baile et al outlined the SPIKES framework for delivering bad news: step 4 for giving knowledge and information suggests that “warning the patient that bad news is coming may lessen the shock that can follow the disclosure of bad news.” ¹ Baile et al describe how a warning statement (e.g., “I'm sorry to tell you that…” or “I wish I had better news to share today…”) may help patients or families prepare to process hard information.

Interestingly, Baile et al never used the phrase “warning shot.” Future articles building upon this paradigm began to introduce “warning shot” terminology. The six-step BREAKS protocol mentions that “a warning shot is desirable, so that the news will not explode like a bomb.” ² The SOLS+ framework for neurosurgery residents advises them to “fire a ‘warning shot,’ pause and give news in a direct way.” ³

Although “warning shots” function as an important communication tool, this terminology is not benign. The “warning shot” illustrates how pervasive and normalized gun violence references are in our vernacular. Fifty-eight percent of adults in the United States reported that they or someone they care for have experienced gun violence in their lifetime, and health care professionals were the most likely to have experienced gun violence in the workplace (SurveyUSA). ⁴

As palliative medicine experts who care deeply about language, we must take ownership over our jargon and rethink the casual use of “warning shots” in communication skills training.

Let us simply call it what it is: “a warning statement.” We do not need to “fire a warning shot” or “pull the trigger” on bad news. These violent references undermine the gentleness that we hope to accomplish. By replacing the phrase “warning shot” with “warning statement,” we can model kind and nonviolent language and help challenge the culture of gun violence around us.