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 5 – Discussion

Discussion

Persons familiar with palliative care will recognize that humour has always been integral to the area. This research establishes that humour and laughter are more than something to be taken for granted; they are important components of compassionate care for the dying.
Humour is not unique to this setting. It is ever- present in health care, as in life itself. However, the centrality of human relationships in palliative care and the importance of the tenor of communication and care create a context in which humour f lourishes.
Ever since the early days of the modern hospice movement, researchers have been fascinated by the idea that persons who chose to work with the dying were in some way different from those who worked elsewhere in health care. “Everyone knows hospice workers are ‘different’ but nobody knows quite how”. There is evidence to suggest that skillful use of humour is one component of what makes those who work there “different.” found that hospice nurses rated personal qualities including discernment, a positive outlook, and humour as more important than technical skills and medical knowledge. A recent eth- nography of hospice nursing echoes the theme.

Descriptors of the essence of hospice nursing emphasized the significance of “attending or being humanly present with”. Accompanying the phenomenon of human presence, nurses introduced humour that was kind, perceived the amusing in everyday life, and was more optimistic than pessimistic.

Families and groups of friends or colleagues typically share a comic culture that defines comic situations, roles, and acceptable contents. The comic culture for this setting was evident in the pervasive sense of good humour, an almost palpable sense of warmth, typified by attitudes of openness and good-natured acceptance. This overarching atmosphere of good humour appears unique. Health care settings are often described as fastpaced and tense. The predominant sense of good humour is related to palliative care philosophy, the significance of quality of life, and the importance of relationships.

Related to the significance of good humour is the importance of the human connection. Humanizing the experience of suffering and loss requires connectedness between caregiver and patient. The significance of humour in establishing and main- taining the human connection is well supported in the literature.

Humour theorist identifies the significance of humour as attraction as key to an- other of humankind’s basic needs, the need for affiliation. Making others laugh creates the sense of being liked. The pleasure of laughter is multiplied when shared. Caregivers will benefit from recognizing that the attraction to persons of good humour will often be in juxtaposition to the genuine needs of persons to whom humour and laughter do not come easily. The challenge is to respect and attend to the needs of all, despite the attraction to partic- ular individuals.

The role of humour as a means of communicating otherwise unspoken messages is well supported by other research. This role is consistent with the idea of humour as a dimension of emotion work. Emotion work refers to a sociological concept that explores emotions as social constructions and considers them strategic for channeling the propriety of expression. Emotions are considered learned behavior and control- lable, with “feeling rules” that determine when and where emotions will be displayed. Humour that covers painful emotions such as sadness, loss, and anger provided a means for emotion management and honoring “feeling rules” that inhibited open expression. Among the staff, humour and joking together pro- vided a means of negotiating the tension around hierarchical differences. There is ample support in the literature to substantiate the role of humour for this purpose. Goldberg notes that the concept of the multidisciplinary team is often idealized. With flexibility of roles and respect for related disciplines as an ideal, acknowledging tensions becomes problematic. Podilchak notes that social inequalities may be temporarily neutralized by the invocation and action of the humour instigator.

The idea that humour provided a moment of reprieve from the reality of illness was illustrated numerous times throughout the data. There was support in the literature for the idea of humour as respite. There was not, however, support for the idea of humour that transformed or transcended circum- stances. This could be related to the heaviness of death and dying. Humour could not alter the reality of terminal illness but it could offer a moment of freedom. The contrast between the heaviness of the situation and the flash of illumination that accom- panied humour was enough to radically change things, sometimes brief ly, sometimes in more profound ways that persisted.
Humour theorists commonly cite relief from ten- sion as one of the most common functions. This was true of this study, as with others who identify tension relief as significant, a means of letting off steam, breaking up tense situations, and releasing liberating laughter. Related to the ideas of tension relief and emotion management was the idea of maintaining perspective. Perspectivetaking is considered a mature defense which allows individuals to cope with difficult circumstances by minimizing negative emotions such as anger and depression.

Possibly the most significant and profound discoveries of this research were the roles that humour played in expressing sensibilities through preser- vation of dignity and acknowledgment of personhood. Within this category was humour that, although potentially trivial or insignificant on the surface, achieved profound meaning for those involved.

“An inability to control basic human functions, especially urination and defecation, seriously threaten a patient’s dignity and violate one of the most basic foundations of adult personhood”. When people are dying, incontinence is an unfortunate and common occurrence. Staff who were able to share gentle humour in such circumstances helped to neutralize the assault on dignity. The focus became not the unpleasant task of dealing with feces or wound drainage but sensitive regard for preservation of the patient’s sense of worth.

A related finding in a study of dying cancer patients reported that humour from patients served a similar function in preserving dignity. By using humour, patients were able to take some distance from the betrayal by their bodies, transforming betrayal into an ob- jective subject that could be taken more lightly.

Incontinence and erosion of the intact body are so unpleasant that they are rarely addressed publicly. The frequency with which such indignities occur in persons who are dying makes such topics difficult to avoid. The regular occurrence of humour that made light of bodily functions was significant. In an exploration of dignity in dying, observes that persons who are terminally ill sometimes perceive that their personhood or worth has been reduced merely to the context of their illness and its encumbrances. He identifies the significance of care tenor, the affective and attitudinal tone of care that conveys respect and affirmation of the patient’s continued worth. This study suggests that humour is an important component of care tenor. The role of humour in acknowledging personhood was an especially significant finding. It reflects one of the ideals of palliative care and establishes humour as an important and noble component of compassionate care for the dying.

Significance

Humour has often been taken for granted, so prevalent that there has been no sense of urgency for research. With the maturing of palliative care as an area with a distinct body of expertise and knowledge, the time has come for acknowledging the significance of humour. The value of humour resides not in its capacity to alter physical reality, but in its capacity for affective or psychological change that enhances the humanity of the experience. This study establishes its importance, not merely as a taken forgranted appendage, but as an identifiable component of compassionate, person-centered care for the dying.
In health care in general and in nursing in particular there has been ongoing debate about core values and concepts that underpin practice. One suggestion is that respect for human dignity is a moral imperative that guides nursing from both theoretical and practice perspectives. In making the case for respect for human dignity, Jacobs cites the Social Policy Statement of the American Nurses Association, which identifies four essential features of nursing practice: a caring relationship, use of scientific knowledge, consideration of both subjective and objective data, and recognition that persons have a wide range of experiences and responses that should not be restricted to a problem-focused approach. Humour cannot address all four of these essentials. However, as this research has demonstrated, humour may be a significant component in the health care relationship. Humour has value as a means of acknowledging recognition of the wide range of experiences and responses that individuals bring with them to the health care setting. Humour has theo- retical significance because of its relationship to respect for human dignity.

Caring is commonly debated as a core philosophical concept that underpins health care. Proponents suggest that caring is ubiquitous as an ideal in health care and is central both to nursing and to all professions. Opponents of caring as a core concept suggest that caring is too limited and perspectival, nonsubstantive, nongeneralizable, antiintellectual, and sentimental. Overplaying the theoretical significance of humour could lead to the same charges. Humour is not a core concept for nursing, palliative care, or for health care at the theoretical level. It is, however, important. Combined with scientific skill and compas- sion, humour offers a humanizing dimension too valuable to be overlooked. In palliative care where the human dimension of caring is especially significant, it is essential.

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