Humour and laughter are present in most of human interaction. Interactions inhealth care settings are no exception. Palliative care practitioners know from experiencethat humour and laughter are common in palliative care despite the seriousness of the carecontext. Research establishing the significance of humor in care of the dying is limited
This is Part 2 – The Research – Part 1
Humour and laughter were pervasive and persistent in the palliative care setting. Ranging in intensity from warm subtleties to uproarious hilarity, they varied in expression from gentle remarks, witty expressions of incongruity, playfulness, dark humour, and the sharp edge of humour with a bite. In each circumstance, humour generated an outcome, ranging from a momentary flicker of a smile, to a small chuckle, or to uproarious laughter that energized and lightened the atmosphere. Humour served myriad functions. Among these multiple functions, three primary categories emerged: building relationships, contending with circumstances, and expressing sensibility.
“… @I#t’s all about connectedness and relation- ship and you never know which relationship and which moment of connectedness is going to make a difference, but . . . it ’s the humour that is the glue that helps you put the connection together.”
As this participant identified, palliative care is “all about” relationships. Expertise in symptom management is incomplete without the significance of the human contact and caring that comprises the whole-person philosophy of palliative care.
Humour was significant in establishing, enhanc- ing, and maintaining supportive relationships. It served therapeutic functions, allowing for development of communication that went beyond mere pleasantries to meaningful support in the crises of death and dying. Among the team, humour contributed to a sense of community, helped to energize the team, and was a means of mutual support.
Many staff noted the significance of humour as a way to “break the ice” at the beginning of new relationships, especially with patients and families. Admission to palliative care is usually a distressing event. Patients and families have heard that active treatment is no longer an option yet they are often in varying degrees of acceptance or denial of the seriousness of their situation. Admission to the in- patient unit is usually provoked by a crisis of symp- tom intensification or deterioration in health status. As these fieldnotes describe, stress is almost inevitably high.
The first thing I notice when people are admitted is they’re scared. They have been through hell already, the person that we see is not the person that once was … You get everything from the person who is ready to put their dukes up and fight you, to the one who’s totally resigned and just do whatever you want with me. So I like to start lightening it up there, right off the bat …
At the time of admission, nurses typically respond first to symptom distress, acting quickly to administer appropriate interventions to address the most urgent needs. Once the most immediate de- mands have been addressed, humour is often intro- duced in an attempt to put people at ease.
Moving through the admission process, Sebastian reaches the psychosocial details: “Are you married?” Mrs. D: “How do you think I got 5 kids?” Sebastian, smiling: “There are several ways these days.” Mrs. D: “I was a good girl, I did it the usual way!” They both chuckle. The atmosphere becomes less tense.
This warm interaction altered the situation. The patient relaxed, tension began to fall, the ice had been broken. Once the ice is broken, there is a foundation upon which to build a relationship. When relationships moved to a different level, there was more trust, patients and families felt safer, more likely to be receptive to the environment and what- ever help it might offer. For some, humour was a way “in,” a vehicle that allowed them to establish a connection. For other participants, it was impor- tant that there first be some connection before there was freedom to introduce humour.
If they’re not in tune then you can’t use it, you know, you’ve got to be on the same wavelength.
The human connection was vital for building relationships. Whether as an introduction to the relationship or a factor that strengthened an ear- lier rapport, humour found a place.
Humour as Attraction
Persons who used lighthearted humour seemed to attract others. Staff who used humour were popular and tended to be the ones others were pleased to work with. Patients and families spoke well of them and looked forward to the shifts when they would be working.
It was the same for patients who favored humour. These patients tended to have a greater number and variety of visitors. Staff tended to linger longer in their rooms. Their lightness and laughter drew others like a magnet. One patient provided an out- standing example. Her sunny disposition attracted others in what her son described as a lifelong pattern. Commenting on this, the son noted the warm and personal quality of the attention and care she received in her illness. He described his father as totally lacking in humour and contrasted the more detached and impersonal manner of caregivers in his situation.
The Hidden Message
Humour was a way for some patients to communicate their deeper concerns to staff in an oblique fashion. Others found safety in humour as a means of communicating that they understood that they were going to die. Astute families and staff learned to hear the message that was unspoken and caregiving relationships deepened as a result.
One participant shared a story about admiring an expensive recliner chair with a lift feature that a patient had brought with her upon admission. When she commented on the chair, the lady responded that it had come from Harry’s Furniture Store, famous for “Don’t pay a cent for 2 years’ financing.” With a twinkle in her eye and a mischievous smile, she quipped: “I’ll never have to pay for this chair!” The message could not be missed, she knew she would not live that long, and she was prepared to be lighthearted in the face of the inevitable.
Aside from expressing understanding about the seriousness of a situation, humour was also a way of expressing reconciliation in families in a light- hearted, nonthreatening manner. A visitor told a story about reconciliation with her mother concern- ing events left over from adolescence.
Her mother died on palliative care eight years ago and the daughter remembers it as one of the most precious times in their relationship. Her mother tended to hallucinate while on heavy doses of drugs. One night after a particularly entertain- ing hallucination, she said to her daughter, “If I had known you were having such a great time when you were taking drugs, I would have been more understanding.”
For this mother and daughter, joking about their experiences with drugs was a healing of the past, an opportunity to laugh together about what had been a stressful and difficult time in their life to- gether. The hidden message that all was past and forgiven offered great comfort.
Humour and laughter were often followed by greater animation and a sense of engagement. One nurse spoke of humour as “an exchange of energy” for those who shared in the episode. The idea of an exchange or change in energy was supported in numerous observations throughout the fieldwork. After a warm and satisfying conversation with a staff member, the following notation was logged in the fieldnotes: “We bonded doing this conversation, we laughed a lot, I could feel both of our energies rising.”
It brings you closer to the people you’re working with, it’s that we can share that something and laugh about it, that things just aren’t that bad even for a very short time.
For staff, a supportive framework upon which they could rely for support and nurture was impor- tant. Laughing together created cohesiveness that made the team both tighter as a group and better able to thrive in difficult circumstances. This expe- rience was identified as a sense of community.
I think that’s part of what makes this unit a community, is being able to laugh together … @T#his is a sad place, but it’s also a funny place, and it’s a place where I think we do have community and I think the laughter is really a part of what draws us together.
Neutralizing Hierarchical Differences
The interdisciplinary team is a hallmark of palliative care. The work of one discipline is comple- mented and accentuated by the work of another. Working as a team was both a source of support and a flash point for misunderstandings. Physicians characteristically carried more status and assumed leadership roles among the team. A joke that one of the nurses shared reflected some tension in this regard.
Once upon a time a patient died and went to heaven. He was not certain where he was. Puzzled, he asked the nurse who was standing by his bedside, “Nurse, am I dead?” to which she replied, “Have you asked your doctor?”
Despite the cooperative spirit and mutual re- spect between medicine and the other disciplines, there remained a power differential. Physician par- ticipants voiced concerns about respecting other members of the team and made a concerted effort to use humour as a means of putting other team mem- bers at ease. One physician engaging in exagger- ated role play with the nurses.
I’ll sort of play the game and bring in the formal- ity of thank you nurse, thank you, and they ’ll play up to that role, yes, doctor, so on and so forth.
Nurses responded well to exaggerated role play around nurse0physician relationships. Lighthearted repartee acknowledged and affirmed their respective roles in a way that built team work and diminished the potential for hierarchical tension.
Keep reading in Part 3 ….
Part 1 – Introduction, background & Methods
Part 2 – The reseach, Part 1 – Building Relationships
Part 3 – The reseach, Part 2 – Contending with Circumstances
Part 4 – The reseach, Part 3 – Expressing Sensibility
Part 5 – Discussion