Cessation of continuous analgesia and sedation in patients with acute respiratory distress syndrome (ARDS) receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) facilitates early extubation, family, patient and provider engagement, and mobility. Outcomes associated with an awake ECMO strategy have not been well described in the literature. The purpose of this study was to evaluate outcomes in patients receiving this strategy. This was a retrospective review of ARDS patients receiving awake VV ECMO. The primary outcome was survival to hospital discharge. Secondary outcomes included days requiring ECMO, time from cannulation to extubation, complications, patients requiring tracheostomy, hospital and intensive care unit (ICU) length of stay (LOS), and discharge disposition. In a subgroup analysis, outcomes were compared between non-COVID and COVID ECMO patients. Sixty-two patients were included with a survival to hospital discharge of 85.5%. Days requiring ECMO was 33.0 (0.0–75.0) and cannulation to extubation was 6.0 (4.0–11.0). Three patients received a tracheostomy (4.8%). Bleeding and infection were reported in 80.6% and 82.3% of patients, respectively. Intensive care unit length of stay was 46.0 days (29.0–90.0) and hospital LOS was 51.0 days (32.0–91.0). Over half of the patients (51.6%) were discharged to an acute rehabilitation facility and 27.4% were discharged home. There was similar survival to hospital discharge between the COVID and non-COVID awake ECMO patients (85% in both groups, p = 1.000). This study highlights the impact of an awake ECMO approach on survival to hospital discharge. Future studies are needed to evaluate this approach as compared to current practice to determine if this should become the standard.