I was interviewed for a research position coordinating a randomised controlled trial (RCT) in the oncology department of a leading metropolitan hospital. During the job interview the Chief Investigators, one of whom headed up the department, wanted to know how I would manage my emotional reactions when working with patients who were very unwell. I replied that I didn’t know the answer to this question, but like so many Australian women, I’d had an early breast cancer1diagnosis myself, and so some insight into, and empathy for, people facing cancer treatment. I gave careful thought as to whether and in what circumstances I would divulge my own experience to trial participants. On balance I decided that it would be unprofessional to do so, whilst not categorically ruling out the possibility in particular circumstances. This behavioural research was focussed on patients’ issues, not mine. The oncology nurses I observed were nurturing, at times fiercely protective, and remarkably patient with the labile emotions of patients. My decision seemed consonant with their approach: a practical expression of that ubiquitous and over-used phrase “patient-centred care.”

I had pre-conceived notions of what would engage the minds of people confronting palliation and death. Patients would be pre-occupied with resolving outstanding issues in their intimate relationships, putting their “spiritual houses” in order and settling their financial affairs. The general tenor of their days would be inward looking and contemplative.Though patients engaged in all of these activities at times, I had a great deal to learn.

One of the great revelations was that patients wanted to really LIVE until they died; to relish the myriad small joys life has to offer, literally until their last breath. In particular, they savoured humour and laughter, enjoying my life-long habit of satirical quips and my terrible “Christmas bon-bon” jokes. We collaborated seriously on the work of the trial, but if I discovered along the way that participants were receptive, that work was leavened with a solid dash of humour. Geoffrey,* a lovely man with stomach cancer with whom I’d worked for over 18 months, had been delivered devastating prognostic news the day before I visited him on the ward. Though I feel that most of life’s unexpected catastrophes crashdown on our heads without warning like a giant Monty Python boot, I was cross with the universe. To die relatively young from stomach cancer, the prevalence of which has been steadily declining in the last century2 seemed so unfair. “Geoff,” I said, “What can I do for you now? I’ll do anything” (wicked grin from the patient) “within reason.” There was a slight pause as Geoff feigned a serious response, followed by a smile that illuminated his face. “OK then, give me one of your really stupid jokes.”

Elizabeth, a brilliant, articulate, opinionated woman in her early 40s had the great misfortune to be diagnosed with two discrete cancers, discovered on investigation after trauma she’d sustained in an accident. She was gifted and feisty, without a smidgeon of “Why me?” Elizabeth promised to puke violently on anyone who used the phrase “cancer journey;” or called her a “cancer sufferer” or “cancer survivor.” She considered the former invoked pity, an emotion she loathed, and the latter battles and heroics, neither of which she aspired to. She worked part-time and pursued her intellectual passions until metastases precluded both. Elizabeth had cherished a formidable command of the English language. Nevertheless she lampooned her fishing expeditions for elusive nouns, her nominal aphasia the subject of endless satire. Through treatment and disease progression her engaging and acerbic spirit remained intact. 

I was impressed by the skill and humanity of the department’s palliative care team. Like some other patients at the end of their lives3, however, Elizabeth viewed palliation and hospices as anathema, and was determined to stay at home for as long as possible. I was on the ward when she was admitted, having had seizures at home. She was febrile and clearly close to death. As she was being transferred to a bed, she opened her eyes. With an arch of the eyebrow she gave me one last sardonic look. “Oh, it’s you again….”she said, her habitual greeting of the prior two years.

There is a substantial body of research in a wide range of clinical areas, including oncology, which demonstrates the physiological, psychological and sociological benefits of laughter.4 Laughter can result in an increase in heart rate, respiratory rate, and oxygen consumption, then muscle relaxation, and decreases in heart rate, respiratory rate and blood pressure.5

Researchers Kinsman Dean and Gregory (2004)6 conducted clinical ethnographic research in a 30-bed palliative care inpatient unit about the functions of humour and laughter. They give a brief overview of the mass of research about the importance of humour in health care relationships, observing that “despite variability in settings and approaches, findings consistently identify the importance of humour as a means of enabling communication, fostering relationships, easing tension, and managing emotions” (Kinsman Dean and Gregory, 2004,p.140). The authors identify three primary functions of humour in their palliative care study: to build relationships, to contend with circumstances, and to express sensibility. Their notion of humour as “energising” or life-affirming resonates with my oncology experience: sharing crazy satirical stories and falling about laughing was a joyous, “normal” part of life: a way for patients in my trial to express the currency of their lives. It was as if they were saying: “Don’t treat me like I’m leaving the world! I’m here now, enjoying life NOW.” Our banter affirmed the uniqueness of each patient who laughed with me. Elizabeth enjoyed pithy, slightly acid phrases. Eddie, a 70 year old from the bush, was a fine raconteur and a master of the deadpan resolution. Sharing humour was, as Kinsman Dean and Gregory (2004) describe, an acknowledgement of personhood.  

*Pseudonyms are used for patients.

References:
1. Australian Institute of Health and Welfare & Cancer Australia 2012. Breast cancer in Australia: an overview. Cancer series no. 71. Cat. No. CAN 67. Canberra: AIHW.
2. Australian Institute of Health and Welfare 2014 Australia’s health 2014. Australia’s health series no. 14. Cat. no. AUS 178. Canberra: AIHW.
3. Dougherty C, Steensma D (2002),The Art of Oncology: When the Tumour is not the Target. Overcoming Obstacles to Hospice Care: An Ethical Examination of Inertia and Inaction. Journal of Clinical Oncology, Vol 20, No 11 (June 1), 2002: pp 2752-2755.
4. Strean W (2009), The Laughter Prescription. Canadian Family Physician.Le Médecin de famille canadien Vol 55: October 2009.
5. Bennett M, Lengacher C (2008). eCAM 2008;5(1)37–40 doi:10.1093/ecam/nem041
6. Kinsman Dean R, Gregory D (2004). Humour and Laughter in Palliative Care: An Ethnographic Investigation. Palliative and Supportive Care ~2004!, 2, 139–148. DOI:10.10170S1478951504040192.