Topic 10: Power differentials

Sedation for the health professionals working in ICU is a necessary tool that allows us to control our patient’s physiology. Control is the most important part of the sedation. It allows us to take over the lung mechanics and keep the patient quiet while we perform invasive and largely uncomfortable but necessary procedures on the patient. We feel that the end justifies the means. If we feel that the procedures are of utility and help get the patient better, then we remain positive about the necessary balance between the good and negative effects of sedation to balance the negative effects of the invasive procedures. If we feel that our treatments are of no or questionable utility, then we discuss the horrors of sedation and the procedures. When we are forced to do treatments that we feel are of no utility we talk of the moral distress this creates within us. 

How is sedation seen through the eyes of our patients? 

The control we seek creates lack of control in our patients. No longer are they able to control what we do to them and when we do it. They are in a world that is often not explained to them, where noises and conversations are often either incomprehensible, scary or simply irrelevant. The procedures done to them are often uncomfortable, and the reasons for having the procedures are often either not explained or not understood. If the treatments are not understood by our patients and our relatives it translates to higher levels of post traumatic distress. 

I tell my registrars to read Roald Dahl’s story of William and Mary to understand the feelings of entrapment that we may be creating in our patients. To summarise the story: William was an overbearing husband to Mary. He was a man of great intellect and sophisticated pleasures including classical music, academic books and intellectual conversation. Mary was the under recognised wife with simple superficial pleasures which included smoking, drinking, watching soap operas and listening to gossip. All Mary’s pleasures were heavily criticised by William and banned from their house. William later dies and arranges for his brain, eye and ear to be kept alive in a box so that he could continue his great work on music and literature and the university could analyse his brain waves. However, his plan was his thoughts and work to be kept alive. This plan is thwarted by Mary who according to William’s will has been left everything. Mary proceeds to take the box containing William’s brain, ear and eye home. Mary plonks the box on the kitchen table. Mary then proceeds to talk to the box about inane gossip, puffing smoke into the eye and when leaving the house runs a constant assortment of soap operas on the television for William’s box to watch. William’s brain could only shudder in the box at the treatment received. 

I tell my registrars “Be careful with the way you look after the ICU patients as they may be like William’s brain and only be able to shudder in the box.” 

To a degree we alleviate this horror by making the patient part of the decision to start and continue the treatment. In this case the patient has signed up to the same agreement that we find so protective. The agreement is of useful purpose to what must be endured. 

We also can reduce the negative effects of the sedation by ensuring that the patient has some control over the sedation and the activities. Pain scores and activities to empower the patient, such as walking the patient while on the ventilator are protective. Relatives controlling the conversation and reassuring the patients are similarly protective. The ability to comprehend your surroundings with good explanation and the absence of delirium is protective. The ability to distract yourself with music or activities you like rather than are chosen for you is protective. 

How is sedation and ICU more likely to be problematic for First Nations Peoples? Trust in our intentions must be present for our patients. The patients must trust that the treatments are both necessary and worthwhile. The trust may be difficult to gain if we have no First Nation faces amongst our staff. If the unit only reflects the colonial history and has no reflection of the rich First Nation’s history, it will be hard for the patients to feel confident that we will look after them with the same care as a white patient. The trust may be eroded by not using terms that are understood or worse, harmful to the patients. Culturally inappropriate wording can cause anxiety in our patients. Trust will be eroded by careless behaviour where the personal dignity of the patient is not considered, or a casual racist comment is made. Relatives may be made to feel unwelcome or feel unsupported as the visitor policies of the unit do not reflect the family sizes of the First Nations Peoples and no one bothers to tell the relatives why those policies are in place. Lack of help or lack of empathy for a relative who has used up all their money to come and visit the patient and has little for food and water to sustain them as they try and support their family member on the ventilator. 

As the person is weaning from the ventilator, what they need to do to stay calm and progress is explained by people in a language that is foreign to them and no one is near them who they naturally trust. 

How could they keep calm? 

They usually do not, so sedation is given to them to control them. This increased sedation to control the patient has two negative effects; it further erodes the patient’s own ability to control the situation and increases the side effects of the sedation drugs. 

How do we negotiate this trust? 

First, we acknowledge that we need to negotiate it. This means we have to understand this from the patient’s viewpoint. The easiest way of understanding the situation from their point of view is to let them be in control. However, to let them be in control trust must be established and we are back to square one. So, we need imagination and empathy to understand it from the patient’s view or advocates for the patient in the form of the relatives. Both mechanisms require cultural safety. 

It is of no surprise that patients and relatives feel disempowered by what we need to do to them. However, if we can make it a journey that gives our patients and their family hope and control then we may have our future nurses, doctors and ward staff come from these families as they will want to help others in a journey of hope.