Resuscitation “slow codes” are compassionate yet deceptive
■ Should a “slow code” be used for patients who have little chance of survival?
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to email@example.com, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Dec. 10, 2012.
Scenario: However well-intentioned, such a code deceives the families or loved ones of a dying patient but is often called when resuscitation is futile and would harm the patient.
Reply: A full code, or code blue, involves calling in a rapid-response team and initiating appropriate resuscitation treatment as quickly and effectively as possible. Properly executed, it is often lifesaving.
A “slow code,” by contrast, involves fewer or partial resuscitative measures, carried out slowly, omitting the most aggressive. Interventions are limited in number, duration and/or intensity. For example, giving gentle chest compressions that do not crack the ribs. Slow code also refers to the reduced speed of staff response. The implicit hope is that the patient will die of his or her condition before they arrive.
The intentions behind a call for a slow code are good. Primarily, it is a way to spare patients and families the full, painful acknowledgement of the extent of the illness and the likelihood of extremely poor quality of life or death. More importantly, it shields them from making the painful decision to let the patient die by choosing “do not resuscitate” or stopping treatment. It also protects the patient from the rigors of aggressive treatment that is likely to be unsuccessful.
Frankly, calling a slow code also spares the physician from the helpless feeling of doing nothing. There also may be the lurking fear of patients' anger at the physician's failure or even malpractice charges if the patient dies with no medical interventions.
In a recent article, John Lantos, MD, and William Meadow, MD, both experienced and respected neonatologists, well-published in ethics, defend a slow code as a legitimate response to end-of-life situations where intensive interventions are judged futile but patient and/or family say everything be done. They define a slow code as a short-term trial of some intervention and emphasize that it is mainly a symbolic gesture, not expected to be effective.
However good the intentions, calling a slow code raises significant ethical questions about truthfulness vs. deceit, paternalism vs. informed consent, patient-physician relationships and teaching good communication skills:
Truthfulness vs. deceit. A slow code gives the appearance of effectiveness, and the physician appears to believe that it will be effective while knowing it will not be. To put it another way, the physician has a hidden agenda: The goal is allowing the patient to die without the emotional cost of a DNR decision. In action and in word, the physician is deceiving the patient and family.
Paternalism vs. informed consent. By calling a slow code, the physician is being paternalistic — making a decision according to what he or she believes is in the patient's best interest. The patient, or family in the case of an incompetent patient, is denied a role in decision-making. By leading them to believe that the interventions may be effective, the physician is withholding information needed to make an informed decision, and informed consent is the basis of medical ethics.
Patient-physician relationship. A slow code erodes trust and damages or destroys the patient-physician relationship. True, the family may never realize that the “treatment” ordered was actually a slow code, but it is always possible they will figure it out. There is bound to be some resentment that they were not told the truth.
Communication skills. Physicians-in-training who are ordered to participate in a slow code are being taught that doctors know best and that patients and their families are incompetent decision-makers, that it is OK to deceive if your intentions are good, that the clever physician can avoid difficult conversations about life-and-death issues.
Our contention is that physicians use a slow code because patients are presented with an either/or choice between two extremes: Do everything or do nothing, i.e., DNR. For the physician, “do everything” means carrying out interventions that are not expected to be of benefit. However, engaging in futile, possibly harmful measures is and should be morally unacceptable to physicians. On the other hand, for patients and families, choosing DNR means giving up hope and choosing death, which may be psychologically or morally unacceptable.
Instead of a slow code, we advocate substituting a time-limited trial of some intervention or the use of some not overly aggressive measures. This allows us to choose a compromise or middle ground between the two extremes. It can be seen as a third option that provides an opportunity for the patient to respond if he or she can, but with everyone's explicit understanding that it probably will not work.
The advantage of this is transparency, with no need for deception. The patient or family makes a decision based on the information required for informed consent. The physician should explain why doing everything is not a good option: It is painful, i.e., harmful to the patient, will not save him or her and will cause regrets. Limited, less aggressive measures are appropriate if the physician thinks there is some chance of their working, based on scientific evidence and a benefit/burden calculation — not just a paternalistic judgment. If the physician actively recommends this third option, and if the patient or family agrees, they have participated in shared decision-making. This represents effective doctor-patient communication and preserves an honest, respectful and rewarding patient-physician relationship.
Terminology can be important, so we recommend calling this option a limited trial run or limited resuscitation, dropping the term “slow code” with all the negative connotations we have described. When physicians hear patients and families say, “Do everything,” they should recognize it as a natural and understandable emotional response to hearing that the patient is not likely to survive. There may be a lack of trust in the physician. There is a strong psychological need for hope, even in the face of dire predictions. And, finally, no one in the family wants to be the grim decision-maker. Therefore, the physician should address each reason in order to move patient and family toward acceptance of limited interventions.
One key to establishing trust and acceptance is to tell the truth. Explain the medical reasons why limited intervention is a better choice. Mention the ways in which the patient's body is telling you that treatment is failing and that more aggressive treatment will cause suffering with no corresponding benefit. Be clear that your judgment is backed by scientific evidence and your own experience. Be explicit: Here is what we will do and why. Either the patient will rally and improve, or the intervention will have no positive effect. In either case it will cause no additional undue harm, and, if unsuccessful, the medical team will then focus fully on palliative care. Assure everyone that there will never be a time when you “do nothing.”
Will this approach achieve consent in every case? Probably not. Eventually, even the most patient physician may have to say: “I hope you will agree with my recommendation. But if you do not, I cannot in good conscience order more aggressive treatment that I believe will be ineffective and will cause suffering.” Many hospitals have adopted the American Medical Association policy on futility, which sets out procedures to follow in such situations, and many physicians find this very helpful.
Edwin N. Forman, MD, professor of pediatrics, Mount Sinai School of Medicine, Division of Pediatric Hematology/Oncology, New York
Rosalind Ekman Ladd, PhD, professor emerita, Wheaton College in Massachusetts; visiting scholar in philosophy, Brown University, Providence, R.I.
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to firstname.lastname@example.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.