Understanding Slow Codes in Cardiac Arrest Situations
A "slow code" is an unethical practice where healthcare providers deliberately perform substandard or token resuscitation efforts during a cardiac arrest when they believe resuscitation is futile, without the knowledge or consent of the patient or family. 1
Definition and Ethical Considerations
A slow code refers to an intentional reduction in the pace or intensity of resuscitative efforts during a medical emergency. It represents an intermediate approach between a full code (complete resuscitation) and no code (no resuscitation), typically performed when:
- Clinicians believe resuscitation would be medically futile
- The healthcare team wants to appear to be doing something
- There is reluctance to have difficult end-of-life discussions with families
The American Heart Association explicitly condemns this practice in their guidelines, stating: "Delayed or token efforts such as so-called 'slow-codes' (knowingly providing ineffective resuscitative efforts) are inappropriate. This practice compromises the ethical integrity of healthcare providers, uses deception to create a false impression, and may undermine the provider-patient relationship." 1
Prevalence and Impact
Despite ethical condemnation, slow codes continue to occur in clinical practice:
- 69% of healthcare providers report having participated in a slow code
- Providers report an average of 1.3 slow codes per year
- 52% of providers believe slow codes may be ethical if resuscitation is medically futile 2
Ethical Alternatives to Slow Codes
The AHA guidelines recommend several ethical approaches instead of slow codes:
Transparent Decision-Making: Have honest discussions about prognosis and resuscitation preferences
DNAR Orders: Implement proper Do Not Attempt Resuscitation orders with appropriate documentation
Trial of Treatment: When prognosis is uncertain, a genuine trial of treatment may be initiated while gathering more information 1
Termination of Resuscitation Protocols: Follow established guidelines for when to appropriately terminate resuscitation efforts based on clinical criteria 1
Moral Distress Among Healthcare Providers
Participation in futile resuscitation efforts causes significant moral distress:
- 75% report distress when required to run a medically futile code
- 80% experience distress when performing chest compressions in futile situations
- 78% feel distress when witnessing futile resuscitation attempts 2
Proper Resuscitation Approach
The AHA guidelines emphasize that resuscitation should either be:
- Full and guideline-compliant when indicated
- Not performed at all when there is a valid DNAR order
- Terminated based on established criteria when efforts are unsuccessful 1
Pitfalls to Avoid
Deception: Slow codes involve dishonesty that undermines trust in the healthcare system
Legal Vulnerability: Healthcare providers performing slow codes may face legal consequences for substandard care
Missed Opportunities: Avoiding difficult conversations about end-of-life care prevents patients and families from making informed decisions
Moral Injury: Healthcare providers experience significant moral distress when participating in what they perceive as inappropriate care 2
The practice of slow codes represents a failure of proper communication and ethical decision-making in healthcare. Instead of resorting to this deceptive practice, healthcare providers should engage in transparent discussions about prognosis, utilize proper DNAR protocols, and follow established resuscitation guidelines.