Who said death was funny?

The multicultural stigmatization of death and dying has sparked an ethical controversy surrounding the use of humor in end-of-life care by medical providers. Humor is a crucial mode to connect with patients undergoing a challenging experience. Yet, balancing the line between comedy and sensitivity regarding such a serious subject poses a difficult challenge for medical professionals. Determining the clinical significance and cultural acceptance of humor may offer insights into how comedy can be utilized as a vital asset in healthcare.

Humor has made a noticeable impact on wellbeing. Several studies have shown that humor in medical settings has enhanced patients’ pain tolerance, as demonstrated through a cold pressor test (1). Moreover, humor has enabled patients to alleviate stress and mitigate agitation towards specific procedures or practices. Krotos et al. illustrated this by introducing clowns and jesters at elder care homes, resulting in decreased doses of psychotropic medications throughout their stay (2). Medical professionals practice beneficence or the act of working for the patient’s well-being. The studies prove that humor actively works to improve the mental state of terminally ill patients and thus should be adopted into standard practices. Comedy helps patients feel more secure and relaxed about their situation, easing tension. However, these studies have limitations, as many experiments employing humor in palliative care lack a longitudinal nature, making it challenging to deduce all trends in humor’s impact on patient health (3). 

The cultural perspective of humor must be considered when evaluating if comedy is a viable treatment method for end-of-life care. Maintaining a sense of humor was rated as highly important in a Western/European cultural setting of patients (3). When dealing with a heavy subject such as death, the type of humor employed can have a significant impact. The balance between discussing the course of action and humor is essential for medical professionals as it could disrupt patient autonomy or the principle on individual choice of treatment. Humor in this setting could skew patients to opt for procedures or therapies that they wouldn’t regularly do, violating this fundamental principle. 

Moreover, the delivery of humor has an impact on patient health. Research has indicated that cynicism or sarcasm can harm patient health and morale, although the extent of this disruption is still being explored (5). Studies have shown that appropriate forms of humor that validate patients’ experiences can enable them to distance themselves from death and feel less isolated during their stay at palliative care homes. Yet, the most challenging limitation in studying cross-cultural humor responses is the variety of definitions that define humor, limiting the ability to compare many humor studies on patient health (4).  Overall, medical professionals who incorporate humor into their practice were able to significantly assist their patients in understanding their conditions and ultimately improve their quality of life.

Humor is widely recognized as an effective coping mechanism for stressors, and its utilization in medical settings aims to provide a better quality of life to terminally ill patients. (6) However, how doctors and nurses employ humor can have diverse positive effects on the patient, from enhancing pain tolerance to reducing medication dosage levels. One thing is clear: death and dying are morose subjects to discuss, but humor might be the best way to reflect, cherish, and acknowledge the natural end of life.

Reviewed by Kiara Lavana

Graphic by Eugene Cho

Sources

(1) : Weisenberg M., Tepper I., Schwarzwald J. (1995). Humor as a cognitive technique for increasing pain tolerance. Pain 63, 207–212. 10.1016/0304-3959(95)00046-U 

(2): Kontos P., Miller K.-L., Mitchell G., Stirling-Twist J. (2015). Presence redefined: the reciprocal nature of engagement between elder-clowns and persons with dementia. Dementia 16, 46–66. 10.1177/1471301215580895

(3) Linge-Dahl LM, Heintz S, Ruch W, Radbruch L. Humor Assessment and Interventions in Palliative Care: A Systematic Review. Front Psychol. 2018 June 19;9:890. doi: 10.3389/fpsyg.2018.00890. PMID: 29973892; PMCID: PMC6020769.

(4) Bag, B. (n.d.). JOURNAL OF PSYCHIATRIC NURSING. The use of humor in palliative care services. https://jag.journalagent.com/phd/pdfs/PHD_12_2_173_179%5BA%5D.pdf 

(5) Ruch W., Heintz S., Platt T., Wagner L., Proyer R. T. (2018). Broadening humor: comic styles differentially tap into temperament, character, and ability. Front. Psychol. 9:6. 10.3389/fpsyg.2018.00006

(6) Lee, E. J. (2020, July 1). Humor in health care. Journal of Ethics | American Medical Association. https://journalofethics.ama-assn.org/article/humor-health-care/2020-07

UPenn leads a study assessing the impact Default Palliative Care Consultations will have on hospitalized populations

Palliative care is a special type of medical care for people who are seriously ill, that has the goal of alleviating and managing symptoms in a way that maximizes comfort and improves quality of life by catering to a patient's needs. Despite this being an option for patients, many are unaware of this option and fail to request it. Combined with the failure of some providers to inform their patients about palliative care, we see that overall it is not as popular. In a study conducted by the University of Pennsylvania, they were curious to see how making palliative care consults a default option for hospital patients would increase the number of people who decide to use palliative care.

The study took place between March 2016 and November 2018, and included over 34,000 patients with chronic obstructive pulmonary disease (COPD), dementia, or kidney failure at 11 hospitals across eight states. Despite being one of the populations that could greatly benefit from this type of research, past palliative care studies have not been inclusive of patients with COPD, dementia, and kidney failure.

The results of the study showed that palliative care consultation rates increased from 16.6 percent to 43.9 percent and the time to consultation decreased by 1.2 days. This means more people were hearing about their options in the realm of palliative care much sooner. While early palliative care consults would be helpful in patients considering their treatment options, it is not explored enough. According to the World Health Organization, Worldwide, only about 14% of people who need palliative care currently receive it. It was also found that 9.6% of providers ended up canceling the palliative care consult.

Of the canceled palliative care consult orders, clinicians said 53.1% had “no palliative care needs at this time.” It would be interesting to know more specifically what went into the thought process of doctors that said their patient did not need the palliative care consultation. This raises the ethical question of if doctors determined the patient doesn't need this type of care on their own, or whether they talked to the patient about it before entirely opting out of it. I think the reasoning for providers who opted out of the palliative care consult might be a mix of these two justifications, but regardless, knowing the thought process behind such decisions could help inform future policy changes regarding how doctors administer and discuss palliative care with their patients. Evidently making a palliative care consult default will increase the amount of people who can benefit from and palliative care sooner. This is a cost effective strategy that would be useful in hospitals across the country, and increase access to and knowledge about end of life care.

“Can I Pass in Peace?” Exploring the Causes and Consequences of Aggressive End-of-Life Care

In July 2022, 84-year-old retired entrepreneur James O’Brien broke his hip following a fall at his home in rural New Mexico (1). Upon being wheeled to the hospital to receive treatment, Mr. O’Brien—who was already dying of heart failure and advanced lung disease—declined to receive surgery for his injury, choosing to “die comfortably” rather than suffer from post-surgical complications. The physicians tasked with caring for Mr. O’Brien, however, attempted to go against his wishes, calling his daughter Jennifer with the expectation that she would convince Mr. O’Brien to accept a hip operation. Ultimately, Jennifer opted to support her father’s decision instead and placed him in a local hospice where he would spend the final months of his life. Although James O’Brien died in the way that he desired, thousands of other end-of-life patients are not given the same liberties; specifically, those who are rendered incapable of making their own medical decisions often become subjected to undergoing invasive treatments that cause them to die painfully rather than peacefully (2). This article analyzes the underlying causes and ethical consequences of the administration of aggressive end-of-life medical care.

Aggressive end-of-life care is defined as any form of medical treatment aimed at prolonging dying patients’ lives rather than improving their quality of life; examples include chemotherapy, invasive surgeries, feeding tubes, and mechanical ventilation (3).

When terminally ill patients who are no longer able to make medical decisions for themselves permit their physicians to choose on their behalf, these patients end up being more likely to endure aggressive or experimental treatments (2). However, previous studies have demonstrated that such invasive modes of intervention lead to increased physical and psychological distress prior to death (4). This evidence thus indicates that patients who opt to allow their physicians to choose their treatments may not be receiving the end-of-life care that they would have desired. Moreover, these individuals are likely not dying in the place that they would have wished; aggressive interventions require prolonged stays in intensive care units or emergency rooms, but 70% of patients have been shown to demonstrate a preference for dying at home rather than in the hospital (5). Evidently, a disconnect exists between the types of care dying patients want and the treatments their physicians actually end up administering.

So why are physicians opting for aggressive end-of-life interventions despite knowing that their patients would likely desire more palliative ones? For starters, medical professionals often believe that the “default” purpose of hospital care is to prolong patients’ lives. Thus, electing to not administer aggressive treatment is perceived by many physicians as a symbol of giving up on their patients. A qualitative study interviewing internal medicine doctors revealed this notion; as one physician put it, patients “came to the hospital to get well” and “were not ready to die,” making it his obligation to utilize whatever means necessary to prevent death from occurring (6). Additionally, discussing the topic of letting patients die is an unpleasant confrontation that medical professionals prefer to avoid, especially when people close to patients such as family members desire aggressive treatment to be continued. Although some individuals—such as in the case of Jennifer O’Brien—opt to permit and accept the deaths of their loved ones, many others choose to interpret grim prognostic information in an overly optimistic light, insisting that their ailing relatives will be able to recover even when told otherwise by medical professionals (7). Evidently, deciding to allow death to happen brings the possibility of legal backlash against physicians and the hospitals they work for; thus, it is no surprise that aggressive treatments are so frequently maintained for end-of-life patients.

Ultimately, the controversy surrounding aggressive end-of-life interventions cannot simply be blamed on the physicians who decide to administer them. Instead, this dilemma is rooted in deeper systemic and social issues that coerce these doctors into making specific medical decisions, even if such choices serve to harm rather than help their patients. Further discussion that aims to improve the ethicality and rationality behind end-of-life care is thus necessary to ensure that patients do not continue to undergo unnecessary suffering in the final moments of their lives.

Reviewed by Kelly Ma

Graphic by Shanzeh Sheikh

References

1. Span, P. (2023, March 14). Aggressive Medical Care Remains Common at Life’s End. The New York Times. https://www.nytimes.com/2023/03/14/health/end-of-life-care-hospice.html.

2. Finnegan, J. (2019, June 18). Patients Get More Aggressive End-of-Life Interventions When Physicians Take Over Decision Making, Study Finds. Fierce Healthcare. https://www.fiercehealthcare.com/practices/patients-get-more-aggressive-end-life-treatment-when-physicians-take-over-decision-making.

3. Gallo, J. J., Abshire, M., Hwang, S., & Nolan, M. T. (2019). Advance Directives, Medical Conditions, and Preferences for End-of-Life Care Among Physicians: 12-year Follow-Up of the Johns Hopkins Precursors Study. Journal of Pain and Symptom Management, 57(3), 556–565. https://doi.org/10.1016/j.jpainsymman.2018.12.328.

4. Mohammed, A. A., Al-Zahrani, O., Salem, R. A., & Elsayed, F. M. (2019). Aggressive Care at the End of Life; Where Are We?. Indian Journal of Palliative Care, 25(4), 539–543. https://doi.org/10.4103/IJPC.IJPC_59_19.

5. Where People Want to Die (n.d.). Healthtalk. https://healthtalk.org/experiences/living-dying/where-people-want-to-die/.

6. Dzeng, E., Dohan, D., Curtis, J. R., Smith, T. J., Colaianni, A., & Ritchie, C. S. (2018). Homing in on the Social: System-Level Influences on Overly Aggressive Treatments at the End of Life. Journal of Pain and Symptom Management, 55(2), 282–289.e1. https://doi.org/10.1016/j.jpainsymman.2017.08.019.

7. Zier, L. S., Sottile, P. D., Hong, S. Y., Weissfield, L. A., & White, D. B. (2012). Surrogate decision makers' interpretation of prognostic information: a mixed-methods study. Annals of Internal Medicine, 156(5), 360–366. https://doi.org/10.7326/0003-4819-156-5-201203060-00008.