The Slow Code

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    During a 'slow code,' the members of the healthcare team are purposely not putting forth their full efforts to resuscitate the patient by moving with no apparent sense of urgency while performing CPR. Do situations arise where a slow code would ever be justified?

    The Slow Code

    I have been a nurse for only seven years; however, certain events and situations will remain embedded in my memory for the rest of my life. One of these events took place during my first year of nursing practice when I was employed at a long term care facility.

    A 'code blue' was announced through the overhead paging system, along with the room number. Since the facility had no designated 'code team,' any healthcare employees who were located nearby were expected to respond. I dutifully ran to the room and entered a scene that was filled with disorder.

    An elderly male patient was lying on the floor adjacent to his bed in a supine position. His body was cyanotic, but still warm. His nurse states that she had been chatting with him less than 30 minutes ago. No rise and fall of his chest was noted. All pulses were absent. This clinically dead man was a full code, yet the multiple people in the room were moving with a disturbingly unhurried pace. I immediately started chest compressions.

    A nurse with more than 20 years of experience glanced at me with a smile and sternly said, "Give it up! Don't waste your energy! Wait until EMS gets here, then act as if you're doing something in front of them!" She ended her statement with a quiet giggle as the house supervisor stood over me, grinned, and nodded in agreement.

    I continued pounding on the man's chest and could feel his osteoporotic ribs cracking with each compression. EMS personnel and the city fire-rescue squad arrived less than ten minutes later to take over the resuscitation efforts. Approximately 30 seconds before EMS staff entered the room, my coworkers began putting on the show and pretended to exert an all-out effort to save the patient (a.k.a. the 'show code' or 'Hollywood code'). Since EMS has their own documentation, I suppose my peers wanted to appear busy to avoid potential liability later on down the line.

    Do situations arise where a slow code would ever be justified? Are slow codes ethical?

    A 'slow code' is defined as a cardiopulmonary resuscitative (CPR) attempt by the healthcare team that is deliberately carried out in too slow of a manner for any viable chance of resuscitation. In other words, the members of the code team are purposely not putting forth their full effort to revive the patient. Some anonymous physicians and hospitalists have offered several explanations for conducting slow codes:
    Three justifications for designating a "slow code" (one or more might be cited by different house officers to explain a decision about a particular case):

    (a) The patient was being kept alive by technology alone and should, as a moral decision, be allowed to die;
    (b) The patient had a chronic disease, which the residents found uninteresting, and from which they felt they could learn little;
    (c) The chronic disease the patient suffered from was beyond the resources of internal medicine, and the use of technology to prolong the patient's life was a waste of time and effort.

    SOURCE: Cassell, J. (n.d.). Handbook on Ethical Issues in Anthropology. Chapter 23: Slow Code. American Anthropological Association. Retrieved December 5, 2012, from
    Although I am a firm believer in end-of-life options such as hospice and palliative care for patients with terminal prognoses, I also feel that no ethical justification exists for slow codes because they infringe upon the patients' rights to have input in their treatment plan. The slow code also serves to breach the trust that patients and families have in the healthcare team to provide swift resuscitative efforts with a sense of urgency. In summary, if the patient has decided he wants everything done, we should fulfill his request.
    Last edit by Joe V on Dec 8, '14
    NRSKarenRN, Cricket183, poppycat, and 12 others like this.

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  2. About TheCommuter, ASN, RN

    TheCommuter is a moderator of and has varied workplace experiences upon which to draw for her articles. She was an LPN/LVN for four years prior to becoming a registered nurse.

    TheCommuter has '9' year(s) of experience and specializes in 'acute rehabilitation (CRRN), LTC & psych'. From 'Fort Worth, Texas, USA'; 33 Years Old; Joined Feb '05; Posts: 28,963; Likes: 43,234. You can follow TheCommuter on My Website

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    148 Comments so far...

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    I couldn't agree with you more. It is my place to fulfill the healthcare wishes of the patient, not what I feel is in their "best interest.". I applaud your efforts and am so sorry you were put in such a horrible spot. When I'm old(er) and my vessels are eroded by too much Baker Square pie, I pray I have a nurse like you who will do the right thing.~~CP~~P.S. Pardon the horrid smartphone formatting. It doesn't understand paragraphs. Or maybe it's the operator.....
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    I very much agree.

    I've never seen/participated a slow code. I've heard of them a couple times from coworkers in other facilities. In my view, it's unethical and paternalistic to assume the responsibility of carrying out only parts of a patient or family's wishes for resuscitation. It's neglecting the opportunity to have a real conversation with the patient/family about resuscitation, comfort options, palliative care, and withdrawal of care.

    If the patient/family choose something we don't personally agree with despite our efforts to give them all the available information, well that is their informed choice. We don't have to do the same with our family members or ourselves come the time, but certainly no one ought to have the power to strip someone of their decision just because we think we know what is best.
    Cricket183 likes this.
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    It is not our job to decide who to save or not save. We are to carry out our patients' wishes to the best of our ability. Maybe i am naive because i am a brand new nurse, but my god i hope i never have to deal with this like you did. I cannot stand the thought of licensed nurses standing around doing nothing when the patient is a full code. I mean, why even bother showing up to the code. I do realize that situations are not always cut and dry, and at times its really sad to perform cpr on a patient who probably shouldnt be a full code, just because someone somewhere in the family doesnt believe in DNR status. Hopefully in those situations, education may help or at least the patient is not suffering too much. But to stand around, and even giggle at the thought of doing nothing until "showtime" shows some really unethical, disrespectful character. Geez i truly hope i never become that jaded!
    smartnurse1982, xoemmylouox, cp1024, and 1 other like this.
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    I feel like a slow code is a myth similar to "pillow love". I have not actually ever smothered a patient with a pillow, and I have never given less than 100% in a code. I may utter the phrases "pillow love" or "slow code" under certain circumstances (making a macabre joke with coworkers, for example, out of hearing of any patients), but the idea that anyone actually does these things is completely unbelievable. I don't believe a slow code happens with any more frequency than the murder of a patient by a nurse.

    Now, I have participated in codes that didn't last very long, because it was obvious the person wasn't coming out of it. But even the shortest code I've ever seen lasted over 10 minutes.
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    Quote from BluegrassRN
    I don't believe a slow code happens with any more frequency than the murder of a patient by a nurse.
    Based on the medical literature, anecdotes, and anonymous recollections from physicians, nurses, respiratory therapists, and others, slow codes do take place.

    I would know. As described in my aforementioned article, I walked in on a deliberately slow code during my first year of nursing that turned into a 'show code' a few seconds before EMS personnel arrived to take over the resuscitative efforts.
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    This is very disturbing. It is unethical and on the verge, if not over the line, of being criminal.
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    I was in nursing in the days of "slow codes" and the extended debate within healthcare about the ethics of slow codes and the eventual official determination that they have no place in healthcare -- you either code people or you don't. You don't pretend to code them.

    I will never forget, in one of my first nursing jobs a few years out of school, I was working nights on a large general med-surg unit (this was actually an open unit, with rows of beds with curtains between them, not separate rooms); you could see the entrance to the unit from anywhere in the unit. There was an older gentleman who was at death's door and expected to go any time. During the course of the night, someone else had some kind of acute incident (I don't recall the exact details) and died, and we called the code. I remember the few of us on the unit frantically starting CPR, fetching the cart, etc., and wondering, for what seemed like forever, where the !@#$ the code team was. Finally, after an extended period, they came strolling casually around the corner into the entrance into the unit -- and I will never forget them looking down the unit, someone saying, "Oh my God, it's not him!" and then they suddenly started running and springing into action (they assumed, of course, when the code was called, that it was the older man who was already v. close to death).

    That's the only true, obvious, slow code I ever personally encountered. It turned out that the man who had died could not have been saved anyway, his cardiac event was too severe; but I've always wondered since then how those individuals on the code team would have felt if it had turned out to be a situation in which someone had died needlessly because they based their actions on that assumption and then found out they were wrong.

    Although they've been denounced as unethical by the larger healthcare community for decades, I'm sure that slow codes do still occasionally take place, just as plenty of other traditional-but-now-outdated practices do.
    NRSKarenRN likes this.
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    (As far the comments about how it's not our job to decide who to save, it's our job to carry out the client's wishes, there is no US law that requires physicians or hospitals to offer anyone any treatment that they consider, professionally, to be futile. Obviously, nurses don't get to make those choices, since we don't diagnose or order medical tx. But physicians can legally choose to override an individual's or family's wishes about code status, and not code someone even though they want full resuscitation. It's just that most physicians and hospitals don't have the nerve to do so. Even in that case, though, the ethical thing to do would be to discuss this openly with the individual and/or family (and the rest of the team) in advance, not keep quiet and only pretend to attempt resuscitation.)
    canoehead and Altra like this.
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    You state in your post that some physicians and hospitals have offered several explanations for slow codes but you quote statements by anthropologists. What do anthropologist know about code blues and slow codes? Nothing.
    PMFB-RN likes this.

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