Years ago, I heard Dr. Wes Ely refer to the “delirium factory” of the ICU as a “malignant normality.”

Those words have stayed with me and continually come to mind as I work with ICU teams.

Because when you see and participate in the same practices every day, even harmful ones can begin to feel normal.

What’s more, you may stop noticing what those practices are costing your patients.

A recent visit to an ICU brought this reality into sharp focus for me.

 

The Patient Everyone Thought Was Receiving Normal ICU Care

Not too long ago, I was working with an ICU team to conduct a gap analysis. My objective that day was to observe how the team approached sedation, mobility, and delirium management.

During rounds, I stood in the doorway of a patient’s room.

Before her illness, this 63-year-old woman had been independent. But by this point, she had spent three and a half weeks in the ICU, and roughly 2.5 weeks longer than I believe was necessary.

Her eyes were glazed over, she appeared lost in delirium, I could hear gurgling in her secretions as she struggled to effectively cough, and her shallow breathing and flaccid posture suggested severe ICU-acquired weakness.

To me, she looked dangerously close to needing re-intubation.

At this point, my mind was racing, and I started asking myself questions like:

• Can we help her sit at the edge of the bed?
• How do we immediately get her a verticalization bed and chest percussion?
• Can someone get her outside into daylight, provide meaningful stimulation, and help restore normal sleep?

I wanted the team to urgently assess every reasonable way to support her breathing, strength, and cognition.

But the conversation during rounds sounded nothing like the concerns running through my mind.

I heard laboratory results and medication updates, but no discussion of delirium, functional mobility, pulmonary hygiene, positioning, or cognitive recovery.

For a moment, I questioned myself.

Was I missing something? Was I overreacting?

Nobody else seemed alarmed, and the patient’s condition seemed to be perceived as entirely normal to the people caring for her.

Then Dr. Ely’s words came back to me: malignant normality.

 

What Is Malignant Normality in the ICU?

Malignant normality occurs when harmful conditions or practices become so familiar that people accept them as ordinary and stop questioning their consequences.

In the ICU, this can mean treating delirium as expected, prolonged bedrest as unavoidable, or deep sedation as the default for mechanically ventilated patients, even when a patient’s condition calls for reassessment.

Believe it or not, clinicians don’t have to be careless for this to happen.

They may be dedicated, experienced, and working under enormous pressure, but established routines influence what teams notice, discuss, and consider safe.

And while we all want the best for our patients, the truth is it’s tough to recognize when an ICU’s “normal practices” are working against that goal.

 

How Routine ICU Practices Can Contribute to Patient Harm

What troubled me the most here was that this patient’s deterioration hadn’t happened overnight.

As I learned more about the care she’d received, I saw how familiar, yet antiquated approaches to sedation, mobility, and respiratory support had continued even as her delirium and weakness worsened.

The team was addressing individual problems, but I couldn’t hear anyone questioning whether the overall approach was helping her recover.

 

Sedation and Delirium

While intubated, this patient had received sedation that contributed to delirium, despite what appeared to be a lack of clear indications for its continued use.

She already had several delirium risk factors, but when delirium developed, the response included more medications that could worsen her condition, and this cycle concerned me.

Sedation can make it harder to assess cognition and function, and delirium can then complicate awakening, breathing trials, and participation in rehabilitation.

And if the response is simply more sedation, the team may never adequately address the underlying problems.

 

Mobility and Physical Function

By this time, physical and occupational therapists had worked with her for more than two weeks, but nearly all of that “treatment” consisted of simply transferring her with a ceiling lift into a reclined chair.

To be fair, simply being out of bed can have psychological benefits, but a passive transfer alone doesn’t necessarily challenge the muscles a patient needs for sitting, standing, coughing, or breathing effectively.

She needed an individualized rehabilitation plan that considered what she could safely attempt and how to progress.

Instead, profound weakness had become another accepted feature of her ICU stay.

 

Respiratory Support and Missed Opportunities

This patient had repeatedly failed spontaneous breathing trials, possibly because of diaphragm dysfunction, hypoactive delirium, or both.

And following unsuccessful spontaneous awakening and breathing trials, the team resumed sedation and repeated the process the following day.

When she was too weak to be “agitated”, they finally extubated her. But she was too weak to sustain the work of breathing independently. So, she stayed supine in bed, receiving BiPAP and Precedex.

Still, she continued to struggle with atelectasis and poor secretion clearance.

As her oxygen needs increased, the team increased her high-flow oxygen support, and her oxygen saturation improved, which seemed to reassure everyone.

But an improved SpO2 did not mean her other problems had been resolved. She still had delirium, severe weakness, and inadequate secretion management.

Each intervention addressed something measurable in the moment, but I worried that the overall direction of her recovery was getting lost.

 

When a Patient’s Survival Is Considered a Success

I raised my concerns that day. But I was a visitor observing a team I had not yet trained.

A brief conversation with suggestions could not give them the shared knowledge, skills, and coordinated support required to rehabilitate such a compromised patient.

Two days later, she experienced a near respiratory arrest and required re-intubation. She subsequently received a tracheostomy and was transferred to a long-term acute care hospital.

The team considered her survival an acceptable win. They had treated her septic shock (3+ weeks prior to discharge), and they expected rehabilitation would eventually get her home.

But I saw the outcome differently.

Her septic shock had resolved by day three, and in my assessment, nine additional days of mechanical ventilation and sedation might have been avoided with an Awake and Walking ICU approach.

Unfortunately, she went on to experience more than a month of delirium and ICU-acquired weakness.

However, I believe her tracheostomy and much of her prolonged suffering were likely preventable, with all this unnecessary bedrest playing an important part.

I can’t prove what would have happened under different care, but what I do know is that there were several opportunities to recognize and address those complications earlier.

Looking back on it, I keep remembering that moment in the doorway, when everyone discussed routine numbers while I feared that the patient was approaching respiratory failure.

They saw her as a person still recovering from sepsis and needing oxygen support. I saw a victim of sedation and immobility continuing to languish in life-threatening delirium and ICU-acquired weakness created by ICU care.

 

How ICU Clinicians Can Combat Malignant Normality

Challenging malignant normality can feel intimidating, especially when the practices you’re questioning are familiar to everyone around you.

But there are practical ways to raise concerns, bring overlooked risks into daily discussions, and work with colleagues to reconsider decisions that may be limiting a patient’s recovery.

With that in mind, here’s some of what you can do to combat malignant normality in the ICU.

 

Question Practices That Have Become Automatic

Start by asking why an intervention is necessary for this particular patient today.

If a mechanically ventilated patient remains deeply sedated, clinicians should ask:

• What is the current indication?
• Has the team established a sedation target?
• If a patient spent another day in bed, what prevented meaningful mobility?
• Was there a clinical contraindication, or did the team lack a coordinated plan?
• Is the patient eligible for an awakening trial, or is there a specific reason to defer it?

These questions do not assume that sedation and bed rest are always inappropriate.

Some patients genuinely need these things, but the concern arises when nobody reevaluates the need, weighs the risks, or considers alternatives.

 

Bring Delirium, Mobility, and Function Into Rounds

A patient’s oxygen saturation, laboratory values, and medication list tell only part of the story.

During rounds, you should make room for information about cognition, muscle strength, respiratory function, sleep, and progress toward independence.

Ask what the delirium assessment showed, discuss the patient’s current mobility level and a realistic goal for the day, identify barriers to secretion clearance, awakening, or participation in care, and ask whether family involvement could help with orientation and engagement.

Most importantly, you should ensure that the discussion leads to a plan.

If the patient is eligible for mobility, who will coordinate it? If delirium persists, what possible contributors need attention? And if a breathing trial fails, what will the team investigate before the next attempt?

Having this kind of routine discussion is crucial, as it can prevent important concerns from disappearing between shifts.

 

Speak Up With Specific Observations

Speaking up is difficult when everyone else seems comfortable with the current plan.

At the same time, hierarchy and fear of conflict can make it even harder.

But you don’t need to accuse anyone of providing poor care. Just explain what you see and why it concerns you.

You might say, “Her oxygen saturation has improved, but she still has a weak cough, significant secretions, and limited mobility. I’m worried that lifting her to the chair is not strengthening the respiratory muscles needed to avoid re-intubation. Can we reassess her respiratory and rehabilitation needs together?”

That gives colleagues a specific clinical concern to consider.

Moreover, you should bring relevant evidence when it helps, ask for a response, and clarify the next steps. And if you believe a patient faces an immediate danger and the team doesn’t address it, you should follow your institution’s escalation procedures promptly.

Respectful communication matters, but patient safety cannot depend on whether raising a concern feels comfortable.

 

Involve the Entire Interdisciplinary Team

No single clinician has every piece of information needed to understand a critically ill patient’s recovery.

Nurses may notice changes in awareness, sleep, or participation, respiratory therapists can assess breathing demands and secretion management, physical and occupational therapists can identify functional limitations, and physicians can help address clinical barriers and coordinate the plan.

Families can also help by describing the patient’s usual cognition, abilities, and preferences.

So, do what you can to invite these perspectives into decisions while respecting each discipline’s responsibilities and the patient’s current safety needs.

The goal is to understand the whole patient and agree on meaningful next steps.

 

When You’re the Only One Sounding the Alarm

If you keep seeing the same concerns, document what you observe, communicate these things through appropriate clinical channels, and look for colleagues who can help examine the pattern.

Recurring barriers should also be brought to the attention of educators and leaders who can support things like better training, protocols, and equipment.

The fact of the matter is you can’t single-handedly change an entire ICU. But your observations may help your team recognize problems that its routines have made difficult to see.

All things considered, I know how unsettling it feels to stand in a room where everyone appears comfortable while you’re deeply concerned about a patient’s condition.

If that happens to you, you shouldn’t automatically dismiss your judgment.

Instead, you should try to recheck your observations, seek other perspectives, and keep advocating when the evidence supports your concern.

Because being the only person raising the alarm doesn’t necessarily mean you’re wrong.

And sometimes the first step toward better ICU care is having the courage to ask why everyone thinks the current situation is acceptable.

 

Could your ICU’s established routines be putting patients at risk?

Book a free consultation to explore how we can help your team recognize harmful ICU practices and make meaningful improvements to sedation, delirium prevention, and mobility.