When his fever spiked, he thought someone was setting him on fire. When orderlies slid him into an MRI, he thought he was being fed into an oven. Frequent catheter changes seemed like sexual abuse. Dialysis? He thought someone was taking blood out of a dead woman’s body and injecting it into his veins.
The horrifying, violent hallucinations plagued David Jones, now 39, during a six-week stay in the intensive care unit at Chicago’s Northwestern Memorial Hospital — and for months after he was discharged. He thought he was going crazy and felt very alone.
Recognizing the prevalence of the problem, doctors and nurses across the country are now pushing an ambitious campaign to change practices in intensive care units to reduce cases of “ICU delirium” — a sudden and intense confusion that can include hallucinations, delusions, and paranoia.
Anywhere from a third to more than 80 percent of ICU patients suffer from delirium during their hospital stay. And one-quarter of all ICU patients suffer from post-traumatic stress disorder once they leave, a rate that’s comparable to PTSD diagnoses among combat veterans and rape victims. Patients with ICU delirium are less likely to survive and more likely to suffer long-term cognitive damage if they do.
“This is a massive, massive public health problem,” said Dr. Wes Ely, a pulmonologist and professor of medicine and critical care at Vanderbilt University Medical Center in Nashville, Tenn., who was among the first to recognize the scope of the problem.
Ely is pushing his colleagues in ICUs across the country to reduce the use of sedatives and ventilators and push patients to get on their feet as soon as possible, in a bid to minimize delirium. The talks he gives to highlight the issue show patients talking and texting while on ventilators — a major break from the traditional practice of heavily sedating them. He also shows patients walking through hospital halls despite grievous injuries.
The “ICU Liberation Campaign,” which Ely cochairs, is organized by the Society for Critical Care Medicine, a professional group for ICU clinicians. If it works, it’ll both improve patient outcomes and lower hospital costs.
But it’s been a hard sell.
Despite its heavy clinical toll, ICU delirium is often ignored. Intensive care units are so stressful, so noisy, and so fast-paced that delirium is often overlooked.
“You may have one patient going into shock while another needs to be reintubated, so people get busy,” said Dr. Matt Aldrich, an anesthesiologist who has been implementing the ICU Liberation Campaign at the University of California, San Francisco, Medical Center, where he directs adult critical care. “Delirium has definitely taken a backseat.”
It’s not that clinicians don’t believe in the protocols, Aldrich said. It’s just hard to make time to implement them. “The challenge is to slow yourself down and do the things you need to be doing. It’s daily work. It’s maintenance,” he said. “It’s not letting little things slide and falling into old patterns.”
Keeping patients alive — but at a cost
In a way, ICU delirium is a problem born of success: Today’s intensive care units keep alive patients who would not have survived 20, 10, or even five years ago. ICUs have come so far in curbing problems like sepsis and acute respiratory distress syndrome that they’ve created a huge population of “ICU survivors” — those who make it out alive but end up severely impacted mentally and psychologically.
“We used to call it ICU psychosis,” said Justin DiLibero, a clinical nurse specialist working to reduce ICU delirium in the neuro and surgical ICUs at Beth Israel Deaconess Medical Center in Boston. “We knew it was common but thought patients got better when they got home. Now we know they come into the hospital as one person and leave as someone else.”
Family members are often the first to see that their loved ones “aren’t themselves.” Patients may act paranoid, lash out in anger, or simply seem quite silly, for example planning large galas while still intubated.
While the exact causes of ICU delirium are not fully understood, risk factors seem to include ventilation, which can reduce the flow of oxygen to the brain, and heavy sedation, especially with benzodiazepines, which can have neurotoxic effects. Immobility and physical restraints appear to contribute to psychological distress as well. The lack of sleep, noisy alarms, constant prodding by nurses and doctors, and patients’ inability to keep their hearing aids and glasses on may contribute, too.
“They come into the hospital as one person and leave as someone else.”
Justin DiLibero, clinical nurse specialist
The effects can linger long after discharge.
“As soon as I got home there were cognitive issues, really bad panic issues, flashbacks, all very gruesome,” said Jones. “I felt like I’d endured months of torture. I was scared to go to sleep. I’d wake up in a cold sweat.”
Jones had entered the hospital in 2012 with stomach pains that turned out to be caused by acute necrotizing pancreatitis. His pancreas was literally digesting itself; then his other organs started to fail. He was put on life support: On a respirator and dialysis, fed through a tube, the stocky and athletic Jones lost 70 of his 260 pounds. Nine days into his hospital stay, doctors gathered his family to say goodbye.
Thanks to surgery, a flood of antibiotics, and dedicated hospital staff, Jones survived. He’s incredibly thankful for the care he received.
But he’s also angry, now that he knows how widespread ICU delirium is, that not a single person talked to him or his family about the mental and psychological issues that so many ICU patients face.
“I thought, ‘Why in the world is this not included in post-discharge instructions?’” Jones said in a telephone interview from Chicago, where he has returned to work as a legal analyst. “They were so happy they had saved my life. But no one told me to expect any of this.”
A culture of ‘protecting’ patients with sedation
Ely has always been proud of the work done at his ICU. But in the late ’90s, he started to notice something deeply unsettling: Many of his patients weren’t doing well after they left the hospital. Some were severely impaired. Many couldn’t return to work.
“They couldn’t find their cars or balance their checkbooks,” he said. “We wondered, ‘What happened to them in the ICU? What went wrong?’”
Ely was shaken by the encounters, but when he tried to bring up the issue with fellow intensive care physicians, or critical care specialists, or even with the National Institutes of Health, he got no traction.
His call to ease up on restraining and sedating patients butted up against what Ely says was a deeply entrenched — and deeply paternalistic — ICU culture. “The idea has long been: ‘We want to keep you unconscious so you don’t suffer.’” Ely said. “We thought we were ‘protecting’ patients.”
There were practical issues too: Heavily sedated patients are far easier for nurses to work with than patients who are frightened, agitated, or in pain. And it can be very hard to detect delirium in patients who are lethargic and seem unaware — but may still be delusional and suffering. “They told me I was in a coma,” Jones said. “But I was aware.”
Ely has spent the past two decades studying the issue and amassing the kind of data that are starting to convince his colleagues. A 2013 study, for example, showed nearly 75 percent of ICU patients developed delirium during their hospital stay. In roughly one-third of those cases, their cognitive problems were so severe that even one year after discharge, they mimicked mild traumatic brain injury.
To minimize such damage, Ely developed a protocol dubbed ABCDEF, with steps such as assess for delirium, choose sedation wisely, and push patients to early mobility.
When the procedures are implemented, they seem to work wonders.
At Beth Israel Deaconess Medical Center, care teams in the medical ICUs have reduced the number of delirious patients by 60 percent since 2012, at a cost savings of thousands per patient. They did this by carefully assessing patients for delirium, making sure multiple care team members agreed on those assessments, and then reducing sedation and particularly benzodiazepine use whenever possible.
“We discussed every patient every day, and delirium was part of the discussion,” said DiLibero, the nurse specialist who ran the project, which was funded by the American Association of Critical-Care Nurses, which recently issued a practice alert about delirium to its members. When nurses weren’t sure what to do, DiLibero said, they could call in “nurse champions,” who act as mentors and leaders.
Looking for delirium is especially important in elderly patients. Without a careful assessment, elderly patients with delirium may be misdiagnosed with dementia and sent to nursing homes unnecessarily.
The project at Beth Israel worked so well, it’s been adopted by other ICUs at other regional hospitals. But it wasn’t easy to get there. DiLibero has been working on the issue since 2010, his commitment sparked by seeing so many ICU patients, including his own grandmother, succumb to delirium.
“This is a massive, massive public health problem.”
Dr. Wes Ely, pulmonologist
“It’s taken years of concerted effort to get to this point,” he said. “It’s been about changing a culture.” That change is now palpable in his unit.
“When I started in ICU, anyone who was going to be intubated, they’d all be sedated, pretty deeply sedated,” DiLibero said. “Now some patients are completely off sedatives while still on a ventilator. I never thought I’d see that.”
While there is agreement that it’s crucial to prevent delirium whenever possible, many questions still remain on how best to treat it after it occurs. Vanderbilt is one of the few hospitals that offers a post-ICU treatment center; opened in 2012, it draws patients from around the country. At the center, patients are treated by a team that includes an ICU physician, nurse, pharmacist, case manager, and neuropsychologist who work together to help patients understand and alleviate symptoms.
Jones said therapy in Chicago was a great help to him, and included revisiting his ICU room to better understand his hallucinations.
He’s also committed to talking publicly about his experience in hopes others won’t suffer as he did. And he always carries a carefully worded life directive in his briefcase that makes clear that any intensive treatment he might need is provided in a way that is less likely to cause delirium.
“As bad as my illness was,” he said, “the post-ICU was more traumatic.”
The opiates, the pain, the sleep deprivation pushed you into dreamland while awake. The stories you lived are told by your body, commenting on the situation, similar to normal dreams. I had that a second time for 10 days after another surgery, and needed strong stimuli to wake up (half an hour MRT loudness did it for me). But the content of the dreams is food for thought for years to come. Wish you all the best,
I was incubated for 11 days in icu , i was never aware that i was even in the hospital for kidney and liver failure double pneumonia and septic, i was in a nightmare cycle of many different lifes, when i finally did wake up i thought everyone was trying to kill me, i lived over a dozen different lifes and was murdered in about 8, i thought i had laryngitis the whole time, the hospital never realized that they were speaking to someone else engaged in conversations i never had, it was not me they were speaking too. Help me understand please
Bull crap! There
s no such thing as “ICU delirium”. It’s all made up to somehow get money thrown at the subject; medications, reports, studies, medications, etc. If a person has delirium there is a underlying cause, and it’s not the ICU. Because medical people don’t know what causes something, they begin inventing acronyms, causing panic and reaching for money. And, by the way, a catheter change IS sexual abuse. Primarily because most nurses and techs don’t know how to select the correct size do it properly.
Ignorance is bliss. maybe you should consider the idea that although you had one experience other people might have had other experiences so do me a favor and don’t State everything you think and feel as fact for the entire world because in my case you are dead wrong
My father in law is going through this right now! Severe car accident, 2 major surgeries and now this. The family are at our wits end. I’m afraid to tell them this may have lasting negative affects.
I am so sorry Lynne. I am praying for you. It truly is an awful, heart-breaking experience. Praying your father in law gets better very soon. When my dad had it, getting up and walking did help him get oriented some. There seems to be a relationship between gross motor movement and improving.
So true, and so scary to see a family member go through this! It is awful!
I am so glad to come across this article! My mother was in ICU for about 4 weeks. They had her heavily sedated and on fentanyl for about 2 weeks of the 4. She was ventilated 3 times. We noticed early on in the second week that she was not mentally right but we were told it will go away when she goes home. 2 years later, she still suffers with severe sort term memory loss and cannot be alone. Is there help for her? Please!
My 20 six-year-old daughter had a recent heroin overdose and was in the ICU for 20 some days. The first 15 she was on a vent, intubated and receiving Versed, propofol, Precedex, and 300 µg of fentanyl an hour. I was told this was because she was an addict and needed this much sedation. After eight days, I felt that they needed to turn down the sedation so that she might wake up, but the nurses told me that she needed to wake up slowly and calmly and cooperatively.
I sensed that she just needed the sedation turned down so that she could cooperate, but no one would listen to me. She ended up with a tracheostomy due to stridor after extubation.
One great nurse, finally turned off her sedation and unrestrained her and she was awake!
When she awoke she pulled out her NG tube and after three failed attempts to re-insert it, she refused it. She went three days without food, oral meds, and no IV fluid, even though I asked for them to at least hydrate her. She wasn’t alllowed ice chips due to failing a swallow study. She also did not receive methadone through the NG, which was fine, but I think it caused her to go into withdrawal. She began having nausea, vomiting and diarrhea. Day three of no food, fluids, she started hallucinating.
The nurse medicated my daughter with Ativan and Benadryl, which did not seem to be helping. I requested Haldol be given for the hallucinations. This calmed her down enough for hospital security to four point restrain her.
When I left the hospital that night, my daughter was restrained. I thought she was safe. I found out at six the next morning that there had been an incident. Apparently my daughter had been unrestrained at some point, got up out of bed, tried to dress herself and leave the hospital room. The 1:1 sitter and her nurse tried to contain her. My daughter ended up scratching the nurse’s arms. The nurse filed criminal charges against my daughter!
I am her temporary guardian and was never notified that charges had been filed. When I was finally granted a meeting with the unit manager (3 days later) I was told that I could request the medical record if I wanted details.
The unit manager totally supported her nurse even though she denied having seen the scratches with her own eyes.
I asked my daughter if she remembered any of what happened. She said she felt terrified that she was in the wrong hospital and the people were trying to hurt her. She claimed the nurse kept injecting and injecting meds into her IV, so much so, that she thought she was trying to kill her.
I should never have left my daughter alone with this nurse. My daughter had a tracheostomy and could not even speak during this entire episode.
The city police, rather than hospital security were called so the nurse could press charges.
This has caused so much stress and emotional pain for my daughter and me. I’m a nurse myself and I WOULD NEVER HAVE DONE THIS TO A PATIENT IN A VULNEABLE STATE!
Why be a nurse if you can’t handle confused ICU patients and end up doing more harm than good to them.
This has traumatized me for any future hospital stay. How can anyone ever trust the nurses of this “safe space” generation to use common sense and care for you? WTF has gone wrong with this world???
I do feel badly for the nurse if she was scratched or scared herself by my daughter’s delirium, but surely there are protocols to follow that are better than filing criminal charges against your patient in ICU delirium. Where is the compassion? My daughter is 5,2 115#.
The nurses on the next shift, sedated my daughter with low dose Presedex and let her sleep 20 hrs, she was back to herself the next day.
Now, she is facing a felony!
Please know this is happening.
Wow, I’m so sorry that your family had to deal with a nightmare on top of a nightmare. What a backwards world we live in where a Nurse files criminal charges on an ICU patient. I hope the charges were later dropped and your daughter is doing better. Thanks for sharing this as I agree that people need to know this occurs.
Are there any facilities in Arlington TX or the Dallas area for patients with ICU DELIRIUM once discharged from the Hospital
I’m sitting here in the hospital cafeteria reading the article about ICU Delirium, it was sent to me by my niece because I had explained her mom’s behavior as it was explained to me by the nurse, ICU Delirium. After 3 days of being in the Coronary Care Unit (ICU) , she began with hallucinations and strange behavior. We couldn’t understand it, but after reading this article, we have a better understanding. My question is, are there any after ICU treatment centers near Southern New Jersey because I fear she’ll definitely need it!
I am praying for you. My dad suffered from ICU delirium, and it was a nightmare I can’t explain. I hope your loved one gets better.
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