Slow code

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This article is about the medical practice. For the programming term, see algorithmic efficiency.

Slow code refers to the practice in a hospital or other medical centre to purposely respond slowly or incompletely to a patient in cardiac arrest, particularly in situations where CPR is of no medical benefit.[1] The related term show code refers to the practice of a medical response that is faked for the sake of the patient's family.[1]

The practices are banned in some jurisdictions.


During a patient cardiac arrest in a hospital or other medical facility, staff may be notified via a code blue alert.[2] A medical response team, based on the institution's practices and policies, attends to the emergency.[3] The team will perform cardiopulmonary resuscitation in order to re-establish both cardiac and pulmonary function.[4]

Cardiopulmonary resuscitation may be withheld in some circumstances. One is if the patient has a do not resuscitate order,[5] such as in a living will.[6] Another is if the patient, family member, individual with power of attorney privileges over the patient, or other surrogate decision maker for the patient, makes such a request of the medical staff.[7] Surrogate decision makers are considered in a hierarchy: legal guardians with health care authority, individual with power of attorney for health decisions, spouse, adult children, parents, and adult siblings.[6]

A third situation is one in which the medical staff deems that CPR will be of no clinical benefit to the patient.[7] This includes a patient in septic shock, one who has had an acute stroke or who has metastatic cancer, and one with severe pneumonia, which all have no probability of success.[8] There is also a low probability of success for patients with hypotension, renal failure, AIDS, or those who are older than 70 or homebound.[8]

A patient may request, in an advanced directive, to prohibit certain responses, including intubation, chest compression, electrical defibrillation, or ACLS.[9] This is referred to as a partial code or partial resuscitation and "such resuscitation commonly violates the ethical obligation of nonmalfeasance".[10] It is regarded as medically unsound because partial interventions "are often highly traumatic and consistently inefficacious".[11]


The practice is "controversial from an ethical point of view",[12] as it represents a violation of a patient's trust and right "to be involved in inpatient clinical decisions".[13]

In a position paper, the American Nurses Association states that "slow codes are not ethical".[11]

Policy and legislation[edit]

Some medical services centres have instituted policy banning the practice.[14]

In 1987, New York became the first state in the United States to effectively end the practice by enacting legislation to require medical staff to honour a patient's refusal of cardiopulmonary resuscitation or a do not resuscitate order, and to grant civil and criminal immunity to those who do so or those who perform CPR without knowledge of the order.[1]


  1. ^ a b c New York Times 1987.
  2. ^ Marks 2006.
  3. ^ NBC News 2008.
  4. ^ Braddock 1998, When should CPR be administered?.
  5. ^ Braddock 1998, When can CPR be withheld?.
  6. ^ a b Braddock 1998, What if the patient is unable to say what his/her wishes are?.
  7. ^ a b College of Physicians and Surgeons of Ontario 2006.
  8. ^ a b Braddock 1998, When is CPR not of benefit?.
  9. ^ Dosha et al. 2009.
  10. ^ Berger 2003, p. 2271.
  11. ^ a b ANA Center for Ethics and Human Rights 2012, p. 6.
  12. ^ DePalma et al. 1999.
  13. ^ Braddock 1998, What if the family disagrees with the DNR order?.
  14. ^ Braddock 1998, What about "slow codes"?.