Episode 134: Are We Sedating Them to Death?

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We know that deep sedation is an independent predictor of mortality. This guides most sedation orders to require a RASS of 0- (-2). Is that what is really happening at the bedside? What percentage of patients are actually lightly sedated to the RASS goal vs. deeply sedated? What is driving oversedation throughout the ICU community? What are the risks to patients and nurses when RASS orders are not followed? We dive deep into this with Alexis Nowling, MSN.

Episode Transcription

Kali Dayton 0:00
To preface this episode, let me disclose the truth that I am guilty of inappropriate sedation practices. Though I started my career in an Awake and Walking ICU, when I started in other ICUs, I slid right into the “norm” that surrounded me. I noticed that care was very different than the ICU I came from, but the normalcy of this differences blinded me to the reality.

That “norm” included automatic sedation for every patient intubated for any reason, deep sedation, and jokes about sedation. As an RN fairly young in my life and career, I assumed that normal meant ok.

I worked in critical care medicine for almost 8 years in absolute oblivion. I became aware of the high risks and repercussions of sedation in the middle of my 3 year doctorate program that was highly focused on the ICU. Shockingly, in training nurse practitioners that were going to guide these practices and prescribe these medications, information about delirium, mobility, long-term outcomes, sedation practices, etc. were NEVER discussed in that program.

The case studies we used for learning continued the assumption that all patients would be sedated upon intubation and even vasopressors would be added to counteract the proprofol being given in cases that I now recognize did not have an indication for sedation.

The only reason I became aware of any of this was when I heard it from a survivor on a plane ride and then scoured the research myself. I was shocked and abhored to learn about what I had been doing. I still get upset to think that I was given the liability as a nurse without the training.

So I absolutely empathize with nurses that come to me dumbfounded during my trainings and tell me, “I’ve been here for years and was never really taught how to do the RASS, let alone WHY I was doing it. I didn’t know how dangerous these sedation practices were.” — I share that devastation and indignation.

Sometimes sedation and even deep sedation- are unavoidable such as cases of ICH, status, epilepticus, the inability to oxygenate with movement, etc. — so it is vital to understand when there is an indication for sedation and when there is NOT, because continuous sedation comes with a price. To do a risk vs. benefit analysis before starting sedation, we must understand and discuss the risks that include:

Increased mortality
Infection
Pressure injuries
Emboli
ICU acquired weakness
More time on the ventilator
VAP
Tracheostomy
Rehabilitation
Delirium
And long-term impairments and disability in the form of post-ICU syndrome.

So when we’re navigating sedation practices, let’s zoom in on delirium.

Delirium alone doubles the risk of dying. It increases the risk of long-term cognitive impairments or, “post-ICU dementia” by 120 times. It increases the risk of post-ICU PTSD.

When we think of delirium as a manifestation of acute brain dysfunction or acute brain failure, we see it as equally concerning as other organ failures.

As mentioned in previous episodes, a positive CAM score should solicit the same or higher concern than elevated troponin or creatinine. Yet, in reality, it is independently associated with the worse outcomes compared to other organ dysfunctions.

We know that sedation is one of the main modifiable risk factors for delirium in the ICU and that mechanical ventilation is not an automatic indication for sedation.

I love what was said in a article published in the Lancet journal this month, “Sedation—defined as the administration of a sedating medication to impair consciousness—is a common practice in the ICU due to traditions of clinical teaching and other reasons that are not evidence-based and not necessarily patient-centred.”

We know that the depth of sedation impacts the rate of delirium as well as the severity of delirium.

One study evaluated ARDS patients with and without COVID. They found that 72% of patients had excessive sedation meaning deep sedation- a RASS of -4 or -5- when patients require touch to stimulate a response. 60% of all the patients had delirium, and 86.4% of those with deep sedation had delirium.

It was concluded that deep sedation was independently associated with the development of delirium- no matter the age, risk factors, acuity, etc.

41% of all of the patients died and 90.2% of those deceased patients had been deeply
sedated. Like many other studies, it concluded that deep sedation was an independent predictor of mortality.

Looking only at the length of stay, the average ICU length of stay of those that had excessive sedation was 22 days.

Those that were NOT sedated had an average length of stay of 14 days. That is an 8 day difference. – they did not measure discharge disposition, but we can imagine the difference in the condition patients left the hospital and where they ended up between the groups.

The ABCDEF bundle decreases the rate of delirium by 25-50% depending on the level of compliance- the less sedation given and more mobility provided, the less delirium patients suffered.

So when we start sedation, and especially when we titrate sedation, we need to be very careful and sober. The deeper we sedate patients, and the higher the dose of sedation we give, the worse outcomes patients will have.

One Brazilian study looked at the first 48 hours after intubation for 5,719 patients and found that only 29.9% of patients were at the target RASS goal of 0-(-3)- meaning responds to voice. Of course they found that those that were within that target RASS had better survival rates.

Bottom line is: Numerous studies confirm that deep sedation is an independent predictor of mortality.

So, if deep sedation is a level of sedation that makes the patients unable to respond to voice…. And deep sedation doubles the risk of dying, then we need to honestly look around and ask ourselves, “Are we sedating patients to death?”. Sometimes it takes a fresh perspective and some objective data to answer hard questions like that. So I invited someone that was willing to find the answers in order to inspire solutions.

Alexis Nowling, MSN 0:24
Well, thank you so much for having me. I am recently graduated from St. Louis University. I did their accelerated direct entry master’s program. So I came in with a degree in marketing, and did the 21 month program and just graduated on the 20th. I’m scheduled to take my NCLEX in two weeks.

Okay. Um, but I, I was drawn to nursing through river guiding, actually, I became a river guide. And one of the certifications I had to get was my wilderness first responder. And doing the wilderness first responder kind of opened my eyes to a little bit more of, you know, emergency medicine and patient care, which was something that I had always been interested in, but I thought that it was too late. I was in my mid 20s. It was too late.

I know, right. So I, after I got my wilderness first responder, I moved to Portland and got my CNA license, and worked in the hospital OHSU there. And during that time, realized that I did want to pursue nursing and had applied to programs kind of all over the country, I was looking for something that was accelerated, hoping to be done within you know, two to three years. And kind of got into slew last minute move to your in 19 days from Portland. And yeah, got started. So that’s, that’s a little bit about where I came from.

Kali Dayton 1:46
That’s great. And so you’ve been a student in the ICU? Yes. And what what drew you into doing critical care medicine?

Alexis Nowling, MSN 1:56
Um, you know, so I think, I think it’s kind of the same the type of people that like, adrenaline sports are the same type of people, I think, that are drawn to critical care. And I initially had thought I wanted to do Midwifery, which was why I was looking at getting a master’s.

And during my labor and delivery rotation, I absolutely loved when we were in delivery, and things were moving quickly, and it was high intensity. But then the other nine hours of the day, were pretty slow. And luckily, most of the women we worked with were in great health, they didn’t really need much, which is what you want. But it just wasn’t the pacing for me. And so when I had the opportunity to do my senior capstone, in the ICU, I was I was really drawn to it just because of the pace of the day, you never know what it’s gonna look like you could get a patient that’s completely stable in the morning. And by rounds, things have totally changed. So I like that kind of the unpredictable, high intensity, fast paced environment.

And similar to where we’re guiding as well as kind of that teamwork that you are really close with the people that you work with. It is definitely an all hands on deck type of thing, which I got to see a couple of times when we had code situations on the floor. So that is all stuff that I found really appealing about critical care.

Kali Dayton 3:16
Yeah, I think we all entered wanting the high adrenaline big stuff, the big sexy things, right. And so that’s actually probably one of our barriers is that we miss take the the power of the someone calls them the soft skills, the smaller things are things that are perceived to be smaller, therapeutic touch, communication, delirium, assessment, those kind of things.

So as a student, and this is where I’m really interested, because I think this is really insightful as to how we get stuck in our sedation mobility practices. So as a student, you’re coming to the ICU, you have no past experience, you don’t carry any kind of training in this. So when it comes to sedation and mobility, what has been your immediate understanding upon entering the ICU?

Alexis Nowling, MSN 4:10
Yeah, um, I think that my immediate understanding is was very similar to, I would say the lion’s share of of lay people when they think about people being intubated. They know from TV shows, or maybe personal experience that when somebody has invasive mechanical ventilation that they are also going to be sedated. It’s like those two things go hand in hand. And because my program was accelerated, the time we spent on critical care, nursing was pretty it was a pretty quick overview.

And so in that time, it was just kind of, you know, these patients are sedated was what we were told, which I think is is probably pretty reflective of a lot of students experience. And so when I was going into the ICU, I had started listening to this podcast, which had given me a little bit of a different perspective. But I went in knowing that I would likely see what I had been taught, which was accurate and reflective of my experience during my senior capstone.

Kali Dayton 5:19
Okay, so you were listening to the podcast, while pretty new into your ICU experience? Yes. Even for seasoned clinicians, it can be very conflicting. Yeah, you hear survivors talking to their experiences and clinicians and researchers, and you’re like, “Oh, this is how it should be. Here’s the problem.”

As a lot of times, people are listening on their way into work, then they get into their units, and they’re seeing the exact thing that we’re preaching against, you know, that we’re so concerned about. So what was that like for you? When everything’s so new? You know, you’re, I know what it’s like, you’re still trying to figure out how to run the IV pump. Right? Yeah. Right. And here I am in your head and your your headphones been like, “We’re traumatizing patients when they’re sedated.”

Alexis Nowling, MSN 6:02
Right.

Kali Dayton 6:03
So and now you’re faced with this reality, while immersed in this culture? So I just I’m always curious, how is the what is that like, for you?

Alexis Nowling, MSN 6:14
Um, it was, I mean, it was definitely, it was conflicting, that’s a great way to put it. I think that for my, the role that I was playing, I knew that in that moment, I could not necessarily be the catalyst that I want it to be to affect change. However, I knew that there are little things that I could do when I was providing patient care. So just, you know, speaking to our sedated patients, and listening to one of the episodes where someone had said that they were saying her name over and over and over.

So just trying to be aware and trying to keep conversation with these patients normal, conversational, and explain what we’re doing, and who knows how much of an effect it had. But I know that from listening to those episodes, patients spoke a lot about the fact that they could be aware, semi aware of what was happening. And no one was talking to them. It was like they weren’t even there. And I, I also had some really good dialogue with a lot of the people that I worked with, I had an incredible preceptor, I love her to death, I feel so lucky to have been paired with her.

And she was shocked as well was had never heard of awakened walking ICUs thought that the concept was, you know, from her experience, she sees the spontaneous awakening trials, right? Where in which patients have already become delirious. And so kind of getting in the mindset of okay, but what if that didn’t happen? What if we just didn’t cultivate that environment from the get go was kind of like this light bulb of, oh, you know, perhaps, and she was kind of like, you know, “I’d have to see it to believe it.”

But I was like, maybe we could see it. And just starting to have some of those conversations with with nurses on the unit. And part of my project actually did involve a teaching element at the end. So those were just little ways that I tried to affect some change. And I think just having the conversations, and it’s kind of nice when you’re a student, because you can just be like, Well, why are we sitting there like, “Okay, but why?” you know, then you can kind of use that student card to your advantage.

Kali Dayton 8:29
Absolutely. I’ve told students that right. Like, you’re there to learn, you’re there to absorb everything that you can in that moment, and it’s overwhelming. But as part of that, you can ask questions, so maybe there is a reason that the patient is sedated. If there is you need to learn why they’re sedated. But that is powerful question.

I think that when I propose that in conferences, when we are today, intubating patients, we need to ask, is there an indication for sedation, and you can just tell it, like, it hurts everyone’s brains, because we never do that. It’s just assumed. So don’t underestimate the power of just asking that question and making people answer “Why are we doing this?”

And having those conversations and again, there might be reasons why it’s necessary, and you need to learn that in that moment. So you’ve are having this whole inner conflict, and you’re learning all these things, and then it comes time to do your project. And how did you determine what made you want to do a project within this realm?

Alexis Nowling, MSN 9:33
Yeah, the Instagram algorithm worked in my favor. I one day just had your podcast pop up and one of the posts, I kind of got sucked in and when I think I read every post on your Instagram and started listening to the podcast, and that was what piqued my interest because I knew that I was going to be in the ICU and didn’t have a project yet. assigned and was really interested in the idea of having this experience of Awake and Walking ICUs and what that could look like.

But also knowing that for Masters projects, you need to find something that’s appropriate and you know, can be done in a timely fashion. And so we actually had the opportunity to chat and I told you kind of the framework for what the project had to look like. And you had suggested that we examine patients prescribed RASS goal with their actual RASS score, which I think is a great first step to opening the dialogue of “Why are we sedating? How are we sedating? How much are we sedating?”

And are we compliant with our orders. And so that’s originally what got me interested. And then just kind of my day to day when I was precepting on the unit, seeing how many patients were intubated and sedated, and oftentimes, how deeply and not even going in and doing an official assessment even on patients that weren’t mine, but being able to see that they’re not responsive to the level that they are prescribed. And that is something that I think is really important to explore, when you want to start a conversation about sedation practices as a whole.

Kali Dayton 11:25
And that suggestion that I gave you was inspired by feedback that I’ve been hearing from clinicians, all over the country in the world of all disciplines. A lot of therapists are saying, I see the the RAS is targeted to negative one, negative two, but I go into work with them. And they’re barely arousal to touch.

If a patient does not respond to voice, they’re deeper than RASS than negative three, and they’re deeply sedated, which is an independent predictor of mortality. So a lot of people are concerned when it when they’re hearing this when they’re wanting to work with patients. They’re realizing what is charted is not what’s happening. And this whole discussion is not to incriminate nurses, right?

We can’t avoid the reality. This is a bad thing. Right? This is dangerous to patients. This is dangerous to nurses. This is a huge liability. When we are sedating, deeper than the prescribed RASS, we’re giving sedation that was not prescribed. We are giving medication without an order. And that is outside the scope of an RN license.

Alexis Nowling, MSN 12:26
Yeah,

Kali Dayton 12:26
That can be a huge liability. So when it’s when the repercussions of this malpractice, I guess can be lethal. That should ring all sorts of bells. Right? Nurses, we’ve seen in recent events that nurses are carrying a lot of liability, which has which has been unfair, right?

‘What happened at Vanderbilt was was really alarming to the entire nursing community. So I am worried about nurses being held accountable for things that they’re never taught or trained on. Yes, nurses that have been in the ICU maybe have been somewhat tired of the RASS there. They have to chart on it throughout the day. But when I’m doing consulting, and I’m training at the bedside, repeatedly, I’m seeing that they do not know the RASS.

I think especially those that have come in during COVID. It pops up in the EHR. They see a scale, they see what’s ordered, and they see what’s charted before them. And they’re like, “oh, yeah, probably it’s probably negative two, there abouts, or whatever.” And they move on.

Alexis Nowling, MSN 13:27
Right.

Kali Dayton 13:28
And so they’re not taught how to really assess for the RASS, but especially they’re not taught why. Why it’s important. Did you see any sense of urgency? When and if you note you brought up to your preceptor Anyone, anyone around you? Hey, they’re received negative for but but they’re supposed to be rested? Negative one, did you see any kind of panic about that?

Alexis Nowling, MSN 13:48
Definitely not panic. Um, I do think that there was a level of concern that varied from individual to individual based on a gamut of things, how long they’ve been nursing their experience in the ICU, what they may or may not know about sedation, but I don’t think that as a whole, the community has learned enough about the, the extremely harmful negative effects that over sedation can cause.

So I think that people are under the impression of, “okay, they’re oversedated, but that’s okay. There’s the you know, yeah, they’re asleep, the resting. It’s not that big of a deal.”

Where, in actuality we can be causing life life threatening harm to these patients. Um, something that I was a way that I kind of related it to one of the nurses that I was talking about was, we don’t put a catheter in everybody. It’d be easier. It’d be cleaner, there wouldn’t be skin breakdown. But the skin breakdown is not the biggest threat. The threat of infection is and that is the price already.

Same thing with sedation is, “Okay, they won’t be pulling out their lines and tubes if they’re deeply sedated. But are we going to leave them with long term cognitive deficits, because that’s the priority.”– And I think that there’s just sort of this disconnect between what those of us that have have kind of done a deep dive into sedation, know about the negative effects versus just a basic understanding of RASS and sedation. And if you don’t know, what can cause the side effects, you don’t know to be concerned.

Kali Dayton 15:33
Absolutely. And this is where I get really defensive nurses, because let’s say for example, something happens, right, delirium happens, there are lethal complications. And this goes to court. And they’re seeing that a RASS is charted as negative two, but the physician and the PT and OT and anyone else that comes in charts, unable to arouse unresponsive to voice, that looks really bad, right?

If you have three other people charting this certain thing, or you have no someone charting at a negative RASS of negative two, and the next nurse comes on, it’s only it started at negative four. But the dosage of medication hasn’t really changed, or you know, different things. There’s so many different ways in which this could be exposed.

And the nurse will be held accountable, right? Because it’s their shift their patient, they’re the ones given that medication. But looking at it, they were never taught the risks of that they were never really taught how to do a RASS score. They didn’t know and so they were just doing what everyone else was doing. Right? We do that in so many other ways where we come on shift, and we just keep things status quo, right?

Unless we’re really questioning why is it this way? Is that right? Is it not? But yet, it’s gonna come down to that nurse, most likely, which is completely unfair, right? It’s a systemic problem. It’s not just that one nurse doing it, or even just that one unit doing this throughout the community, but so I get really defensive.

And I’m worried about nurses holding that liability, because the public is going to know at some point, and this could look really bad. And it’s unfair. No one’s doing this maliciously. No one’s trying to harm patients. But I remember when I first met my, this ICU survivor on the plane ride, and I was realizing the trauma had suffered. I had the thought, “Well, this can’t be a normal thing, because I would have heard about it. I would have known I’ve done ICU and like 11 Different ICUs over seven years, you know, I, I would have known, right?”

And then when I went on to Facebook groups, and I was listening to survivors, like hundreds of survivors talked about this, I was going into the research, I was just enraged. I just thought “What, what have I been doing? Why didn’t anyone telling me? If I am the one running starting titrating, the sedation? Shouldn’t I have a right to know what it really does to patient’s?

Because I believe just above everyone else that it was “sleep”. So when we don’t change those beliefs, we cannot change those practices. So yep, so you, you understand. And you’ve seen this concern, right? You were noticing this and so you’ve set out on your project, to really put it into numbers.

How off are our RASS goals because I’m hearing this from all over the country. But I was like, “You know, Alexis, if you could just figure out, you know, go throughout your unit, break it down to the numbers compare what’s charted to what’s actually happening at the bedside? What does that look like?”

Alexis Nowling, MSN 18:24
Yeah, So the unit that I did my project on is a large Midwestern medical ICU. So the patient population kind of runs the gamut, pretty broad, you see a lot of different conditions. And so on that units, the breakdown was 52% of patients were over sedated, according to their prescribed RASS goal.

So the the lineshare of patients on this unit, if they were prescribed sedation, they were given a RASS goal of negative one to negative two, and 52% were over that, over that prescribed goal.

And of that 52% 38% were one point away on the rest score from their prescribed goal. And 62% were two points or more– so deeply sedated, especially if you are already at a goal of negative two, you’re getting in a negative four, negative five, you are completely unarousable.

And one of the one of the papers, I can’t remember exactly what when it was found that it was I think it was the patients or a negative three or greater. The likelihood of mortality doubles–both within the ICU within the hospital and within the first year of discharge.

And it was alarming. I had thought that patients would be oversedated. I think that that is common in most ICUs that haven’t started this dialogue, but I was pretty surprised that it was as prevalent as It was,

Kali Dayton 20:01
And this is not unique to that unit. I’m so glad that you did it there. Because when you you shared this at an IC revolutionist group meeting, and if anyone wants to join that, let me know. What would you share that everyone was nodding their heads?

You know, you had a couple dozen people from all around the country and even the world. And they’re like, “Yeah, that happens. Yep.” Um, that that group, they were concerned about it, they were glad to see actual numbers to it.

But they were not surprised. Right? They’re like, “Oh, finally, Alexis put numbers to what I’m seeing at the bedside and my team.” So this is not just one nurse. This is not just one team. This is a huge systemic problem. And it is lethal, right.

Alexis Nowling, MSN 20:43
And that was something that I really tried to convey during the teaching portion of my project. I can only imagine what it would be like to be a seasoned ICU nurse and have a student come in and present this information. And kind of be like, “number one, what are you talking about? And number two, you don’t know what you’re talking about?:

Kali Dayton 21:03
“Who are you to tell me?”

Alexis Nowling, MSN 21:04
Exactly. And I understand. And that was why it was important for me to try and stress. This was not, this is not unique to us. This is not unique to a shift. This is not unique to a set of nurses. This is pervasive throughout the ICU community. And it was the research that I did, along with my paper really highlighted some of that that we’re seeing for for different units that have kind of examined this.

Kali Dayton 21:31
Did they seem shocked?

Alexis Nowling, MSN 21:34
I wouldn’t say that they seemed shocked. I think that people are aware that patients are heavily sedated. I think the thing that was surprising to them was when I was elaborating on the long term negative effects. That I think was shocking.

‘ I don’t think the the, you know, the numbers were necessarily what was shocking, which kind of just circles back to the need for more thorough teaching and better understanding of what sedation actually does to the body?

Kali Dayton 22:08
Absolutely. I mean, I’m sure there are some isolated people that maybe are, quote, “lazy”. You know, I’ve heard people say that. That’s not my general experience at all. When I present this at conferences, I see so much concern, people come up to me with tears in their eyes. And I really try not to be abrasive or totally jarring with this, but I’m pretty honest about “here’s what patients experience, here’s what the data shows, here’s the reality of it.”

But nurses care so deeply that they are disturbed by it once they know. But I just feel like past efforts to roll out early mobility or the ABCDE F bundle. We’ve been very either tactful, or just not forthcoming about what we’re actually doing. And so it hasn’t really made sustainable change.

You have to hit the heart of nurses, which is compassion, love, connection, like that’s what they care, they deeply care about patients. And when they still believe that sedation asleep, that it’s more humane, that’s preventing trauma, there’s no way you’re gonna get them to change sedation practices, because they believe that they’re doing the right thing for patients. And that’s what they want to do.

Alexis Nowling, MSN 23:18
Right!

Kali Dayton 23:18
So why why would they ever? I would never write I would be like, Yeah…. So I asked one team when I was at this bedside and like, so do you know why we’re doing simulation training? Or why are we worried about delirium? And I kept hearing, “Because it increases length of stay.”

I was like, “Yes, that is true. It does. I mean, it can increase like this day by almost five days in the ICU almost seven days on the floor.” Absolutely. But I think that they were, I got the sense of “Yes. Because the administration wants you here to do this training so that we save money.”

Alexis Nowling, MSN 23:51
Yeah, it feels like the NCLEX- “That’s correct. But it’s not the most correct.”

Kali Dayton 23:56
But not the most correct. Yes, It’s an aspect of it. Like when I’m presented with the C suite about the financial picture. I do bring in survivor testimonials. But I really do focus on the financial picture, which is very compelling, right.

But for clinicians, that’s not that’s not any skin off their back, right is that they’re not going to try to save money at the expense of patients, but they are going to care about what patients experience and how will they survive. So once we talk about that, then they’re like, “Okay, I’m in.”

But if we’re just posing this as for decreasing length of stay, they’re not going to buy in, right, right. But once they experience for themselves, that it decreases workload that they walk out the door is better, like all these other benefits. It all adds to it, but they have to hear it from survivors, and we’re not providing that perspective. We are setting nurses up for really inappropriate liability.

Alexis Nowling, MSN 24:44
Yeah. Well, and I know that for the unit that I was on in particular, they, the education team did have the intent to try and introduce some of these awaken walking practices early 2020 It COVID hit and it set us back years.

And I think on top of that you also have that generation of nurses that started work during the pandemic. And so their understanding of what nursing is, is different than any other generation before them. And many of those patients did have to be deeply sedated because they had to be prolonged and paralyzed.

And that was appropriate. And so then when you get in the mindset of sedation, deep sedation is appropriate. It’s hard to come out of that and say, you know, in some circumstances, yes, but not at all. And

Kali Dayton 25:39
This perception of higher acuity equals higher sedation levels of sedation. Yeah. Even even with physicians, I was at a meeting and someone said, “Yeah, but a lot of our physicians are worried because…we like what you’re saying, but our patients have vasopressors.”

And I was not sure how to respond at first because I’m like, “Well, then what is the indication for sedation in vasosuppressors?What evidence supports that?”— so this is not just a nursing problem, right.

I mean, there’s a universal perception of “The sicker patient is, the more indicated they have to be sedated, and even the more sedation they’re going to need because they’re so sick.” And so how do nurses even have a chance to do best practices?

And recently, I saw a video someone sent me a video about it was a head of propofol bottle had someone kind of smirking and saying when the nurse when you know the nurse before he has been giving extra doses of propofol throughout the night. And it obviously that’s bothersome, but even the comments were divulging the reality. They’re like, “yeah, I dropped up propofol from before the pump and I inject it after the pump.”

They were sharing their their ways of giving bolus doses, and is laughing about it. And I was like, “Don’t let any attorney see this. Don’t let any family see this. This is such a huge, like, you’re just exposing your malpractice all over the place.” But the fact that they were laughing about it did not show to me so much as cruelty, but of oblivion.

Alexis Nowling, MSN 27:16
Right!

Kali Dayton 27:17
If they knew like how we’re increasing trauma and death and infections and work and long term disability and cognitive impairments, like if they knew that, there’s no way I really don’t think any nurse would be joking about that, let alone so openly online.

But this has been shared in the 1000s. liked in the 10s of 1000s. Like it was going like wildfire, like any meme on sedation does, because everyone does think it’s funny. I used to laugh those jokes before I knew. And so when I first started realizing what was going on, I just felt so guilty and so sick, just remembering how nonchalant how casual and how humorous, I found all of it.

And I’ve had to go through the process of just forgiving myself moving on. Just letting myself have some grace that I just I did not know, that’s not what I was really laughing about, in my mind. But it just is so exposing, and there are so many sedation memes out there, that the podcast listeners are just upset about it now, but I don’t know any other corner of society in which we openly joke about inhumane treatment that causes suffering and harm and even malpractice, like where else.

You know, we’re in such a culture that we’re very protective of each other about being insensitive about any kind of disparities and yet, and in amongst the the discipline that should be the most trustworthy. The most compassionate, the most protective. That’s where the worst jokes lie. Right? It doesn’t make sense. But if people say that’s how we deal with our trauma, but I don’t think that’s really, I don’t think that’s really what these jokes are rooted.

Alexis Nowling, MSN 29:07
Right? Well, I think there is something to be said too about this. It’s it’s kind of like a camaraderie that is formed through making these types of jokes. Because the layperson doesn’t know what profile is, doesn’t know what it does.

And so it’s like, a little nudge to your buddy. Like, “Isn’t this funny? This is a joke that you and I get.” And we kind of discussed this briefly to I had a sticker on my water bottle that said, “I can’t fix stupid, but I can sedate it”. Because I didn’t know. I had no idea.

Kali Dayton 29:39
And it’s almost like a rite of passage to be an ICU nurse.

Alexis Nowling, MSN 29:42
Yeah, it is.

Kali Dayton 29:43
And I can say that because I started my career in an ICU, which we kept almost everyone awake and walking, right? Went to other ICUs. And I would ask questions like, “Why are this sedated? Should we get them up?” Things like that. But when I realized that, no one else was doing that and they thought I was crazy. And also you’re the new person you kind of want to fit in like?

I think that’s why I laughed at the jokes so I’m like, “oh, yeah, like how you’re right. That is funny…”-because I want to get ignited at that moment and say, “I don’t know, that’s that’s the right thing…” especially without knowing the research because I didn’t. I’d be even more isolated and less accepted.

So I think there’s a lot of level of “If you’re a real ICU nurse nurse, these are the jokes that you that are funny”— right? “This is just the way we practice.” And it’s such a disservice, because you’re going in the ICU, because you want to see patients survive and thrive.

Alexis Nowling, MSN 30:31
Right.

Kali Dayton 30:32
But when we teach you that “This is the best thing to do for patients, and especially this is funny, and that we can control patients with chemical restraints”– and things like that. We’re depriving you of that experience.

Alexis Nowling, MSN 30:43
Yeah.

Kali Dayton 30:44
And how are you not going to get burned out if you compensate patients, I hate to say, but like rotten bed, right, just like lay there and just disintegrate before your eyes, you’re doing all this work of turning, running the sedation, the vasopressors, to compensate for the sedation, you’re doing so much work to keep them alive, yet, you never get to see them actually survive.

You may see them roll out of the ICU and a gurney. But you don’t really get to see them thrive. How are you going to stay in your practice? Why would you say in the ICU for that long term? Yeah. What are your thoughts as you’re entering the field? You know, we’re seeing people leave in droves….

Alexis Nowling, MSN 31:20
Yeah. Um, well, I, some of my concerns about starting work in the ICU is exactly what you described, is that I… do you feel like I know, this research, I have this knowledge, I understand what could be done. But I’m the new kid. And I don’t really, you know, I’m done with nursing school, but I don’t really know anything.

Kali Dayton 31:43
Right.

Alexis Nowling, MSN 31:43
And so it’s kind of a, it’s gonna be a tough balance to strike. But I agree, I think that, I think that it just needs to be a mind frame shift from, we’re just, we’re getting them out of the ICU to, we’re getting them well. And that is where I think the disconnect lies. Because I think a lot of times, we’ll have patients come in that are already kind of seen as a lost cause.

And so I think that in those instances, it’s easier to say, well, you know, I did what was ordered, and I did what I could do. But if we are trying to revolutionize the way that we’re providing care, we can offer these patients a better shot, and it is the ICU, not everyone is going to make it but more people could be. And I really think that sedation is a huge thing that we could change that would improve patient outcomes.

And it really would take the same amount of work. Like you’ve said previously, the ICU was worth regardless, and you can spread it out over your shift through turns and changes and skincare, or you can cluster to the front end and try to keep them from being sedated at all. And the choice is yours.

Kali Dayton 33:05
So powerful. Polly Bailey, my mentor, the nurse practitioner that really started this whole process, I call it the Bailey method of allowing patients to wake up right after intubation. She always says that the front end determines the back end of critical illness. Yeah. So if we prevent malaria and prevent it acquired weakness, it just sets them off in a completely different trajectory.

And yeah, you might have to spend another extra 15, 30 minutes, right after intubation, helping them acclimate to the tube and touching their tube and looking in a mirror and things like that. But their family can help with that too. RTs can help with that, too. You know, you’d have up this whole culture where you’re not alone as a nurse doing things.

Alexis Nowling, MSN 33:46
Right.

Kali Dayton 33:46
As a nurse, you’re the only one turning the patient. You’re the only one on that station, or you’re doing the double checks with that it just it it’s an exchange and efforts if that.

Alexis Nowling, MSN 33:55
Yeah.

Kali Dayton 33:56
But nurses need to have the opportunity to experience that. And Alexis, I really hope you get that opportunity. And I’m optimistic.

Alexis Nowling, MSN 34:03
I hope so. I’m, I’m, I’m nervous. But I think that it can be done. And I know that the education team is on board already wanted to implement this, which I think is huge, because like we said, it’s not just a one nurse thing, you have to have a team behind you. And if they think it can’t be done, then you’re gonna have a much harder time than if you’re on a unit where the team is open to change. So I know that I have those guys in my back pocket. And I’m hopeful that there are enough people on the unit that are just as curious and interested in like podcasts and get on board.

Kali Dayton 34:42
Absolutely. I remember years ago before I started the podcast, I was interviewing in an A into an ICU and I mentioned the medical director that the greatest value I could bring is to help change our sedation mobility practices and walk patients on ventilators. And as medical director said, just so casually. “Yeah, the research shows that about that, it’s probably good. But good luck getting our nurses to do that.”

And I just, it took everything within me to stay calm and composed in that moment because again, I’m very defensive of nurses. I’m super bias coming from the nursing discipline. I was like, “You must not know nurses like I know nurses.” It’s not that they won’t do it. It’s like your team, they’ve never even been exposed to that information.

That concept, they’ve never been given the why, the tools to do it, the support to do it. So don’t say that they won’t do it. Give them a chance to do it. So your findings are so significant, but not to incriminate nurses. Right, but to expose the lack of support that nurses have had, especially during COVID, that they’ve been left on their own to navigate these things with this weight of impact that they have no clue about.

Alexis Nowling, MSN 35:54
Right.

Kali Dayton 35:55
And so add that to the list of injustices that are happening to nurses right now. And in reality, if we’re talking about safe staffing ratios, more education, more support, better culture. Advocating for sedation mobility practices, is probably the best way to do that. If you want to put dollar-figure to why they should have text on the unit, when nurses shouldn’t be increasing sedation to go answer phones, or running to grab bedpans…that’s why.

Alexis Nowling, MSN 36:21
Right.

Kali Dayton 36:21
So nurses that may feel defensive about your findings, need to understand that this is in support and advocacy for nurses for greater support, staffing ratios, all of it so that nurses can really practice within their license and to the top of their license. Yeah, absolutely. So low nurses out there, we we appreciate how lonely and frustrating this can be to have this perspective.

But please hang in there if you even just changing and lightening the sedation avoidance ation on your shift for that one patient. Having those communications with your colleagues teaching them in that moment, like,

“Hey, I see that, you know, that came on shift and they were negative four and they’re a RASS of negative one or zero right now let’s keep them that way. Because they have delirium, and we need to treat that delirium” or “Well, let’s avoid deeply sedating them because that increases mortality.”

Just those like little comments, those little tidbits, they plant the seeds, they bring awareness. And so even just you as one new nurse, you are making an impact. As a student nurse, you’ve made an impact. So don’t underestimate your power as a nurse.

Alexis Nowling, MSN 37:28
I think about two, I think when you know, when Polly Bailey was starting this, she couldn’t change sedation practices for the entire country and the entire hospital, the entire unit, but you start with one, and you change that person’s life. And it builds from there. And I think that that is that is something that I keep in mind when I am starting to feel overwhelmed is that I don’t have to change the whole world in the day, but I can start with that one patient’s world and go from there.

Kali Dayton 37:58
Absolutely. And the impact that makes on your colleagues to see your patient awake, communicating, even mobilizing, that just is all part of the paradigm shift. And it’s going to build from there. So thank you, Alexis, for caring about this for your incredible work as a student and keep us posted on your career. I’m excited to hear what happens.

Alexis Nowling, MSN 38:16
Yes, absolutely. We’ll be calling you for a consultation. I’m sure. I Oh, thank you so much. Yeah,

Transcribed by https://otter.ai