The Slow Code: Justified?

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? Nurses Safety Article


The Slow Code: Justified?

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;

© 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 Case 23: Slow Code - Learn and Teach

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.

TheCommuter, BSN, RN, CRRN is a longtime physical rehabilitation nurse who has varied experiences upon which to draw for her articles. She was an LPN/LVN for more than four years prior to becoming a Registered Nurse.

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Specializes in Sleep medicine,Floor nursing, OR, Trauma.

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.....

Specializes in Pediatrics (neuro).

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.

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!

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.

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
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.

Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

This is very disturbing. It is unethical and on the verge, if not over the line, of being criminal.

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.

(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.)

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.

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.

OK I am going to disagree. A proper slow code is an art. How to make it look like you are doing something when not really trying to save the patient. As far as I am concerned the slow code will be needed as a self defence mechanisim for health care providers so long as our society maintains it's irrational refusal to talk openly about end of life issues and accept that dying is part of life.

I am a full time rapid response nurse. I am the code administrator for my hospital and the alternate code team leader until / if the "code chief" (usually a senior med or surg resident) arrives on the scene. Occasionaly I will run the entire code like the few times there have been two codes going on at the same time or the code chief doesn't show up for some other reason.

ON several occasions I have refused to code a patient at all. Other times I will let the team know this is going to be a a "show" or "slow" code. In every instance I had reason to know the patients wishes and knew that being coded was aginst their wishes. For example one man with severe necrotic bowel, literaly rotting from the inside out did not wish to be coded. When he was alert and oriented early in his hospitalization he made the informed decision to be a DNR. Later, when he could no longer make his wishes known, his estranged wife changed his code status to full code. The real problem is that she would be allowed to do that at all. That his weak kneeded-fearful-of-a-lawsuit physicians agreed to the change in his code status is another major problem that needs to be adressed. However all that is water under the bridge when "code blue" is called on him.

If the patient has made an informed decision to be full code I will code the heck out of him. I will not go aginst a patient's informed decision and wishes. I hope it doesn't cost me my job (so far not an issue) but if i does it does.

Specializes in cardiac CVRU/ICU/cardiac rehab/case management.

Having worked on a code team my experience was there is no "kind of " code,it either is or it isnt. It is my job to act unless there is a DNR order but ...before anyone pats them self on the back for heroism often this is the picture...... A pt zapped so many times the room smells like bacon, a pt who has been "down" for so long you may restore the heart but there is little brain left, a lengthy code where we get the pt back so they can have the 3mth slow excruciating death.As a nurse I have learned there are far worse cruelties than dying.

Yes ,these are the rules and need to be followed but I am wondering.....If you were one of the pt described here,would you be grateful? Is it the care would you would hope that your family gets ?

The reality I learned (and was shocked at ) is few pt survive a code unless it was witnessed. In a CVRU an impending code can be anticipated and the action is immediate, which yields a good outcome. Rapid response has helped the odds but back in 2000 when I was on the code team it seemed to me about 2-3 out of 10 make it. (their functioning capacity afterwards I don't know )

Personally, I feel the problem lies that we don't take the time to explain proxys in a way pt understand. This should be done on admission .The hospital culture sees death as failure so we wait too long to even ask for a DNR when it clearly needs addressing.. Death is part of life and continuing to deny this creates these horrible codes. It is our duty to follow pt wishes , so it would behoove us greatly to spend the time at admission to find out what those wishes are.

We need a greater respect of death by addressing its presence. To not know a pt wishes is as grievous an omission, to me ,as not performing the code. (I have a proxy but I (semi) joke that if it is not honored I will make it my mission to personally haunt that person after death ) People say, "we die when its our time", or "only God decides when we die ". If a pt is blue, cool and clearly dead, hasn't death been decided ?......Have we reached a point that we are coding people to the point that we have actually taken God out of the equation.

So do I act decisively in a code,absolutely but I can privately feel that to do so sometimes is to deny the sacredness of both life and death. Care about your pts, invite a proxy discussion.