When is Black Humour Unwise?

If you’re a health care professional, you know black humour. Inculcation starts early. When I was a student working through a med-surg rotation, I cared for a demented patient who was literally bleating like a sheep; my instructor, walking by her room, began to sing “Mary had a little lamb” before throwing a mock-shocked hand to her mouth, and giggling. Later on, younger and idealistic, I was appalled by what I now know is typical cynical emergency department humour. GOMERs* go to ground and GOMERs never die. Elderly patients with conspicuous luggage, dropped off by families unable to cope, have a “positive suitcase sign”. Certain patients get labels, humorous in intent, but not usually in execution. Repeat visitors are called “frequent fliers”, young women (“MIDs” — muffins in distress) and persons wanting narcotics (“DSIs” — drug seeking individuals). Codes and death are in particular subjects of black-toned laughter, as we rustle the body bags and remove the tubes. I’ve heard some remarkably dark humour after the death of children, none of which I can bear to repeat. As nurses and physicians, we’ve all been there. Something unbearably awful happens to a patient, and somebody cracks wise. It’s all wildly inappropriate, horrible, demeaning to us and to the patient. We laugh anyway. Is it unwise? Perhaps.

A few days ago Paul Jones documented his discomfort with black humour:

Recently I heard a physician make a comment that this patient is “a classic case of FTD”.

I as a naive medical student enquired what “FTD” meant?
The physician responded drly, “failure to die”.

This comment left me with a deep sense of discomfort and reminded me of the type of humor I had witnessed many times before in the ER, OR and ICU. Often in the health care profession we are placed under extraordinary amounts of pressure where human lives hang in the balance. Doctors and nurses say things which would horrify the lay public (or even sometimes ourselves in any other context).

I’ve heard the term “FTD” myself in my emergency department. It’s not a term I particularly like, though it has a certain currency with my younger colleagues. Having said that, I know exactly who this FTD patient is. She is the nonverbal, contractured, 80-something from the nursing home down the road, with Alzheimer’s dementia and multiple strokes, who’s come for the fifth time in three months in for aspiration pneumonia/urinary tract infection/blocked PEG tube. She’s the one being kept alive, almost pointlessly, because our professional ethics demand no less. I’ve written elsewhere about black humour. We can talk about how stress, and the peculiar institutional culture of health care agencies fosters gallows comedy in all of us. But I think now there is something more essential happening; the term “Failure to die” provides a real clue. Simply, black humour allows us to maintain a semblance of control, and perhaps more importantly, distance over the seemingly endless, ungovernable suffering of the human beings we treat. Having seen, assessed, and cared for such patients in the multiples of hundreds, I can understand the impulse intimately. And so it goes for all the other instances of black humour. Laughter is insurance against giving up completely.

Black humour can be unwise. Patients and families may overhear us, and misconstrue our words as indifference or callousness. Danger lies when black humour stereotypes and therefore devalues a patient or worse, dehumanizes or even demonizes. It can destroy empathy and distort objectivity. This is how nurses provide poor care, and physicians misdiagnose. The wisdom is having the insight to understand the sources of black humour in our own relative helplessness, and to recognize it, first, as an inevitable part of our practice, and secondly, as having a time and a place. Truthfully, we see ourselves in our patients. We are burdened with the knowledge of what will debilitate, and eventually kill us. We laugh against fear. To that end, perhaps, black humour allows us to remain fully human professionals and to carry on treating and caring for our patients with care and empathy.

__________

*GOMER = Get Out of My Emergency Room, i.e. typically elderly, demented patients with chronic, complex and usually incurable conditions.

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  1. #1 by Sean on Thursday 28 October 2010 - 1316

    Sad to say, but it’s our own horrible coping mechanism for all the stress and ‘less than ideal’ situations we ‘deal with’.
    Doesn’t mean it’s justified or allowed or right. It just is.
    One thing is for sure – it should be used with discretion amongst ourselves and NEVER in front of patients or their families.
    That’s just bad taste and immensely unprofessional (not that anything about this is remotely professional).
    We all are guilty of it to one degree or another.

  2. #2 by Cartoon Character on Thursday 28 October 2010 - 1506

    sometimes I may *think* something but I definitely don’t verbalize it. Black humor can land one in a court of law….I have seen it happen, where a nurse says something in “black” humor and then those comments are repeated and in the retelling – attitudes and intent are applied and “evidence” for indictment is collected and an arrest made. Think that is far-fetched? It can and has happened.

  3. #3 by Tyler on Thursday 28 October 2010 - 1710

    Insightful post, thanks.

    Have you ever read Anspach’s Sociology of Medical Discourse? It touches on this and the language medical professionals use. You can read it here: http://instituty.fsv.cuni.cz/~kabele/archiv/Mirek/medical%20disourse.pdf

    • #4 by torontoemerg on Monday 01 November 2010 - 0553

      Thanks for the link. I’m working my way though it — pretty dense, and I was never much a fan of sociology, anyway, so your recommendation evidently has some influence.:)

  4. #5 by Anonymous on Friday 29 October 2010 - 0628

    I’m a racetrack veterinarian, and you would be beyond horrified if you heard how my colleagues and I discuss some of what we see. Remember, this is a sport where an ambulance with EMTs follows the field around the racetrack, and a jeep with one of us inside follows the ambulance.

    We laugh not because the horses are numbers to us, but because we remember every one that breaks down. There are horses I dream about. Even if we wanted to forget, we must input every detail into a national database and add every horse’s name to the drug log.

    We don’t joke with the trainers or owners. Those who care about their horses – the majority – would be hurt. Those who don’t care, who sometimes do not act in their horses’ best interest, haven’t earned the privilege of being allowed the outlet of dark humor.

    I think every profession that sees death and suffering has its own lexicon of black humor.

  5. #6 by jenjilks on Friday 29 October 2010 - 0929

    Excellent points, TERN. I am volunteering at the Palliative Care Conference this week. It is a tough burden for many.

    It is important to keep up professional boundaries, or you sink into an emotional abyss. Yet, one must be dreadfully carefully about others around, as others have said. Teachers do the same thing in staff rooms, FWIW. However, with more volunteers in schools, we are not as careful as we should be!

    I have a regular Thursday night Hospice client and have to come home a depressurize. I understand from whence you speak. Well said.

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