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Slow codes, also known as partial, show, light blue, or Hollywood codes, are cardiopulmonary resuscitative efforts that involve a deliberate decision not to attempt aggressively to bring a patient back to life. Either because the full armamentarium of pharmacologic and mechanical interventions is not used, or because the length of the effort is shortened, a full attempt at resuscitation is not made. Unlike a true code, in which time is critical and a state of medical emergency exists, a slow code may seem to occur in slow motion, with staff members stiffly going through the motions, then breathing a collective sigh of relief when the effort is terminated. A slow code differs from a failed code, in which all appropriate efforts are made yet the patient dies. A slow code is also not one that results from the medical team's previous negotiation with the patient or the patient's family, deciding on a brief trial of defibrillation or vasopressor drugs, for example, with rapid termination of the effort if the patient is not responding. The presumption inherent in a slow code is that the patient will not survive.
No data exist on slow codes, but they are not uncommon. A review of the medical literature reveals a small number of commentaries on the practice.2,3,4 The medical-ethics literature on the topic is equally sparse, but it provides strong admonitions. The 300-page 1983 report of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, "Deciding to Forego Life-Sustaining Treatment," devotes one sentence to the subject, in which a slow code is described as "a kind of dishonest effort."5 The American College of Physicians ethics manual concludes, "If DNR [do-not-resuscitate] orders are not written, it is unethical for physicians and nurses to perform half-hearted resuscitation efforts."6 And in the practical guide Clinical Ethics, Jonsen et al. write that "the `slow or show code' is to be repudiated as crass dissimulation."7
The public is virtually unaware of the practice of slow codes. Discussions of end-of-life preferences and options rarely include information about slow codes. In a medical and legal system in which informed consent is a basic tenet of ethical practice, the slow-code resuscitation effort stands out as a practice performed without the consent and without the knowledge of the patient or the patient's family. More disturbing still is the lack of questioning of this practice by members of the medical profession.
What constellation of circumstances leads to a slow code? Is there any medical rationale for the practice? In performing slow codes, are physicians abdicating their responsibility to do no harm? Why is informed consent not obtained? The remainder of this article examines these issues to provide a framework for the analysis of this practice.
When Do Slow Codes Occur?
Slow codes tend to be used when patients have advanced terminal illness or dementia, or when they are in a persistent vegetative or other comatose state. They occur in the same settings as full codes — academic medical centers, community hospitals, or long-term care facilities. In many cases, a terminal event is anticipated and comes as no surprise to those caring for the patient. Typically, the patient's or family's end-of-life treatment preferences have not been ascertained, and there is no do-not-resuscitate order. Reasons for the omission include physicians' discomfort with the topic of death and dying, the belief that honest discussion of the prognosis would lead to a loss of hope, and an assumption that patients and their families should be the ones to initiate dialogue.8,9,10,11,12,13
The prevailing standard of practice throughout the United States is to perform resuscitation in cases of cardiopulmonary arrest in all patients who do not have a do-not-resuscitate order. In the absence of a discussion of the patient's wishes, physicians often assume that there is a legal requirement to attempt resuscitation. Such an assumption is incorrect; the single exception may be in New York State (Annas G: personal communication). Acknowledging that successful resuscitation is not possible or making an assessment that even if it is possible, the patient's overall prognosis or quality of life is too poor to warrant the attempt, an attending physician may informally indicate that a slow code should be performed. No order is written, and communication with house staff may be as minimal as "If the patient codes, just give it a brief try." In other cases, there may be no communication between the attending physician and the house staff. In the absence of discussion about the patient's wishes or a unilateral decision by the attending physician to assign a do-not-resuscitate order, the house staff may believe that they are legally required to perform cardiopulmonary resuscitation. Recognizing the inappropriateness of resuscitation attempts but feeling that the decision is out of their control, the house staff may see a slow code as their only option. The slow code may provide an adaptive response to an untenable requirement of their job.14
A different rationale is operative when end-of-life wishes have been discussed and the patient or family has stated a wish that "everything" be done to resuscitate the patient. Instead of hearing the request that everything be done as evidence of despair on the part of a patient or family faced with imminent loss, physicians often take such a request at face value. Indeed, the physician may believe that respect for the patient's autonomy requires an unquestioning acceptance of the patient's stated wishes. Rather than probing the patient's fears and concerns and providing reassurance that the patient's suffering will be treated and that he or she will not be abandoned, a physician may see a slow code as a way out of a dilemma — as having the appearance of respecting a patient's wishes while lessening the consequent harm.
Are Slow Codes Medically Appropriate?
Sound medical practice typically relies on explicit or implicit clinical logic. Is there any clinical basis for using a slow code in resuscitation attempts? Studies of in-hospital cardiopulmonary resuscitation reveal an overall success rate of only approximately 15 percent15,16,17; rates for survival to discharge are as low as 3.8 percent among elderly patients.18 With a slow code, death is virtually a foregone conclusion.
According to a seminal 1990 article, a futile medical intervention is one that does not lead to "improvement in the patient's prognosis, comfort, well-being, or general state of health."19 By this definition, a slow code, which succeeds in resuscitating the patient in fewer than 1 in 100 cases, is clearly futile. More important, the slow code is not a benign intervention. Although the full effort is truncated, most slow codes nevertheless are highly invasive and traumatic. Without the hope or intention of saving the patient, it is difficult to justify an intervention that causes a fellow human to spend the last minutes of life in such a way. The contrast between death in a quiet room with loved ones, or even alone, and death after even the most limited resuscitation effort is disturbing at best.
Patients' Autonomy and Medical Paternalism
Patients' autonomy is frequently cited as the most compelling reason for providing treatment that offers no medical benefit. While some view autonomy in the extreme, as a pure and independent statement of the patient's wishes, a more encompassing view holds that true autonomy exists only in the context of the physician's commitment to help a patient achieve that which is in his or her best interest.20 There is also controversy about whether respect for autonomy necessitates the provision of futile interventions. Furthermore, the offer of futile measures can serve to undermine, rather than support, the ability of patients to act autonomously.21
In offering a therapeutic option to a patient, a physician is implicitly indicating his or her belief that such an option offers some sort of benefit, no matter how marginal. If this were not the case, then why, from a patient's perspective, would a competent, caring physician offer the option? To offer an option known by the physician to be ineffective sends a double message to a patient and creates expectations of efficacy that are not warranted. In offering an ineffective option that entails considerable harm, the physician not only compromises the patient's autonomy but fails to meet his or her own responsibility to avoid doing harm. As summarized by Tomlinson and Brody, "it is inherently and unavoidably misleading to offer a futile treatment, and so [it] is corrosive of autonomous choice to do so."21
In most cases, however, physicians make the decision to perform a slow code unilaterally, without the consent of the patient or a surrogate decision maker. No attempt is made to obtain anything approximating informed consent. Failure to discuss options or, more accurately, failure to discuss the intervention actually planned, represents paternalism of the strongest kind. One might attempt to argue that lack of shared decision making is justified because of the belief that the provision of truthful information would lead to greater harm than good. But how different is this view from a decision not to tell a patient that he or she has cancer because doing so might destroy hope? It is now generally acknowledged that patients are ill served by failure to disclose information, however grave that information may be. No clinical intervention performed in a secretive manner will be one that enhances a patient's right to self-determination.
The Physician's Responsibility
The shift in modern medicine over the past 20 years that has made more open discussion of end-of-life care possible and made autonomy for patients a realizable goal has also generated confusion about the fundamental role and responsibility of physicians: to cure disease when possible, to alleviate pain and suffering when cure is not possible, and to do no harm. The slow code is an intervention in which a flawed conception of patient autonomy and inadequate communication between physician and patient combine to set the stage for a harmful event in the last moments of a patient's life. Although a physician may believe that denying a request for futile end-of-life care is paternalistic, the duty to prevent harm must prevail. As noted by Blackhall, it is "insufficient for physicians to cite patient autonomy and wash their hands of further responsibility."22
Physicians have a critical responsibility to frame a patient's options with compassion and within the scope of that which is medically realistic. Avoiding the discussion of predictable terminal events does not keep them from occurring. Discussing such events affords physicians the opportunity to offer more humane care and to provide stewardship to patients in their final stage of life, in an effort to keep them from suffering unnecessary harm before they succumb to inevitable death.23
Physicians are taught early in their training that, even under the most dire of clinical circumstances, they must never take away a patient's hope. But what does hope mean in the context of end-of-life care? Many physicians believe that hope lies only in the possibility of prolonging life and that honest discussion of the lack of effective therapeutic options will eradicate hope and even lead to premature death.24 Such a viewpoint, however, serves to reinforce the notion that death can somehow be avoided, that with enough optimism the inevitable can be averted. For terminally ill patients, hope needs to be more broadly defined to include a death with dignity, one without undue suffering, and one that does not strip those who survive of memories of their loved one as a whole and intact person. In the words of Sherwin Nuland:
For dying patients, the hope of cure will always be shown to be ultimately false, and even the hope of relief too often turns to ashes. When my time comes, I will seek hope in the knowledge that insofar as possible I will not be allowed to suffer or be subjected to needless attempts to maintain life; . . . so that those who value what I am will have profited by my time on earth and be left with comforting recollections of what we have meant to one another.25
Being the bearer of sad and tragic information will always be a part of the practice of medicine. Physicians have an obligation to discuss the rationale for a do-not-resuscitate order with appropriate patients or their surrogates, difficult though that conversation may be. They also need to be aware that there are no legal requirements to perform any intervention that would reasonably be expected to be of no medical benefit. We owe it to our patients and our profession to acknowledge the unethical nature of the slow code and to terminate its use.
Gail Gazelle, M.D.
Brigham and Women's Hospital
Boston, MA 02115
Address reprint requests to Dr. Gazelle at Harvard Vanguard Medical Associates Division of Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.
References
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Related Letters:
The Slow Code
Segal E., Halamish-Shani T., Rich H., Greenfield L. J., Fried T. R., Wachtel T. J., Ish C., Krause R. G., Gazelle G.
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Full Text
N Engl J Med 1998;
338:1921-1923, Jun 25, 1998.
Correspondence
This article has been cited by other articles:
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