For years, health care professionals
believed that all measures taken in
intensive care units (ICU) were for the
patients’ own good.
Patients were tied down so they couldn’t
pull out their lines or tubes. They were put on
machines to help them breathe. Intravenous
lines were inserted to deliver life-saving
medications. Powerful drugs immobilized them.
The drugs gave patients the desired amnesia
about the trauma they faced, but it also gave
them something less desirable — delirium.
“As a nurse,” said Michele Balas, Ph.D.,
assistant professor in the UNMC College of
Nursing, “I remember thinking, ‘I don’t want
them to remember anything we’re doing
But the drugs also contributed to
something less desirable. Two-thirds of ICU
patients show signs of “ICU delirium,” or acute
confusion. “For years we thought that was just
a normal condition, something that happens
to all old people when they are in the ICU, and
that they would get better before they went
home,” Dr. Balas said.
“But in the past decade we have found
that we’ve been so wrong.”
While the ICU keeps patients alive, it
turns out the delirium can have lasting, even
deadly effects. It is an independent predictor of
higher mortality. Delirium often causes a loss
of functional and cognitive ability such as an
inability to balance the checkbook or help kids
with homework. And older adults are more
likely to go straight from the ICU into nursing
homes or other long-term care facilities.
Up to 80 percent of people who are put on
ventilators in ICU will experience delirium, Dr.
“You never go home quite the same as
when you went in.”
Though all of these measures are done
with the best of intentions, the long periods of
immobility and ensuing muscle atrophy, along
with the drugs, not only erase memory, but
also distort reality.
Studies have shown between 15 percent
and 40 percent of ICU patients face symptoms
of post-traumatic stress disorder.
Except the people Dr. Balas calls “ICU
survivors” often don’t fully remember their
traumatic experiences. They’re not sure if
they really lived through them or not. They
don’t know why they suffer from depression,
anxiety, delirium and the rest. They don’t
know why their brains don’t work the way
they did before.
Some are left with emotional triggers,
shadows of memories, horrific flashback
fantasies that rival an alien abduction,
paranoid nightmares from somewhere out of a
doped-up benzodiazepine fog.
“They think they’re crazy,” Dr. Balas said.
“They’re embarrassed to talk about it.”
But Dr. Balas is talking about it. In fact, she’s
all but shouting that something needs to change.
Dr. Balas and her interdisciplinary
team, which includes William Burke, M.D.,
professor of psychiatry, are trying to find a
way to decrease or even prevent ICU delirium.
Their interdisciplinary team of clinicians and
researchers are in the midst of an 18-month
$300,000 Robert Wood Johnson Foundation
grant-funded study to test an evidence-based,
nurse-led program called the ABCDE bundle
— Awakening and Breathing, Coordination,
Delirium monitoring and management and
The goal is, for a little while each day, to
let patients wake up, get them off the drugs,
take off the ventilators to let them breathe on
their own, get them up and moving, and look
closely for signs of delirium to address it in the
Evidence has shown that patients who
breathe a little on their own each day are off
the ventilator more quickly, Dr. Balas said.
Those able to touch base with reality every
24 hours are less likely to slip away, she said.
But it won’t be easy. The ‘C’ — coordination
— is key. It takes an interdisciplinary team
effort — all members must talk to each other
and appraise the patient’s condition beyond
meds and vital signs.
“The problem is changing the culture,” Dr.
Balas said. She admits it herself: “Patients are
much easier to take care of when they’re down.”
But we never fully realized, until lately, all
that was really going on, while they were down.
Part of the project will be building a
website, which will be the first step toward
establishing a national support network for
ICU survivors, Dr. Balas said.
UNMC and its hospital partner, The
Nebraska Medical Center, are the first in the
country to concurrently try every element of
ABCDE to see if it will help patients. And yes,
Dr. Balas said, doing it this way is going to be a
lot more work.
For years, health care professionals