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. The related term show code refers to the practice of a medical response that is faked for the sake of the patient's family.
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. A medical response team, based on the institution's practices and policies, attends to the emergency. The team will perform cardiopulmonary resuscitation in order to re-establish both cardiac and pulmonary function.
Cardiopulmonary resuscitation may be withheld in some circumstances. One is if the patient has a do not resuscitate order, such as in a living will. 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. 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.
A third situation is one in which the medical staff deems that CPR will be of no clinical benefit to the patient. 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. There is also a low probability of success for patients with hypotension, renal failure, AIDS, or those who are older than 70 or homebound.
A patient may request, in an advanced directive, to prohibit certain responses, including intubation, chest compression, electrical defibrillation, or ACLS. This is referred to as a partial code or partial resuscitation and "such resuscitation commonly violates the ethical obligation of nonmalfeasance". It is regarded as medically unsound because partial interventions "are often highly traumatic and consistently inefficacious".
Policy and legislation
Some medical services centres have instituted policy banning the practice.
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.
- New York Times 1987.
- Marks 2006.
- NBC News 2008.
- Braddock 1998, When should CPR be administered?.
- Braddock 1998, When can CPR be withheld?.
- Braddock 1998, What if the patient is unable to say what his/her wishes are?.
- College of Physicians and Surgeons of Ontario 2006.
- Braddock 1998, When is CPR not of benefit?.
- Dosha et al. 2009.
- Berger 2003, p. 2271.
- ANA Center for Ethics and Human Rights 2012, p. 6.
- DePalma et al. 1999.
- Braddock 1998, What if the family disagrees with the DNR order?.
- Braddock 1998, What about "slow codes"?.
- Braddock, Clarence H. (1998). "Do Not Resuscitate Orders". Ethics in Medicine. University of Washington School of Medicine. Retrieved 2013-04-06.
- Berger, Jeffrey T. (October 2003). "Ethical Challenges of Partial Do-Not-Resuscitate (DNR) Orders". Archives of Internal Medicine 163 (19): 2270\u20132275. doi:10.1001/archinte.163.19.2270.
- DePalma, Judith A.; Miller, Scott; Ozanich, Evelyn; Yancich, Lynne M. (November 1999). "\u201cSlow\u201d Code: Perspectives of a Physician and Critical Care Nurse". Critical Care Nursing Quarterly (Lippincott Williams and Wilkins) 22 (3): 89\u201399. ISSN 1550-5111.
- Dosha, Kristofer; Dhoblea, Abhijeet; Evonicha, Rudolph; Guptaa, Amit; Shaha, Ibrahim; Gardiner, Joseph; Dwamenaa, Francesca C. (September 2009). "Analysis of limited resuscitations in patients suffering in-hospital cardiac arrest". Resuscitation 80 (9): 985\u2013989. doi:10.1016/j.resuscitation.2009.05.011.
- Marks, William J. (1 January 2006). ""Code Blue", "Code Black": What Does "Code" Mean?". WebMD. Retrieved 2013-04-06.
- "Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions" (PDF). ANA Center for Ethics and Human Rights. American Nurses Association. 12 March 2012. Retrieved 2013-04-06.
- "Decision-making for the End of Life". Physician Advisory Service. College of Physicians and Surgeons of Ontario. May 2006. Retrieved 2013-04-06.
- "Hospitals' 'code blue' most deadly at night". Chicago: NBC News. Associated Press. 19 February 2008. Retrieved 2013-04-06.
- "Slow Codes, Show Codes and Death". New York Times (New York Times Company). 22 August 1987. Retrieved 2013-04-06.