The Use of Slow Codes and Medically Futile Codes in Practice

Abstract

Context: Slow codes, which occur when clinicians symbolically appear to conduct advanced cardiac life support but do not provide full resuscitation efforts, are ethically controversial.

Objectives: To describe the use of slow codes in practice and their association with clinicians' attitudes and moral distress.

Methods: We conducted a cross-sectional survey at Rush University and University of Chicago in January 2020. Participants included physician trainees, attending physicians, nurses, and advanced practice providers who care for critically ill patients.

Results: Of the 237 respondents to the survey (31% response rate, n = 237/753), almost half (48%) were internal medicine residents (46% response rate, n = 114/246). Over two-thirds of all respondents (69%) reported caring for a patient where a slow code was performed, with a mean of 1.3 slow codes (SD 1.7) occurring in the past year per participant. A narrow majority of respondents (52%) reported slow codes are ethical if the code is medically futile. Other respondents (46%) reported slow codes are not ethical, with 19% believing no code should be performed and 28% believing a full guideline consistent code should be performed. Most respondents reported moral distress when being required to run (75%), do chest compressions for (80%), or witness (78%) a cardiac resuscitation attempt they believe to be medically futile.

Conclusion: Slow codes occur in practice, even though many clinicians ethically disagree with their use. The use of cardiac resuscitation attempts in medically futile situations can cause significant moral distress to medical professionals who agree or are forced to participate in them.

Keywords: Slow code; clinical medical ethics; critical care; futility; intensive care unit.

Fig. 1.

Are slow codes ethical to conduct? Survey question: Imagine you are caring for a patient who is deteriorating rapidly in the intensive care unit in whom you believe CPR would be medically futile. Here medical futility is defined by 1) the inability of CPR to correct the underlying known cause and 2) the fact that CPR will most likely be unsuccessful, and even if ROSC is obtained, it will be short-lived. In this context do you believe that (choose one): Full survey responses: ^aA full, guidelines consistent code should be performed if the patient or alternate decision maker requests CPR. Performing a slow code for this patient is wrong. ^bPerforming a slow code in this scenario is wrong. No CPR should be performed for the patient, regardless of the wishes of the patient or alternate decision maker. ^cPerforming a slow code is ethically acceptable if the patient or alternate decision maker requests CPR. The alternate decision maker should be notified that the CPR duration will be limited. ^dPerforming a slow code is ethically acceptable if the patient or alternate decision maker requests CPR. The patient or alternate decision maker should NOT be notified that the CPR will be limited and allowed to believe the patient underwent full, guidelines consistent CPR. **P ≤ 0.01 among groups.

Fig. 2.

Attitudes toward slow codes and medically futile codes. Full survey questions: ^aI believe slow codes can be beneficial for patient families because it shows them everything was done to save the patient. ^bI believe watching a code can be beneficial for patient families as it allows them to witness the efforts of the medical team to help the patient. ^cIf a family asks that you “do everything” to save a patient, I believe we are obliged to code the patient. ^dI believe for some patients coding them is medically futile. ^eI believe physicians should have the option to not offer CPR for patients who it is not medically indicated or the harms outweigh the benefits. Survey responses of “agree” or “strongly agree” were defined as “agreement.” *P = ≤0.5 among groups. ***P ≤ 0.001 among groups.

Fig. 3.

Why do slow codes occur? ^aTo reach a middle group among physician, patient and family preferences. ^bDifficulty in communication between medical professionals, patients and families. ^cMedical trainees includes fellow physicians and resident physicians.

Fig. 4.

Moral distress, slow codes, and medically futile codes. Survey question: How often do you experience moral distress from the following situations? Full survey questions: ^aBeing told to conduct a slow code. ^bBeing required to run a code when you believe it is medically futile. ^cBeing required to do chest compressions on a patient when you believe it is medically futile. ^dBeing required to witness a code when you believe it is medically futile. Survey responses of “sometimes,” “often,” or “always” were defined as in “agreement.” *P = ≤0.5 among groups. **P ≤ 0.01 among groups.