Humor Plays An Important Role In Healthcare Even When Patients Are Terminally Ill

Humour can play an essential role in the most serious healthcare settings, even when patients are receiving intensive or end of life care, according to research in the April issue of the UK-based Journal of Clinical Nursing.

Canadian researchers spent nearly 300 hours observing and carrying out interviews with staff, patients and families in an intensive care unit and a palliative care unit for people with terminal illnesses.

They concluded that humour played an essential role in promoting team relationships and adding a human dimension to the care and support that staff provided to seriously ill patients and their families.

The researchers found that staff used humour in a number of ways, including:

• To cope with, and sometimes distance themselves, from difficult situations. As one interviewee commented: "When you've had the most stressful day and you're ready to cry, sometimes it's easier to bring out humour and take it in the other direction instead of bawling on somebody's shoulder.
• To connect with other healthcare professionals and provide mutual support. Shared laughter energised and nurtured a sense of community. "If you have those fun moments and that connectedness even the worst hell can happen" said one healthcare professional who worked with terminally ill patients. "You sail through it as opposed to walking out really wounded"
• To reduce tension when things don't go as well as they could do. A doctor who admitted he had been hasty suggesting that a terminally ill man give up his apartment so soon was greeted with the quip: "Shall I chart that you made a confession or that you made a mistake"
• To express frustration at life-prolonging measures that staff disagreed with. Staff in the intensive care unit told researchers how they paralleled what was happening to one patient by using an inflatable dinosaur called Dino and putting him through the same interventions. He became a symbol of their dissatisfaction with the situation.
• To connect with patients and make them feel cared for as individuals. When a health care aide took a joke picture of a patient with a bubble bath helmet on his head to put him at ease it became one of his prized possessions. He showed it to everyone who visited as evidence of the special treatment he was receiving. And when he died, it was displayed alongside important family photos.
• To reduce patients' embarrassment with the indignity of needing help with toileting and other highly personal functions. When a patient suffered an episode of incontinence she reported that she found the nurse's matter of fact humour - "what goes in must come out" - made her feel less distressed.

However, the researchers also found that humour could also create distance and prevent serious discussion. As one nurse commented: "If I'm joking with you, I'm interacting with you. We're talking but I don't ask you what's bugging you...I'm not really finding out why you're upset."

It wasn't just the healthcare staff who used humour to alleviate difficult situations.

One nurse recalled admiring an expensive recliner chair a patient had brought in with her to the palliative care unit. The patient was delighted that she didn't have to pay a cent for two years and quipped that in that case she would never have to pay for it!

Another recalled how a patient's monitor kept going off in the intensive care unit. "Don't worry, if I can hear it I'm still alive" the patient joked.

Then there was the satisfaction that staff felt when they saw a patient smile. "It makes you feel you've done something, if not medically, maybe emotionally" said one nurse.

"Some people feel that humour is trivial and unprofessional in healthcare settings, but this study shows that it is neither" says co-author Dr Ruth Dean, a nurse researcher from the University of Manitoba.

Dr Dean carried out the study in the palliative care unit, spending 200 hours observing and informally interacting with care providers, patients and family members and carrying out semi-structured interviews with 15 healthcare staff, including nurses, doctors, a social worker and physiotherapist.

Her colleague Joanne Major from the Health Sciences Centre in Winnipeg spent 72 hours in an intensive care unit, observing and carrying out semi-structured interviews with 15 nurses.

"Despite major differences between the work of the intensive care and palliative care units, they are both areas where serious illness, high anxiety and patient and family distress are prevalent and staff are placed in emotionally demanding situations" says Dr Dean. "Crises are frequent, death is close by and emotions tend to run high."

The authors conclude that humour was very important in these stressful healthcare settings.

"One member of staff referred to humour as the glue that holds human connections together, a statement that was clearly reinforced by our findings" says Dr Dean.

'Our research suggests that nurses and other healthcare professional don't need to suppress humour. They should trust their instincts about when it is appropriate. Combined with scientific skill and compassion, humour offers a humanising dimension in healthcare that is too valuable to be overlooked."

Journal reference: From critical care to comfort care: the sustaining value of humour. Dean R A K and Major J E. Journal of Clinical Nursing. 17, 1088-1095. (April 2008)