Getting to 'the heart of the bad'
Getting to 'the heart of the bad'
Sam had completed six of his 30 radiation treatments. When he first started his treatment course, chemo and radiation for colorectal cancer, we discussed what kind of side effects he could reasonably expect to have. Knowing the start of treatment can be relatively benign, I waited until he had finished his sixth treatment before I checked to see if he was having symptoms and to ask him how he was doing. He said, "I'm trucking along, just a little diarrhea. Nothing I can't handle." Sam liked to joke and laugh so it didn't surprise me when he added with a wry smile, "It's all good down below, if you know what I mean. I haven't had to go commando yet." I smiled at his remark.
I had reviewed with him how air was one of the best things for the probable skin irritation and desquamation. I explained that many of our patients ended up going commando, then had to explain that meant going without underwear as much as possible when he was at home. When I described that possibility, he responded, "Whoa! I'm an old fashioned kind of guy. I don't see myself going commando." Now, at 20% of the way through his treatment, Sam seemed satisfied that things were going well.
The beginning of treatment can be deceiving. I had warned him of what was coming; but because there is lag effect, some patients begin to think they are the ones who will not have all the side effects. I could tell by Sam's jovial countenance that he thought he was destined to be one of the lucky ones. It was hard to determine how insistent I should be when predicting side effects. I wanted to be sure he was well prepared. Sam laughed when he told me, "Don't look so serious, I'm going to be fine." Okay, I thought, we'll go day by day.
A few days later he told me that the diarrhea had started to give him more trouble. As usual, he resorted to laughing and joking as we chatted. As we reviewed the options for managing the diarrhea, he said, "It's a pain in the butt you know, literally, but it's not going to get much worse, is it?" I was stumped by this. We had discussed the trajectory of his treatment. The combined force of chemo and radiation for his rectal cancer were expected to cause considerable side effects. I thought we had been clear on what to expect, so his question surprised me. I knew his joking was not a sign of joy or happiness but his way of coping, maybe the only way he knew how.
"It will get worse before it gets better," I reminded him. When he paused before responding, I knew he was considering the veracity of my statement but I saw immediately that he didn't really believe me. "Yeah, you warned me about going commando. But I'm planning to keep this butt under cover." Once again he used humor to avoid reality.
I wondered if there was anything else I should do. His laughter ran out ahead of him whenever we interacted, an invisible shield that prevented him from hearing what I had to say. It kept the information at bay too. His coping mechanism was his ability to engage others in laughter. The adage is to go to where the patient is, but I worried that my use of humor might reinforce his barrier rather than break through it. I chose to match his humor with a little of my own thinking, it was one way of reaching him. I didn't need to hit him over the head with dire predictions, yet mitigating the impact of the side effects from treatment does require aggressive attention to what those symptoms are. Paying attention to the subtle changes as they occur helps me to help the patient.
Sam's joking attitude stayed constant but cracks appeared every now and then. By the time he was past the half-way mark, some of his resolve had slipped. "My wife got me an extra-large pair of cotton boxers and I've been prancing around the house in those." I told him, "Well, a loose pair of boxers is pretty close to commando." He grinned even bigger. "Don't I know that!"
Our plans were loose. I checked in regularly, and he knew he could call me with questions. It started to look like his joking attitude might be enough to carry him through, until one Monday when the radiation therapist asked me to see him after treatment. Poor old happy Sam looked drawn, almost ashen colored. He shook his head when I sat down, and got straight to it, "It was the BBQ ribs that did me in. You told me not to eat spicy stuff. But we went out with friends on Friday, and I figured I could handle it."
By this point we had chatted many times about his treatment and side effects, but I felt like this was the first time Sam was really listening to me. We went over dietary considerations again and then he asked, "How much worse will it get?" I told him what I tell many of my patients when they reach this low point, "This is the heart of the bad." I watched as he took the information in. He had another week of treatment and knew it was going to be tough. He repeated my words, "The heart of the bad." We both nodded. There was a long pause, a slight grin from him. "Maybe it's time to go commando." We both laughed.
Up till then, Sam had listened patiently to my descriptions but was a nonbeliever. Now he was a convert, willing to do anything and everything. The heart of the bad was the place where he came to understand.
Sam made it through the rest of his treatment. When he returned for his 2-week follow-up appointment he was back to teasing and joking. "I'm past the heart of the bad and just into the not so bad. Guess I'm going to make it after all." Then he told a joke, and I heard him laugh his hearty laugh and I knew he finally got it. The worst was behind him. Literally. ONA
Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.
Join the conversation
In this scenario Sam's humor was a coping mechanism that blocked him from hearing some of the patient teaching. Think about patients you have had who use humor to cope.
- What were the benefits, or complications, their use of humor interjected into their care?
- How did you deal with the humor? Do you find humor to provide a barrier?
- Do you think it is more effective to ignore humor and focus on facts? How do you keep from getting distracted by patient's use of humor?
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