I meet Ms. A, a frail 80 year old woman, at her first palliative care appointment (read Post 1: What Exactly Does a Palliative Care Specialist Do?). When I ask her what she has been told about "palliative care," she exclaims, "I know my primary care physician wants me to talk to you, but I'm still here! I talk to God daily. I tell him, 'Thank you for giving me another day. Now leave me alone.'"
We envision the sick patient as serious and the atmosphere around them as somber, and often it is. Some people may consider humor as inappropriately making light of a difficult situation. They may feel awkward interacting with a friend with whom they used to joke around and now wonder how they should act. Sometimes, it is only after this person with the life altering diagnosis, shortened prognosis, or life impacting illness makes the first joke, reminding their friends, acquaintances, and healthcare professionals that they are still a person with personality and humor, that others relax a bit and respond in kind.
As a palliative care physician, I have many times been momentarily stunned, and then appreciated, the humor that unexpectedly comes out of the mouths of patients (and their closest family members). Sometimes the humor is dark, sometimes morbid, sometimes ironic, sometimes sad, and almost always causing someone in the room to chuckle. Their humor reminds me that they are not just patients identified by a list of medical conditions and symptoms, but rather fellow human beings, each with their unique personalities, characters, hobbies, and relationships. The following examples are their legacies to me (read Post 11: An Unintentional Legacy), illustrating how humor can be helpful even in illness. Humor can
1. Diffuse tension
An 86 year old woman is transferred from a local hospital to the hospital I am working in for evaluation for potential surgery for severe bedsores on her backside. She has advanced dementia, hospitalized for the second time in four months. Our palliative care nurse practitioner tells the family, "I'm worried that she will continue this trend and require hospitalization again in the future." She asks the family, "What do you think gives her quality of life now? What do you think she would say about her current health and day to day life? At what point do you think your mom (the palliative care nurse practitioner nods to the adult children), your grandmother (nods to the adult grandchildren) would say, 'I've had enough. Let's focus on comfort at home.'?"
These questions are followed by tense silence, suddenly broken when a grandson half-jokingly responds, “We want to go back to the other hospital. They never talked about this stuff.”
2. Lighten a heavy atmosphere
During a joint palliative care and oncology patient meeting in the hospital, a woman in her 60s listens as the oncologist confirms her new cancer diagnosis and reviews treatment options with a plan to start one of the treatments in the hospital. She is subdued, and her husband wearing a Boy Scouts of America pin on his shirt keeps his eyes on the floor. In this heavy moment, the woman speaks up, "The Scout motto is 'Be Prepared.'" She gives a small smile and points her thumb towards her husband, who finally looks up with a short chuckle when she exclaims, "Well, he wasn't prepared for this!"
3. Help a person obtain some sense of control in a bleak or anxiety-provoking situation
A woman in her early 70s with end stage kidney failure and dependent on three times a week dialysis sees me in clinic. She has had to significantly limit her driving this year due to worsening fatigue, and this has caused many moments of frustration and grief. "I'm not this person who stays in all the time." When I ask her what gives her strength during these moments when she feels down, she says, "I still drive to church." She grins and adds, "I made a deal with God. He knows I don't want to fall. If I can't find a parking space close enough to the church where I feel safe enough to walk, then I'll drive back home. God knows I was there, so it counts!"
4. Help a person cope with difficult news [using humor to deflect is sometimes a form of denial, which is a valid coping mechanism (read Post 13: Sometimes It's Denial, and Sometimes It's Just Really Bad Timing)]
"What are you hoping for?" our palliative care fellow (a fellow is a trained physician receiving additional training in a subspecialty) asks the elderly gentleman with newly diagnosed pancreatic cancer. "I'm hoping for recovery!" the man quickly replies, "whether it be by drug, God, Jesus, or Buddha!"
5. Distract from strong negative emotions
The 65 year old woman sits up in her hospital bed, chatting with me during her palliative care consultation. She had gone to the hospital for a planned knee replacement, and through a series of events had undergone a chest x-ray, which had revealed a lung mass worrisome for cancer. The palliative care team had been asked to follow along to manage her symptoms, which included anxiety. I ask her, "What hobbies do you have? What do you enjoy doing?"
"I do hair," she replies, "I used to do hair a lot."
"What else do you like to do?"
"Him," she grins mischievously towards her husband sitting next to her bed.
"Well," he bursts out laughing, "it's true."
6. Relieve stress, anxiety, or worries
A 78 year old woman with stage 4 stomach cancer tearfully tells me, "I'm really okay. I'm okay. Sometimes I worry too much about how my children will be when I'm gone, and I do get tearful. But it's not every day. And it helps to focus on what's most important." I ask her, "And what is that? What are your most important goals at this time?" She holds up her phone and jokes through her tears, "I want to get to level 2000 in Candy Crush."
7. Enable a person to make a connection with another human being (such as by commenting on the absurdities of a situation that many of us would agree are surreal or by referencing experiences that many of us recognize in our own lives)
"Happy wife, happy life," says the 70 year old gentleman with advanced pancreatic cancer, admitted to the hospital for severe dehydration related to his current cancer therapy. He had survived over a year already of attempting various cancer therapies and clinical trial medications, and either his cancer would not respond to the cancer therapy or his body would not tolerate the cancer therapy's side effects. He is now rehydrated and close to being discharged home. "Honestly, I'm ready to stay home where I can play with my grandchildren until it's my time. I'm not scared of dying, but my wife wants me to keep trying, and I don't want to piss her off. Secret to a long lasting, happy marriage," he winks.
8. Decrease embarrassment and preserve some sense of dignity when a person is at their most vulnerable physical state
The frail, elderly man with Parkinson's disease looks at his hands and jokes in a soft voice, "I know sometimes my tremors are really noticeable. When I see someone staring at my hands, I tell them, 'I play the maracas!'"
9. Aid in communicating difficult-to-articulate messages
The man tells my palliative care team that he wants to talk to his father, the patient, to see if his father understands the significance of his end stage heart failure and prognosis. He sits down next to his father's hospital bed and awkwardly starts with, "Dad, I'm worried about you." His father chuckles and pats his son's hand, "Too bad for you," his father replies, "I'M not worried, as long as I don't outlive my pallbearers. It took me a week to come up with that list."
10. To maintain perspective
We are nearing the end of a two-hour, emotionally wrenching family meeting for a 76-year-old woman with end stage lung disease. Her lungs could only function properly while receiving continuous intravenous (IV) medications administered in the pulmonary intensive care unit (ICU). Her children have been told that severe breathlessness symptoms would recur each time these life support medications are turned off. They know that if their mother wanted to be free from life support medications, she would need to be given morphine beforehand to make sure she did not suffer uncomfortable shortness of breath symptoms. The four adult children are starting to accept that their mother desperately wants to leave the hospital to die at home, not in the ICU, with her collie cocker spaniel mix lying at her side.
"Mom," a daughter asks, "How do you envision life at home, after the drips are turned off by the hospice team?"
"Short. Now get me home."
I hope these serve as reminders to all of us that we can still have moments of levity and connection during terrible, difficult times. If humor is part of how we express ourselves, we can continue to do so to express to the world our thoughts, our feelings, and our personhood.