CNNT Lead Article: The Intentional Application of Humor with CKD Patients

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Karyn Buxman, RN, MSN, DAIS, CSP, CPAE

Introduction
Chronic Kidney Disease (CKD) is no joke, but given the implications of humor on health and well-being, it may be a laughing matter. Researchers in a long-term study found that persons with severe diseases, including CKD, increased their odds for longevity by having an increased sense of humor.1,2 Other researchers have found humor to have a positive effect on blood glucose levels, levels of renin and angiotensin, blood pressure, pain and discomfort, and anxiety and depression—all of which would benefit the CKD patient. 3,4,5,6,7,8,9,10,11,12,13,14

What's not so funny about CKD?
Suffering from chronic kidney disease is no laughing matter. Persons with CKD suffer from many negative effects including fatigue, poor concentration, trouble sleeping, pain and discomfort, stress, anxiety and depression, and isolation.15

Because CKD is a chronic condition, these effects may be experienced for months, days, or years. Chronic stress affiliated with long term illnesses has been shown to correlate with increases in stress hormones such as cortisol and catecholamines.5,14 These hormones increase the inflammatory effect in the body that in turn, speed up the advancement of illnesses which can be detrimental to the CKD patient including diabetes and cardiovascular disease.16,17

As healthcare professionals, we need to help CKD patients acquire and develop as many strategies as possible to deal with their pain and suffering and assist them in reaching their fullest potential of health. A powerful yet often overlooked tool is therapeutic humor.

Humor defined.
While most of persons recognize humor when they experience it, researchers have a more difficult time pinning down an exact definition of humor so that it is quantifiable.14,18,19 A review of the literature will turn up numerous definitions such as the ones below:

Psychologist Steve Sultanoff states, "Wit is considered a thought-oriented experience. Mirth is considered an emotionally oriented experience. Laughter is a physiologically oriented experience. While all of these can be experienced independently of the others, when experienced together they synergistically create the experience we refer to simply as humor."20

Nurse researcher Vera Robinson21 was one of the first to research humor in a healthcare setting and defined humor as, "any communication which is perceived by any of the interacting parties as humorous and leads to laughing, smiling, and (or) a feeling of amusement."

I have defined humor as "a feeling of delight, wonder or release that comes from surprise, perspective or insight."18,22,23

The Association for Applied and Therapeutic Humor has taken a step further and defined therapeutic humor 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. This intervention may enhance health or be used as a complementary treatment of illness to facilitate healing or coping, whether physical, emotional, cognitive, social or spiritual."24

Functions of humor and the implications for CKD patients
Humor can enhance communication, offer positive psychological and social benefits, and provide positive physiological benefits.21 These benefits can prove especially useful to those suffering from CKD.

Psychological
Patients with CKD may suffer from stress, anxiety and depression. Being diagnosed with a disease that is chronic, or potentially terminal, can result in feelings of anger, fear, resentment and despair.15,25 In an effort to cope with such unpleasant feelings, it is not uncommon for people to turn to unhealthy ways of coping including emotional eating, smoking, drinking excessively, and excessive time on the Internet.26

Humor can serve as a positive coping mechanism by relieving anxiety and tension, serving as outlet for hostility and anger, providing a healthy escape from reality, and lightening heaviness related to critical illness, trauma, disfigurement, and death.27

Much of the humor found used by CKD patients and their support system may be dark (also known as gallows) humor, making light of body fluids, death and dismemberment.28,29

Sign: Dialysis: Damned if you do, dead if you don't.
Button: Dialysis patients do it 3 times a week.
Joke: Heard that Kevin Bacon is going to star in a new movie about a 50-year-old non-compliant diabetic. It's called Footless.

It is not uncommon, however, for both patients and caregivers to use gallows humor when facing chronic and terminal illnesses. The closer one is to tragedy, death, and/or feelings of injustice, the darker the humor may become.30 It is important for the healthcare professional to not judge a patient based on the type of humor expressed, and recognize that it may be a healthy way for him to express stressful feelings.

Social
CKD patients may feel isolated. Restricted diets, pain, medication, dialysis or other treatment regimens may make it difficult for patients to participate in social functions that most of us take for granted. Therapeutic humor strengthens rapport and enhances relationships. Hierarchy can also be decreased when two or more persons share a joke, enabling the patient to feel more empowered.14,17,27 Encouraging patients to participate in humor during office visits, during dialysis, during hospitalizations, and even when confined to their home can help them feel less alone and more connected to others.

Communication
CKD patients may not feel comfortable discussing their frustrations, fears, and feelings with their healthcare professional. Humor is a great means of voicing frustration, or even anger, around the unfairness of being diagnosed with CKD.21,30

A number of CKD patients have expressed their frustrations through cartoons, funny images, and jokes or humorous stories online.28,29,31 There are even products that can be purchased such as posters, coffee mugs, t-shirts, toys, and even cake pops that convey humor and kidney disease.28,32,33

I love you with all my kidneys.
My Mondays, Wednesdays and Fridays are all in vein.
Oooh baby! Nice kidneys!

One comedian, Michael Elizondo, has even turned his life experience into part of his comedy routine:

"Nephrotic Syndrome is a type of kidney ailment, categorized as an autoimmune disease, in which damage to the capillaries of the glomeruli (microscopic blood vessels in the kidneys) cause the protein albumin to leak into the urine. If the leakage of fluid from blood vessels into tissues depletes the liquid component of blood and the blood supply to the kidney is diminished, there is a considerable risk of kidney failure. This proposition made me cry, not because of the fear of possible kidney failure, or the uncertainty of living with kidney disease, but because the biopsy hurt like a SOB.

"The fact that my procedure was done at County USC Medical Center in Los Angeles made it all the more terrifying. The place was scary. I walked in and saw a guy on a ventilator handcuffed to his own gurney... obviously a flight risk. I don't want to say the hospital was a dangerous place, but when I was admitted, they didn't give me a gown, they gave me a bullet-proof vest... that opened in the back... for easy access."34

Physiological effects
Patients with CKD have challenges with numerous body systems including cardiovascular, endocrine, and immune. Humor has been shown to have a positive impact on each of these systems.3,4,5,6,7,8,9,10,11,12,13,14,21,35

One of the largest contributing factors to CKD is diabetes. If a patient can better control their diabetes, then perhaps they could decrease the onset or severity of CKD. Studies have shown that patients with diabetes or pre-diabetic patients experienced a decrease in blood glucose after watching a 30-minute funny video.6,7,8 While researches have not been able to pinpoint why this is the case, it is recognized that humor lowers cortisol that in turn decreases insulin resistance.

In another study, researchers exposed diabetics and non-diabetics to a six-month regiment of comedy videos once a week. At the beginning of the study the diabetics' levels of renin were five times higher than typical non-diabetics. By the third month of the study, the renin levels of the diabetic patients dropped (and stayed down through the rest of the study) on average by 2/3 (putting half of the diabetic subjects into normal range). At the same time, angiotensin levels dropped over the first three months of watching these humor videos and stayed down the remainder of the study. The researchers went as far to conclude that "laughter therapy can be used as a non-pharmacologic treatment for the prevention of diabetic microvascular complications."7

Humor and laugher can also decrease muscle tension, resulting in diminished pain, as well as serve as a distraction which decreases the perception of pain and discomfort.20

Implementation of humor by patients and staff
There are numerous ways that both patients and staff can increase the likelihood of experiencing humor. Here are 5 tips for implementing humor with CKD patients:

  1. Manipulate the healthcare environment (waiting rooms, dialysis areas, exam rooms, patient rooms) with humorous cartoons, books, posters, coffee mugs, toys, videos, games, gaming devices.28,29,31,32,33,36,37,38 Many patients enjoy gaming by themselves and with others on devices like Xbox or online video games.36,37 There are now services, such as LaughMD, which installs free channels of comedy onto hospital televisions and tablets.38
  2. Lighten up work attire with humorous pins, scrubs with cartoon-like characters, and light-hearted jewelry, socks, handbags, ties. Encourage patients to wear their humorous attire, as well.
  3. Model humor by sharing funny stories about self, family/friends/colleagues.
  4. Encourage patients and their family members to share their humorous stories and jokes.
  5. Encourage patients to create a list of activities that are fun for them and suggest that they pick an activity daily to practice from this list. Practicing humor routinely will not only help that patient to cope with acute stress, but will help them build resilience for the long-term stressors.17

Summary
The needs of the CKD patient are many, and resources are limited. Humor is an easily accessible, cost-effective means of helping CKD patients and their support team deal with the physical, psychological and social challenges they face. The opportunities to experience humor can be increased by both the patient and those providing their care. Humor may occur by chance with CKD patients and their care providers, but given the number of benefits, it would be a disservice not to show them how to intentionally harness humor and leverage laughter on a regular basis.

References

  1. Svebak, S., Kristoffersen, B, & Aasarod, K. (2006). Sense of humor and survival among a county cohort of patients with end-stage renal failure: a 2 year prospective study. International Journal Psychiatry in Medicine, Vol 36(3), 269-281.
  2. Svebak, S., Romundstad, S; & Holmen, J. (2010). A 7-year prospective study of sense of humor and mortality in an adult country population: The HUNT-2 study. International Journal of Psychiatry in Medicine, Vol 40(2).
  3. Berk, L.; Felten, D.; Tan, S; & Bitman, B. (2001) Modulation of neuroimmune parameters during the eustress of humor-associated mirthful laughter. Alternative Ther Health Med. Vol 7(2), 62-72, 74-6.
  4. Berk L. & Tan, S. (2006). [beta]-Endorphin and HGH increase are associated with both the anticipation and experience of mirthful laughter. The FASEB Journal, Vol 20:A382.
  5. Berk, L.; Tan, L.; & Tan, S. (2009). Mirthful laughter, as an adjunct therapy in diabetic care, increases HDL cholesterol and attenuates catecholamines, inflammatory cytokines, C-RP, and myocardial infarction occurrence. The FASEB Journal, Vol 22 (2), 1226.
  6. Hayashi, K.; Hayahsi, T.; Iwanaga, S.; Kawai, K.; Ishii, H.; Shoji, S. & Murikami, K. (2003). Laughter lowered the increase in post-prandial blood glucose. Diabetes Care, Vol 26 (5), 1651-1652.
  7. Nasir, U; Iwanaga S; Nabi, A; Urayama O; Hayashi K; Hayashi T; Kawai K; Sultana A; Murakami K; & Suzuki F. (2005). Laughter therapy modulates the parameters of renin-angiotensin system in patients with type 2 diabetes. International Journal of Molecular Medicine, Vol 16(6) 1077-81.
  8. Hayashi Hayashi, T. & Murakami, K. (2009). The effects of laughter on post-prandial glucose levels and gene expression in type 2 diabetic patients. Life Science, Vol 85(5-6): 185-187.
  9. Bennet, M. & Lengacher, C. (2009). Humor and laughter may influence health IV. Humor and immune function. Evidenced-based complementary and alternative medicine, Vol 6(2), 159-164.
  10. Peeples, L. (March 28, 2011). Laughter, Music May Lower Blood Pressure. Retrieved from September 28, 2015 from http://www.cnn.com/2011/HEALTH/03/25/laughter.music.lower.blood.pr essure/index.html
  11. Zweyer, K., Velker, B., & Ruch, W. (2006). Do Cheerfulness, exhilaration and humor production moderate pain tolerance? A FACS study. 1-27. Accessed from author September 18, 2015.
  12. Cann, A. & Colettea, C. (2014). Sense of humor, stable affect, and psychological well-being. Europe's Journal of Psychology, Vol 10(3), 464-479. ejop.psychopen.eu/article/download/746/pdf
  13. Seiler, B., & Levitt, B. (March 9, 2009). University of Maryland School of Medicine Study Shows Laughter Helps Blood Vessels Function Better. Retrieved from http://www.umm.edu/news/releases/laughter2.htm
  14. McGhee, P. (2010). Humor. The lighter path to resilience and health. Bloomington, IN: AuthorHouse.
  15. National Kidney Foundation. (2015). About kidney disease. Retrieved September 18, 2015 from https://www.kidney.org/kidneydisease/aboutckd
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  17. Hanna, H. (2105). Recharge. Investment strategies for your most valuable resource. San Diego: Synergy.
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  19. Weems, S. (2014). Ha!: The Science of When We Laugh and Why. Philadelphia: Basic Books.
  20. Sultanoff S. Exploring the land of mirth and funny; A voyage through the interrelationships of wit, mirth, and laughter. Originally published in Laugh It Up. Publication of the American Association for Therapeutic Humor. July/August, 1994; 3. Retrieved September 24, 2015 from http://www.humormatters.com/articles/explorin.htm
  21. Robinson, V. (1991). Humor and The Health Professions, 2nd ed. Thorofare, NJ: Slack.
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  31. KidneyCorner.com Dialysis cartoons by Peter Quaife. Retrieved September 25, 2015 from http://kidneykorner.com/AK/Comics.html
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  33. Cake pops. Retrieved September 25, 2015 from http://www.bakerella.com/yipee/
  34. Elizondo, M. Finding the funny. Retrieved September 25, 2015 from http://www.aath.org/assets/docs/humor-articles/findingthefunny.pdf
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