Humour and Difficult Conversations in Healthcare – Dr Anthony Herbert

Humour difficult conversations

There are many difficult conversations in healthcare.  These include giving a diagnosis of a life-threatening condition (such as cancer or a neurodegenerative condition), acknowledgement that a condition is progressing despite treatment, and the transition to palliative care, amongst others.  

I remember a conversation with a family when I was a paediatric medical fellow (specialising in palliative care) in Sydney in 2007. In the context of a difficult conversation about prognosis and lack of response to treatment, towards the end of the meeting with the family we struck upon a section of the conversation that was quite humorous.  This was the first time that I had observed humour juxtaposed beside the delivery of sad and difficult news. This article will review this topic further by exploring historical acknowledgement of this phenomenon and neurobiological considerations. I will conclude by looking at the presence of humour in my own area of specialty – paediatric palliative care.

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Definition

The Association for Applied and Therapeutic Humour has defined humour as, “Any intervention that promotes health and wellness by stimulating a playful discovery, expression or appreciation of the absurdity, or incongruity of life’s situations.” (1).  Victor Borge, the American and Danish comedian and musician, noted that laughter might be “the shortest distance between two people.” (2) However, care has to be maintained in the use of humour within the clinical context, as the poor use of humour may generate stigma or humiliation (1,3).

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Historical Context

In describing the brain, Hippocrates noted, “From it only arise our pleasures, joys, laughter and jests as well as sorrows, pains, griefs and tears.  Through it in particular we think, see, hear and distinguish the ugly from the beautiful, the bad from the good, the pleasant from the unpleasant.” (4)

It has also been observed that humour was a relief from both the fear and boredom experienced by soldiers at the frontline during World War I.  This form of humour is felt to be a coping mechanism and has been described as ‘gallows humour’. (5)  Such humour was often found in letters to loved ones and family back home.

Victor Frankl, psychiatrist and survivor of the concentration camps during Nazi Germany, described a sense of humour as a coping strategy that could be learned while living in the face of omnipresent suffering.  “It is well known that humour, more than anything else in the human makeup, can afford an aloofness and an ability to rise above any situation, even if only for a few seconds.” (6)  He observed that despite the all- consuming nature of suffering, it is also possible for “trifling things” to  cause the greatest of joys. He gives an example that occurred on a train trip from Auschwitz to the camp affiliated with Dachau:

We had all been afraid that our transport was heading for the Mauthausen camp. We became more and more tense as we approached a certain bridge over the Danube which the train would have to cross to reach Mauthausen, according to the statement of experienced traveling companions. Those who have never seen anything similar cannot possibly imagine the dance of joy performed in the carriage by the prisoners when they saw that our transport was not crossing the bridge and was instead heading ‘only’ for Dachau”. (6)

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Theological Context

The Bible deals with the question of human suffering from cover to cover.  Hope is often juxtaposed with suffering:

Not only so, but we also glory in our sufferings, because we know that suffering produces perseverance; perseverance, character; and character, hope.  And hope does not put us to shame, because God’s love has been poured out into our hearts through the Holy Spirit, who has been given to us.” Romans 5:3-5.  

The topic of suffering and how God, other people and individuals respond is dealt with in detail in the book of Job.  Even in a book which examines such a heavy topic as suffering there is the presence of humour. In Job 38, God speaks to Job from a “whirlwind” after being silent for some time. Job has been overwhelmed by the mystery and paradox of suffering and his own situation.  His friends have not helped.

God then uses humour in Job 39:13 (NRSV)7.   

The ostrich’s wings flap wildly…

God speaks of the proudly-waving wings of the ostrich – who cannot fly!  Only God, and not Job or other humans, can explain why such a bird has wings – or is even referred to as a bird!

“It is what it is, a silly bird, because God made it so. Why? The comical account suggests that amid the profusion of creatures some were made to be useful to humans, but some are there just for God’s entertainment and ours.” F Anderson 8.

“This passage is remarkable in that it continues the first and only real humour in the book of Job. Leave it to God to pull a stunt like this, forcing a smile out of Job at a time when the poor fellow has been so intent on his misery.” M Mason 9.

Job 39:17 (NRSV) states,

…because God has made it forget wisdom, and given it no share in understanding.

Here God reminds Job that God is the is the dispenser of wisdom.  It was through the humorous example of the ostrich that God both taught and entertained Job.

“Get used to my absurdity, and live by faith rather than by sight. Be like the ostrich: though you cannot fly, you can still flap your wings joyfully!” M Mason 9.

Humour difficult conversations2.JPG

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Societal Context

Although many of the things that happen to us, or that we do, are not inherently humorous, humour can generally be found in most situations (10). We see the words pleasure and pain used concurrently in modern music: “It’s a fine line between pleasure and pain” (11).  Comedians are able to make us laugh about difficult situations such as divorce, unemployment, phobias and even death (10).  At funerals, in the midst of grief and sadness at the loss of a loved one’s life, we often see humorous anecdotes shared about the person’s life.

The role of humour in healthcare is demonstrated in the life of Patch Adams (and in the movie of the same name).  There has been a subsequent emergence of “clown doctors” within the health system (12).  A recent study of the interaction between children, parents, medical clowns and healthcare professionals found the following benefits: happiness, distraction, carefree feeling and a positive activation (13).

“Well-placed humour is somehow capable of taking the sting out of a pain, of making new or frightening topics more acceptable, and of taking the gravity out of a situation so that it no longer excessively weighs one down.  [Milton] Erickson understands the usefulness of humour in coping with setbacks and unpleasant surprises, and he not only uses his own infectious sense of humour effectively but he is able by example and experiences to instil in his clients a similarly lighthearted perspective on the comings and goings of human beings.” (10)

We often speak about our choice to either laugh or cry when a difficulty arises.

“The only way to get through life is to laugh your way through it.  You either have to laugh or cry. I prefer to laugh. Crying gives me a headache.” (14) Marjorie Pay Hinckley  

This quote offers truth in that laughter can be therapeutic, and sometimes we find there is a fine line between laughter and crying.  However, we need to both laugh and cry.  We should not diminish the importance of crying in terms of the expression of emotions.  Clinicians also need to be able to support patients appropriately when they cry in a supportive and non-judgemental way.  For example, they may allow silence or say something such as, “Take your time”. How to respond to a patient who cries is out of the scope of this paper but approaches have been developed around this clinical situation in the literature (15).

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Neurobiology

A study of twenty bereaved patients analysed their functional MRI during a task which contrasted ‘deceased-related words’ with ‘control’ words.   Activity in the amygdala predicted ‘induced sadness’ intensity. An association between grief style and prefrontal and amygdala region activity was found.  Activity in and functional connectivity between the amygdala and prefrontal regulatory regions was associated with different styles of grief and the mourners’ regulation of attention and sadness during pangs of grief.

Functional imaging of the normal brain has implicated cortical and subcortical networks in processing different aspects of humour perception (eg. in response to sight gags or comic strips) and comprehension with separable cognitive, affective and social dimensions (2).  There is a distinction between the recognition of humour and the provocation of amusement.  The onset of laughter has been taken to signal the dawning of amusement, associated with insula and amygdala activation (2).  

The amygdala therefore seems a common region of the brain that is involved in both intense grief and emotional reaction.  Another similarity between laughing and crying is the potential spontaneous onset at unpredicted times, as noted by scientist and philosopher Thomas Hobbes (1588-1679),  “But in all cases, both laughter and weeping are sudden motions, custom taking them both away. For no man laughs at old jests or weeps for an old calamity.” 16  In this context, there is differentiation between spontaneous and planned humour (1).

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Paediatric Palliative Care

Some of these observations and principles appear to occur in clinical contexts, such as palliative care.  A research study which involved video-recording paediatric palliative care consultations (using a methodology called “conversation analysis”) captured this juxtaposition of humour while discussing serious topics (17).  An example is given of a conversation between a nurse and the mother of a child with a life-limiting condition.  The topic related to when and how a deterioration in the child’s clinical condition might look in the future (17).  This was closely related to the mother’s concerns and questions relating to how the dying process may look.  The nurse responds in a way that displays the delicacy of her response. She delays her response by 2 seconds.  She also punctuated her response with laughter. Delays and laughter are both recognized practices that can be used for delicately discussing utterances. What is also atypical in this conversation, is that it is the health professionals who initiate humour.  Usually it is the parents who initiate humour and the health professionals who would respond. It can carry some risk for a health professional to initiate humour during a difficult conversation. Initiation of humour by the health care team may become more feasible when the clinicians are well-known to the family (e.g. this conversation occurred during a home visit, and the team had known the family for over two years).

Conversation 1 (17)

Nurse: So how’s he looking?

Mum: I know he’s looking peaceful, but in relation

Nurse: Actually he looks good

Mum:  compared to July, and the future?

Nurse: Look I’m, as far as I’m concerned, William does everything his own way.  It’s like …

Doctor and nurse: (gentle laughter)

Nurse: William’s way.  And one minute you think he’s

Aunt: I know it’s

Doctor: mm

Grandmother: That’s it, William’s Way

Nurse: You’d be

Mum: He even smiled this morning. Cos

Aunt: Yeah

Nurse: William’s Way

Aunt: It’s Williams way

Nurse: William won’t be here tomorrow or in a few hours, but there he is.  You know, it’s really hard, isn’t it.

Aunt: mmm

Mum: Especially when he was laughing yesterday.

On another occasion, during the same consultation, the patient’s mother explicitly discusses the fact that her son is dying (17).  However, the focus of the conversation relates to the topic of airway suction, challenges related to this and this is approached in a way using humour.  This is done during the course of what is described as a “laughable telling” (18).  This is evidenced by his mother smiling and laughing at times.  Those present at the family meeting reciprocate this humour.

Conversation 2

Mum: He even smiled this morning cos we couldn’t get into his mouth

((3 seconds omitted))

Mum: To do the: the suction – you hear it in that. So I hold his  

(mum touches top of sternum)

hose for a little bit

Aunt:  Heh heh heh (laughter)

((4 seconds omitted))

Mum: But you see he still won’t mouth breathe but when I let go

Doctor: mmm

Mum: He sort of releases his clenching and I duck in

Aunt and doctor: mmm

Grandmother: heh heh

Mum: Ah I’m like y’know only a mother can do this:

((clicks finger))

to a dying child

Aunt: heh heh heh (laughter)

Doctor: Yeah

Mum: And he even actually grinned at that and it’s like

Doctor: Yeah

Nurse: (laughs)

Aunt: So funny

Doctor: So his teeth are still very clean…

A randomised controlled study of 38 pregnant mothers carrying a baby with a diagnosis of single ventricle heart disease, found that mothers who were referred to palliative care antenatally had less anxiety throughout their treatment course (19).  In this study, they also looked at the Brief Cope Inventory tool (20). This tool includes humour as one positive coping strategy of parents and patients within healthcare.  Other positive coping strategies included positive reframing, planning, acceptance and religion. Examples of problematic coping strategies included self-distraction, denial, substance use, behaviour disengagement, venting and self-blame.  There was a suggestion that the use of humour increased as a coping strategy as a result of the palliative care intervention, although the study was too small to determine this was statistically or clinically significant (19).

This research underpins a broader recognition of the role that humour paradoxically plays in palliative care.  As an example, two systematic reviews and one correlational study were published on this topic in 2018 (1,21).  Two types of humour have been identified within palliative care (1).  Spontaneous humour that emerges with no planning  in a conversation between the patient and relatives and health-care professionals.  There is also “planned” humour which relies on resources to support, generate, and use humour.  Table 1 provides a summary of some of the principles and approaches to the use of humour in healthcare.  

Checklist humour diff conversations.JPG

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Graphic Medicine

The term ‘graphic medicine’ denotes the role that comics can play in the study and delivery of healthcare (2).  Two trends have resulted in this development.  The medical humanities movement places emphasis on classic and other literature (eg. novels) to gain insight in the human condition.  There has also been the rise in popularity of the graphic novel. Graphic novels are full length “serious” comic books, aimed at adults and written and illustrated by one person.  Some deal with experiences of patients or caregivers. Some health professionals also create their own cartoons which shed humour on different aspects of healthcare. These cartoons can play a valuable role in reflecting on changes in medicine and enabling conversations around difficult subjects.  For example, ComicNurse (@ComicNurse) reflects on the complexities of illness, caregiving and challenging topics such as advanced care planning (24).  Dr Nathan Gray, palliative care physician, has created cartoons relevant to medicine and humanity (25).  His cartoon relating to an “empathy robot” (fig.1) makes me think about the role of compassion and technology in healthcare and communication.  “Preparing a colleague for a family meeting” (fig. 2) reminds me of the importance of non-verbal communication and the importance of listening and observing others in the process of becoming better communicators.  

Fig. 1

aherbert1Fig. 2aherbert2

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Conclusion

It is somewhat paradoxical that in healthcare we can see humour and suffering co-existing.  There are historical, theological and societal considerations to this connection. Research and theoretical principles from palliative care also support this connection.  It is possible to respond to humour (and sometimes initiate humour) in a way which enhances the therapeutic relationship between the clinician and patient/ family. The use of humour can be one clinical tool which, when used appropriately, considerately and with sensitivity, can assist in managing complex situations.  This phenomenon adds depth and texture to clinical medicine (and life in general). It is something that we as healthcare professionals can take with us through the different seasons, phases and cycles of clinical practice and life. We are “wounded healers” who sometimes have the privilege of laughing with our patients, colleagues and quietly, to ourselves.

Notes:
The Australian/English spelling for humour has been used in this paper. (Humor used in the United States.)

Dr Nathan Gray has given permission for the use of his cartoons.

Dr Anthony HerbertDr Anthony Herbert
Anthony has been director of Paediatric Palliative Care at the Queensland Children’s Hospital, Brisbane, since 2015. He has been the national secretary of CMDFA and is the current chair of the CMDFA Queenland branch.

Back to issue: Laughter

References:

  1. Pinna, M. A. C.; Mahtani-Chugani, V.; Sanchez Correas, M. A.; Sanz Rubiales, A., The Use of Humor in Palliative Care: A Systematic Literature Review. Am J Hosp Palliat Care 2018, 35 (10), 1342-1354.   10.1177/1049909118764414
  2. Neergaard Clark, C.; Warren, J., Advances in Clinical Neuroscience and Rehabilitation 2014, 13 (7), 9-11.   
  3. Chapple, A.; Ziebland, S., The role of humor for men with testicular cancer. Qual Health Res 2004, 14 (8), 1123-39.   10.1177/1049732304267455
  4. Ray, M., The Hippocratic Tradition. Post-Graduate Medical Journal 1934,  (March), 116-122.   
  5. Grayson, R., Gallows humour from the trenches of World War 1. The Conversation 2013.   
  6. Frankl, V., Man’s Search for Meaning. Beacon Press: Boston, 1959.
  7. Guzik, D. Enduring Word https://enduringword.com/bible-commentary/job-39/ (accessed January 31, 2019).
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  20. Carver, C. S., You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med 1997, 4 (1), 92-100.   10.1207/s15327558ijbm0401_6
  21. (a) Linge-Dahl, L. M.; Heintz, S.; Ruch, W.; Radbruch, L., Humor Assessment and Interventions in Palliative Care: A Systematic Review. Front Psychol 2018, 9, 890.   10.3389/fpsyg.2018.00890; (b) Robalo Nunes, I.; Jose, H.; Capelas, M. L., Grieving With Humor: A Correlational Study on Sense of Humor and Professional Grief in Palliative Care Nurses. Holist Nurs Pract 2018, 32 (2), 98-106.   
  22. Borod, M., SMILES–toward a better laughter life: a model for introducing humor in the palliative care setting. J Cancer Educ 2006, 21 (1), 30-4.   10.1207/s15430154jce2101_11
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  25. Gray, N. The Ink Vessel. https://inkvessel.com/ (accessed January 30, 2019).

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