Is a slow code ethical?

[blackvans1234]

I assume not, but let me provide detail.

Im a pct at a hospital, this nurse is new to our unit and was talking about how a patient of hers (in the past) did not have a DNR but really should have, he coded multiple times etc.

She made a statement about how they ran a slow code so he could just die.

Is a slow code ever ethical?

Personally I think that this nurse should not have been judging if someone should be a DNR or not. Especially if it is her patient.

[carolinapooh, BSN, RN]

I think you are asking the wrong question. Is it even ethical to code some poor person just so they can survive long enough to do a slow lingering death in ICU?

Very often I feel like I am hurting my patient and being an evil person for no reason.

^This.

I have no problems with letting morals kick in here. Ethically I think it's probably a gray area, but morally?

Either way, I agree with you. Completely.

[carolinapooh, BSN, RN]

Depends on the patient and if a "slow code" is what's need to "stop doing harm" to the patient then it might be the lesser of two evils. We had a patient on my unit once who was going to die. Slowly each and every organ system was shutting down. This was a baby whose primary issue was cardiac but as a result of that other organs began shutting down, kidneys, intestines, lungs, brain (neuro status was questionable on admission actually) but the family could not accept that their baby was dying. We had multiple other centers consult to see if there was something else they would be doing but none had any suggestions nor would accept the patient to their center. We coded this baby multiple times over three months until the final code. I wouldn't necessarily say it was a "slow" code but when the 4th round of epi did nothing the code was called. And we had discussed over those last few days when we knew we were nearing the end the "if the pt codes today" scenario every morning during rounds. As the RN we were told not to hit the code button, to call the doc and start compressions and that things would unfold slowly. We were all in agreement with this. The moral distress the patient placed on those caring her was far worse for staff than the relief we felt that she was finally no longer suffering. Keeping that baby alive was not ethical in any sense of the word. It's unfortunate that things have to get to that point but I also have never been a parent in that situation so I can't speak for the parents. It's a heart breaking situation any way you look at it.

As a civilian RN I had this situation. I was even approached as soon as the resident cross-cover came on the floor.

And I had absolutely no problems with agreeing (she even said, "you have X, right - I'm so glad"). Fortunately the pt was made DNR just in the nick - and I do mean NICK - of time.

Aggressive codes have their place. And then they don't. And I'm capable of living with that. I hope someday someone has the courage and the concern to do the same for me, should I need it.

I actually can think of situations where I just might put the patient ahead of my license. And honestly, this is probably one of them.

[TheCommuter, BSN, RN]

If anyone's interested, I wrote an article about slow codes a few months ago: https://allnurses.com/nursing-issues-patient/the-slow-code-801028.html

I also wrote an article about our death-defying, death-denying society: https://allnurses.com/nursing-activism-healthcare/our-death-defying-773839.html

[Vespertinas]

Fast or slow code, when the heart stops, it often for good reason. Most of the dead are going to stay dead.

Gross generalization. Dangerous.

[Daisy_08, BSN, RN]

Is it ethical to let grandma live on vents and tubes roting away from the inside out, alone and suffering? I think they are done for the right reasons. I think we do a lot more harm by not.

But it's really a systems problem, we need more education and MDs who spend more then 2 min explaining it

[wooh, BSN, RN]

If the patient you're referring to has been coded many times then they're clearly not a medically futile code. ... but codes are apparently effective in this patient.

Depends on what you mean by "effective." If you put aspirin in a vase of cut flowers, they'll perk up, but the flowers are still gonna be dead in a week. If they were meant to be brought back, perhaps they wouldn't be continually trying to leave over and over again.

"Above all do no harm" certainly applies here. Ethically health care providers cannot do a "slow code." Also ethically health care providers need to allow death with dignity. Performing ACLS on an elderly, dying, comatose, non-responsive, (but not dead) person is the most "harmful" undignified way for a person to die.

I think you are asking the wrong question. Is it even ethical to code some poor person just so they can survive long enough to do a slow lingering death in ICU?

Very often I feel like I am hurting my patient and being an evil person for no reason.

It's unethical to torture someone instead of letting them die with dignity.

It's unethical to just let someone die.

It's all about which ethics are going to "win" on any given day.

[Daisy_08, BSN, RN]

We are just so petrified of death. I think as nurses we all know there are a lot worse things then death

[MunoRN, RN]

Depends on what you mean by "effective." If you put aspirin in a vase of cut flowers, they'll perk up, but the flowers are still gonna be dead in a week. If they were meant to be brought back, perhaps they wouldn't be continually trying to leave over and over again.

I actually gave an example of when it can be expected to be 'effective'. A patient who took too much beta blocker has a near 100% of survival to discharge and beyond should they need to be coded, which often will only consist of a single round of compressions while pacing pads are placed and started. There's absolutely no reason to believe that they will still die within a week once the underlying cause has resolved.

At the same time, there are many underlying causes for which there is literally zero potential for survival to discharge, such as severe sepsis, advanced cancers, and acute strokes.

I think for some reason we try to assign a single rate of effectiveness to all patients in the event of a code. We drastically overestimate and simultaneously underestimate the effectiveness of coding someone. It varies greatly depending on the underlying cause.

[wooh, BSN, RN]

But here we're talking about someone CONTINUING to code over and over again. That to me is a body trying to tell us something and we ain't listening.

[MunoRN, RN]

But here we're talking about someone CONTINUING to code over and over again. That to me is a body trying to tell us something and we ain't listening.

I think we're talking about two different things, I was referring to the generalization that codes are never effective; it totally depends on the patient. There are times when there's no chance it will be of any benefit, yet there are also times where it would be surprising if it wasn't. Even the patient who continues to code over and over again doesn't necessarily mean it's not totally reasonable to code them; I had a patient not long ago who's pacer had lost all sensing and kept putting them into VT/VF. We coded them multiple times while waiting for the PM rep to arrive, it would have been sort of silly not to. Then there are also patients we refuse to code even once for good reason, depends on the patient.

[Esme12, ASN, BSN, RN]

If anyone's interested, I wrote an article about slow codes a few months ago: https://allnurses.com/nursing-issues-patient/the-slow-code-801028.html

I also wrote an article about our death-defying, death-denying society: https://allnurses.com/nursing-activism-healthcare/our-death-defying-773839.html

They are great articles by the way.

To use the term "slow code" sounds unethical is inhumane and unethical to code these patients. In the old days this was the DNR we would go into the room and quietly close the door....absolving the family from these agonizing decisions....and grandma to die in peace without a crushed rib cage. Sadly those days are gone and we torture people at the most stressed time of their lives to ask them to understand impossible medical jargon....and come to a sensible conclusion to allow their loved one to leave them peacefully.

It is perfectly legal and ethical to assess the patient's situation and in the preponderance of the evidence........decide that any further medical intervention is futile. The MD will document the patients terminal obtain the documentation of a couple of peers and write "DNR Code not indicated" But in today's litigious society and the craziness of most people.....the effort and expense to confront the family with this, make them angry, and spend the next 15 years in court. They document the futility of the situation and we go through the motions of a code with the intention of allowing the patient to die with some shred of dignity.

Case in point....when my MIL....who had never been sick in her life.....had a massive heart attack at age 79 (we actually thin she was 84 she got younger with the birth of every child and the record of her birth destroyed in Germany) My SIL....after coding (intubated and in renal failure) and a angio and lengthy discussions with the MD that she was NOT a CABG candidate and a DNR was in order wanted my MIL (great lady) flown to Chicago for a heart and kidney transplant!!!!!!!!!!!! BELIEVABLE! Had it not been me and the MD's assuring my hubby and the rest of the family to deal with her....(and the MD who plainly told her he didn't need her permission)my MIL would have been a slow code and rightfully so.

[PMFB-RN, RN]

It's unethical to torture someone instead of letting them die with dignity.

*** Yes it is.

It's unethical to just let someone die.

*** Who says? What is the source for this? I have gone against a family's (but not a patient's) wishes a few times and refused to code a full code patient. The first time I fully expected to at least lose my job. However nothing was ever said to me about it one way or the other. I know, without being told, that many were relieved at my refusal. Some of the people who I refused to code were coded anyway, just not by me.