It was nearing 3 am on a long night shift, and I was dutifully reviewing a patient when a nurse called out from the room next door asking for anyone to help. Being a keen junior doctor, I rushed through the door to answer her call. An emaciated patient lay on the floor, clutching his chest and gasping. As we helped him onto the bed, we were informed that he was palliative and had clear documentation of his wishes for no life-prolonging interventions. After managing his pain and apnoea, a nurse held his hand while we waited out his Cheyne-Stokes breathing until finally, the breathing stopped.
Nodding at me, a nurse indicated that I should check for signs of life.
I gingerly placed my stethoscope on his chest, carefully listening for the thump of a heartbeat.
Without warning, the patient’s eyes shot open, his jaw extended wide in one last gasp before slumping back into the bed.
The nurses around me burst into laughter. When it eventually died down, I was asked to maybe wait fifteen more minutes before returning, just to make sure the patient was actually dead. I earned myself friendly jabs every time I entered that ward for the rest of the shift.
Through the giggles, something gnawed at my stomach. As a straight-laced junior doctor, an aspiring professional, and a strictly moral being, how could I find humour in a man’s dying moments?
And yet, I laughed.
The Cambridge dictionary defines black humour as “a humorous way of looking at or treating something that is serious or sad”.(1)
Your average person walking by the hospital has not sat through a person’s dying breaths, nor have they counted intently, arms beginning to ache, while pounding on someone’s chest. For them, joking about death or dying would indeed be unconscionable. Yet for those of us who have seen the extremes of life, the lines can seem more blurred.
Multiple professions at the coalface of human suffering, such as nurses, paramedics, firefighters and the armed forces, report the use of black humour in their work. The benefits include being able to blow off steam, detach oneself from difficult emotional experiences, and develop social cohesion.(2) These can all be used to reduce emotional fatigue, frustration and dissatisfaction with work.
Despite my misgivings, some of my favourite moments in medicine have involved sharing a joke with a colleague about some absurd or horrific situation. After yet another nightmare shift, I would be able to look back at the mess of the day and pluck, like a flower amongst weeds, a few single moments of laughter, growth and shared experience.
I recall another night shift, for example, where we were unsuccessfully attempting to re-orientate a delirious, elderly woman. Swiping towards us with a clawed hand, she burst free of the nurses’ grip and hobbled, fully naked and with surprising speed, down the corridor. Following closely behind her, a nurse dryly noted the patient’s thoughtfulness at leaving a breadcrumb-like trail of faeces leading to another ward, right up to the supply closet she had chosen to barricade herself within. Incidentally, this marked the second time I had stepped upon human faeces that rotation.
The purest and most cynical forms of black humour come from the mouths of our patients themselves.
Through cancer, chronic disease and infinite frustrations, patients manage to find release and solidarity in this humour. Multiple online forums exist where black humour flows freely. One user posted, ‘‘I find it very distressing you mentioning the importance of the arsehole, when I actually don’t have one anymore. Mine went in the bucket with the rest of my rectum!”
Life-changing diagnoses and surgical complications become normalised, their sharp edges ground away by absurdism and a stubborn grin in the face of tragedy. Stories about brain fog, missing leg hairs and stoma bags abound. Another user grumbled about ‘‘[getting up] at 4am ‘cos [the stoma bag] was full of wind and I nearly floated off.’’(5)
In a 2017 article, Karen Duffy, a cancer patient, recalled finding joy in the absurdity of illness with a fellow cancer patient and friend – “We started a competition to see who’d be first to successfully bribe an orderly to wheel [them] to the VIP catacombs”.(6)
Like us, patients need emotional release, detachment from distressing circumstances, and the opportunity to generate solidarity with others. Just occasionally, if we’re lucky, our patients will share some of these moments with us. I recall meeting a delightful elderly woman with recurrent urinary obstruction. After placing a catheter for her, she exclaimed, “Thank God! My bladder was so large I thought it was going to knock my dentures out!”
Unfortunately, when walking the tightrope between productive humour and outright cruelty, mishaps are inevitable.
Many professionals, including myself in my less introspective moments, will swear the use of black humour is specific only to the situation at hand, and not mocking of any particular patient or person. Sadly, this is only occasionally true.(3)
Take the example of the 2015 court case where a patient recorded a routine colonoscopy in order to better remember their post-operative instructions. Instead, the patient listened back to the gastroenterologist releasing a barrage of insults toward them, which included calling them a “retard” and expressing a desire to punch them.(4)
As a medical student, I watched an anaesthetist wait only a mere three seconds after sedating a bariatric patient before delightedly ridiculing her size and ethnicity. He joked that she “got that way from eating too many dumplings”, was “disgusting”, and suggested she undergo a gastric sleeve in addition to the cholecystectomy she was consented for. I realised then, that I would have to choose my surgeons carefully should the need arise, lest I got a surgeon who would mock my naked body. I wondered what had been said about my mother years ago while she underwent a cholecystectomy. Had she been given the dignity she deserved?
While the anaesthetist’s jokes may have acted as a release of emotion, it also succeeded in dehumanising the patient and fracturing a medical student’s trust in the sanctity of the doctor-patient relationship.
As an intern, I was involved in the care of a particularly difficult patient with significant infection following surgery. Every ward round, he would argue with the surgeons about their diagnosis and treatment plan. He insisted on his own poorly-researched diagnosis, would ignore dietary advice, ask us to change antibiotics, then refuse to take the new antibiotics he was prescribed. He routinely went off the ward and his infection, true to form, developed into full blown sepsis. The few medications we managed to get into him did keep him alive, but only just.
As the week drew to a close, my conscientious registrar went over the treatment plan for each patient under our care. When it came to our most difficult patient she paused, pen hovering over the handover sheet, and said with a deadpan expression, “I don’t care what you do with him. If he wants to die, let him die.”
I laughed, as did the rest of those in the room, shocked at her bluntness. The joke released the tension, but it had a more sinister undertone.
In joking that the patient was “trying to die”, we released ourselves from having to deal with the truth.
Here was a man who had significant difficulty with the loss of control inherent to being a patient. He also harbored a resentment of doctors as he felt we were judging him from a more privileged position. We never truly addressed these fears, only putting up with him until such time as he left the hospital.
Ultimately, black humour is a tool, and as such it should be wielded carefully. It can be used to reduce tensions and bring people together, but it can also be used unscrupulously, even cruelly, acting as a barrier to compassion and empathy. As medical professionals, we must take care when using this tool in our working lives, and encourage its positive and responsible use in our peers.
BIO: Anna Szubert is a junior doctor working on the sun-kissed beaches of northern New South Wales. She has been a member of CMDFA since her time at ANU medical school, and graduated in 2016.
- BLACK HUMOUR | meaning in the Cambridge English Dictionary [Internet]. Dictionary.cambridge.org. 2019 [cited 10 March 2019]. Available from: https://dictionary.cambridge.org/dictionary/english/black-humour
- Cain C. Integrating Dark Humor and Compassion. Journal of Contemporary Ethnography. 2012;41(6):668-694.
- Tomlinson T. Humor in Medicine: Nasty, Dark, and Shades of Grey [Internet]. MSU Bioethics. 2015 [cited 10 March 2019]. Available from: https://msubioethics.com/2015/09/29/humor-in-medicine/
- Jackman T. Anesthesiologist trashes sedated patient – and it ends up costing her [Internet]. The Washington Post. 2015 [cited 10 March 2019]. Available from: https://www.washingtonpost.com/local/anesthesiologist-trashes-sedated-patient-jury-orders-her-to-pay-500000/2015/06/23/cae05c00-18f3-11e5-ab92-c75ae6ab94b5_story.html?noredirect=on&noredirect=on&utm_term=.6202e966ee99
- Demjén Z. Laughing at cancer: Humour, empowerment, solidarity and coping online. Journal of Pragmatics. 2016;101:18-30.
- Duffy K. How to Battle Chronic Illness With Humor [Internet]. Lenny Letter. 2017 [cited 10 March 2019]. Available from: https://www.lennyletter.com/story/battling-chronic-illness-with-humor-karen-duffy
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