"SLOW" codes are a cardiopulmonary resuscitative efforts "that involve a deliberative decision not to attempt aggressively to bring a patient back to life. Either because the full armamentarim of pharmacologic and mechanical interventions is not used, or because the length of the effort is shortened, a full attempt at resuscitation is not made." 1(p.467) "Slow" codes are performed infrequently and, when they are, it is usually because the health care team feels that a full aggressive code would be futile or possibly detrimental to the patient. When the topic of "slow" codes is approached, both nurses and physicians have issues with "slow" codes. Some express the impression that when they are used it is because there is no other recourse. Others feel that "slow" codes should never be an option. This point of view follows the reasoning that a "slow" code is deemed necessary by the health care staff because they have not been effective in communicating with the family and helping the family make appropriate end-of-life decisions for their family member. The following are conversations with a physician who is a medical ethicist and has an internal medicine practice and a critical care nurse about their views and experiences with "slow" codes.

INTERVIEW WITH A PHYSICIAN WHO IS A MEDICAL ETHICIST AND HAS AN INTERNAL MEDICINE PRACTICE

How would you define a "slow" code?

It is a code that is not run to the exact specifications that are traditionally used. It is generally thought of as a code where everybody moves slower, where everything that is supposed to be done in accordance with the ACLS protocol is done in a "slower" format. This "slow" code is generally done when the physicians caring for the patient object to the fact that they feel forced to put the patient through the trauma of being resuscitated. It does not occur very frequently.

Is it usually decided prior to the event that the code will be a "slow" code?

It's generally decided at the time of the code. Those involved feel that the particular patient should not be going through this, and therefore they are making the patient's death easier on the patient.

Whose needs are being met by doing a "slow" code?

The answer depends on who you ask. Some physicians believe that a decision to resuscitate is a medical decision and that families don't completely understand what it means to resuscitate someone. A "slow" code is the way in which physicians can respond when they feel they are forced by the patient or the family to attempt resuscitation. I would say that the physicians believe it's meeting everyone's needs-patient needs are met because the doctors believe that resuscitation is not appropriate therapy for the patient and can, in fact, be quite harmful and/or painful; doctors' needs are met because they are allowing the patient's death to occur much easier; and family needs are met because they have indicated that they will only be able to accept the patient's death if "everything" has been done. In fact, the physicians believe that their somewhat deceptive behavior is in everybody's interest. But if you were to ask the family, their perspective might be very different.

How do situations get to this point?

Many times the need for the "slow" code evolves because these are difficult issues to talk about, and sometimes doctors and families are not good at discussing the details surrounding a dying patient. Patients and families may have an unrealistic expectation about getting better, and they may have unrealistic expectations about what is involved in resuscitating patients and how unlikely resuscitation is to succeed without causing further harm. Many people get their information about codes and resuscitation from television shows like ER and Chicago Hope, a very unrealistic view. Even doctors may not know all the data behind who survives resuscitation efforts and who doesn't. Some physicians are not very good at conveying the information in an understand-able way.

Can you elaborate?

Doctors tend to ask the wrong questions, focusing on the specifics of the code itself, rather than placing the resuscitative effort in the context of the patient's goals for treatment. Almost every patient sees resuscitation as a means to a goal of getting better, of getting home, and getting back to a life where they can be with the ones they love. If the patient is so ill that resuscitation is not likely to achieve this goal, most patients are not going to want to go through the resuscitation effort just to die anyway. But doctors tend to ask patients and families if they want the treatment without connecting it to any specific goals. As a general rule, however, most patients and families make a good decision when given the right information about resuscitation. It is that small percentage of patients and families who remain unrealistic, who insist on resuscitation despite the doctor's objections, that prompt consideration of the "slow" code.

There is another reason that "slow" codes happen. One scenario is that the discussion about resuscitation never took place at all, and now the patient arrests. A code is called automatically, but the arriving team doesn't feel that resuscitation should be taking place and objects to the fact that the issue was never raised with the patient by the attending physician. By doing a "slow" code, the patient dies without being harmed, and everyone's interests are being served, as I addressed earlier. But I would rather have had the conversation about resuscitation take place than have the problem dealt with in the "slow" manner.

Is the conversation really that difficult?

Yes, it is difficult for many reasons. Doctors and patients are not good at talking about death and dying, and finding the right words can be difficult and time consuming. Doctors don't receive adequate training in how to talk to patients about these issues. Some patients and their families are very unrealistic about outcomes, and they can concentrate on miraculous recovery possibilities rather than on the more likely scenarios.

Additionally, some doctors just don't know all the data about resuscitation and are unaware of the categories of patients in which a code is either more or less likely to succeed. Having the data, and explaining some of it to the patient or family, can go a long way toward developing a good understanding of whether or not a patient should be resuscitated or whether it would be futile treatment.

Are "slow" codes ever medically appropriate?

No, I don't think so. Doctors should either code someone fully or not at all. "Slowing" the code down seems a little deceptive to me. I don't think there is a place for that in the good practice of medicine. If you, as the physician, don't believe resuscitation is indicated, then it is your responsibility to educate the family as to why you think that. If, after appropriate discussion, you and the patient or family disagree about resuscitation, you should either accept their perspective and perform CPR or ask the family to find another physician. Sometimes just taking a strong stand against the resuscitation can convince the family that maybe it isn't in the patient's best interest to undergo this. Also, doctors who aren't sure can get additional opinions from other colleagues about whether or not the resuscitation is as awful for the patient as the doctor seems to believe. But telling the patient or family you will resuscitate them, and then doing it "slowly" so it can't possibly succeed, seems to go against the grain of a good doctor-patient relationship. Thankfully, I don't think it happens all that often.

So one of the central issues is who ultimately determines whether a patient is resuscitated?

Yes. Physicians want to have the final say, the final ability to decide whether offering resuscitation makes sense or not. Traditionally, however, patients and their families have had the final say-if you are going to die without resuscitation, why not just give it a try? But we have learned that resuscitating someone who is dying can be quite traumatic and painful and may leave someone alive but with severe neurologic damage. Doctors want to be able to avoid having these kinds of things happen to dying patients. But if a patient insists on resuscitation over a doctor's objections, and the doctor genuinely doesn't want to harm the patient, but feels he must do the resuscitation, then he might choose to do a "slow" code.

So resuscitating patients can do harm to them?

In some cases, absolutely. Successful resuscitation only means that you have the heart and lungs working again. But the act of resuscitation doesn't stop the brain from being damaged by the lack of oxygen that occurs during the arrest and resuscitation phase. Some patients who survive remain with significant neurologic damage-they may stay permanently unconscious, they may no longer function independently, or they may appear as if they have had a severe stroke. Most patients who want to be resuscitated do not want to end up like this, and so, in most of these cases, it would be better for those patients not to be resuscitated at all. This is one of the reasons some physicians do the code "slowly"-it prevents the harm associated with a successful resuscitation (the patient survives) but a poor outcome (the patient would not want to have survived like this).

There is also harm in doing the resuscitation itself. It is a very invasive, intense, and fast-paced activity. Doing something like this to someone in the last minutes of their lives is viewed as very traumatic, especially if the belief among physicians is that the patient isn't going to survive this anyway. Most patients' idea of death is peaceful and dignified, not traumatic and invasive.

Could there be legal concerns about the practice of "slow" codes?

I think there could be. During a "slow" code, everyone assisting will be aware of what you are doing. If even one person in the room is not supportive of what you are trying to do, he or she may bring it to someone else's attention. Some state laws have made it very clear that patients have a right to be resuscitated, and a "slow" code on the part of the physician effectively takes that right away. And I don't see how a physician can defend his participation in a resuscitative effort that is predetermined to fail.

What about the fact that you are asking other health care professionals to cooperate with a "slow" code?

This is a significant problem as well, especially if as I mentioned before, not everybody shares the physician's view that we ought not to be coding this patient. Having said that, I believe that most "slow" codes, when they do occur, tend to have a sense of unanimity on the part of the personnel involved-everyone there recognizes that, from the medical perspective, this patient should not to be resuscitated. If anyone openly presents an objection, the code is likely to proceed in a more traditional fashion.

How does all of this affect the doctor-patient relationship?

I think that the doctor-patient relationship hinges on trust, and the "slow" code, even if rarely carried out, removes some of that trust. I think that if doctors developed a better way of communicating these issues the physician's relationship with the patient and family would improve. Finding out from your patients what is important to them, and helping them understand the difference between "doing everything" and "doing everything that will help" will go a long way toward improving patient care.

How does knowing a patient's goals and values help?

First, it helps to know what is important to a patient in his or her life in general. Some people value independence and remaining active; some people accept poor health but value loving interactions with friends and family. If a patient tells me they value being alert, active, independent, able to feed and dress themselves, and being able to read and understand books and the news, and then they have a stroke that has taken all this away, I can be pretty sure that, if they then have a cardiopulmonary arrest, they are not going to want to be resuscitated. The act of resuscitation is not going to achieve for them any of their goals. On the other hand, if a patient tells me that he or she values life, regardless of the quality, and would accept whatever limitations is placed on his or her life, then I can probably know in advance that this patient is likely to want to be resuscitated. My point is that knowing these kinds of things about patients is helpful in having the discussion about resuscitation and can make it easier for doctors to respect the decisions of their patients. It also gives the physician a point of view when talking with the family. If the physician knows the patient's values well, the discussion can center around those values and goals of treatment. Often that focus helps families make the difficult end-of-life decisions.

Do medical schools have anything in the curriculum to address this issue?

Yes, most medical schools now teach classes in end-of-life care and related ethical issues, including how to communicate with patients, how to express empathy, and, most importantly, how to listen. There are programs like this affiliated with most major medical schools. But we also need to teach the practicing physicians as well-the ones who didn't get this education in medical school and, therefore, are afraid to have these discussions. One group trying very hard to improve education on these issues is the American Medical Association. They are now involved in a train-the-trainer educational conference on many aspects of end-of-life care, including code status and advance directives. Finally, there has recently been a lot written about this whole area of "slow" codes in the medical journals. Overall, I think the direction we are heading in is the right one, but it does take a lot of time to affect change in actual behavior. In the meantime, I would hope that the option of a "slow" code is less and less likely to be taken seriously.

INTERVIEW WITH A CRITICAL CARE STAFF NURSE

How would you define a "slow" code?

A "slow" code usually occurs when a family wants everything done to keep the patient alive even though the patient has no chance of surviving. The health care team all knows the code is going to end badly, and they don't really want to torture the patient. So a "slow" code means the health care staff responding to the code take their time.

Tell me about a "slow" code you participated in

In one Medical ICU setting where I worked, we had a large elderly population who had a lot of pulmonary problems that resulted in sepsis. These individuals would be lying in their beds, frequently contracted, having been transferred from a nursing home. Basically, because they had no Advance Directive or no one to say otherwise, they were considered a full code. This type of patient would definitely be a "slow" code. When ventricular fibrillation or tachycardia developed, no one would want to defibrillate them, feeling it was almost torturous. We would probably defibrillate them once, to say we tried.

Tell me about a situation in which family was involved

I remember a specific case involving a 30-year-old patient with a particularly virulent strain of pneumonia. Blood was sent to NIH to rule out hanta virus. It was a case that was frightening but also very enlightening and interesting. She developed full-blown ARDS so severe that only bilateral lung transplants would have saved her. Routine turning caused her to desaturate because she was that unstable. I can understand that, because she was 30 years old, the family wanted everything done. No matter what we said to them, they didn't hear that there were no alternatives. Of course, this was an extreme case, one in which I can understand the family's wishes. If I didn't have the medical knowledge about ARDS and someone told me that my 30-year-old sister was going to die, I would have wanted everything done. The family thought we could do lung transplants right there in the room. They had to be very gently wooed into the idea of a DNR status. She coded before a DNR status could be obtained. In this case, the family was very much opposed to a DNR status and a "slow" code was performed to satisfy their needs.

When do "slow" codes usually occur?

I have seen "slow" codes occurring mostly with an elderly population; usually, with someone whose family just hasn't been properly educated. We have a patient right now who could be a "slow" code. He's on inotropic medications, he's paced and ventilated. If he were to code, you would take your time and hope that once you get there, drugs will not work. He's in pain constantly and the family does not want to give up on him, even though his graft is infected and he's septic. There's absolutely no way, with all of the extensive complications that he has, that this patient will survive. He will need more surgeries, none of which he could possibly survive. It is very frustrating to take care of someone like that. The frustration of dealing with the suffering of the patient and the family is overwhelming. I think a lot of doctors feed into this type of situation, rather than helping to resolve it.

In what way? Can you expand on that?

The admitting doctor tells the family one thing, the surgeon tells them another, and the resident tells them still another. If the physicians aren't all saying exactly the same thing, any family is going to read what they want into it. In other words, the families make misinterpretations because of lack of consistency in medical information that is shared with them. They do not get a clear message of the poor prognosis and the futility of additional care. Sometimes the medical professional must be blunt and say something like, "I'm sorry, but he's not going to live no matter what we do." This information must be given to the family by the doctors. It becomes difficult for the nurse who is put on the spot on a day-to-day, hour-to-hour basis. I just don't think its appropriate for me to be the one to tell the family what they should already know. I think its more appropriate for a physician to say it. I'm very reluctant to give information in a situation like that because I always think that I will put myself or the hospital at risk. I wish someone would just say to the family, "he will not live," but no one will do that. It's frustrating. It's the patient who ultimately suffers, and that's what is upsetting to me. You see them, you see the look in their eyes, and you know they don't want to continue, they are in their own process of dying and withdrawing from all of us. They have the family coming in and wanting them to be awake for them. The patient is miserable, but the family does not want them sedated.

Do you think that "slow" codes are ever ethically appropriate?

On a personal level, feeling that I am a true patient advocate, I think they are in some situations. In a strict ethical sense, they are not. It is my view that life on mechanical support is not life at all.

And have you ever worked with anyone that has objected to a "slow" code when it is being conducted?

I think the only time that would cross someone's mind would be a brand new graduate-someone who has never had any critical care experience, or someone who has never seen a patient die. It seems to be an unspoken law among the whole staff. We've talked about it amongst ourselves, giving report from nurse to nurse, and during physician rounds. Usually there is agreement that it's the right thing to do.

What do you feel precipitates the need for a "slow" code?

I think usually its optimally what is good for the patient. Especially as nurses I think we tend to think more along those lines; I think a physician looks at it from a different perspective. Physicians don't like to give up, which I can understand. I think that the nurses are more adept at looking at it from the patient's perspective.

From your perspective, what is needed to prevent "slow" codes from occurring in the future? What do you think would change things?

I think, first of all, it's admirable that we encourage Advance Directives for everyone. However, I think that there needs to be a revised policy about how we state desired end-of-life care and code status. For example, on the DNR order sheets that families are given, there is a choice of drugs, defibrillation, and ventilation. I think that is confusing. We give them a menu instead of "either or" many times without sufficient information upon which to make the decisions. Withdrawing treatment is different from a DNR and I don't necessarily believe it should be. In some cases a DNR should mean there will not be further aggressive treatment. Maybe the best action is to withdraw treatment such as the ventilator as well. A menu confuses people, and also it gives loopholes to physicians who are tenuous about talking to the families in depth about such decisions. The other issue is the elderly population, especially the nursing home population. We should encourage them to have someone appointed as their Durable Power of Attorney for Health Care, who can make sure that when they code they will not be intubated and rushed to the hospital. I think that this is something that should be done statewide, starting with the lawmakers. I think that's something that nursing as a profession could probably have a great effect on by research and by lobbying. If a Durable Power of Attorney for Health Care were available to those who cannot speak for themselves, a lot of confusion and unnecessary codes could be prevented.

SUMMARY

The interviewed physician and nurse view "slow" codes slightly differently. The nurse, perceiving her role as that of the patient advocate, focused upon preventing more suffering and complying with what the patient would want. The physician, with his strong ethics background, viewed such a code as an outcome of lack of appropriate communication with the family. Both state that if anything is to change, there needs to be better communication of what options are truly feasible in each clinical situation and people discussing the options who have a reliable knowledge of what the patient values in life. The physician saw that responsibility primarily with the physician group, and the nurse stressed the need for a less-confusing DNR and an authorized proxy decision maker. The nurse saw the solution both at the bedside and at the legislative level of health care.

"Slow" codes, although infrequent, are an emotionally charged topic. A varied level of comfort exists with the staff in the clinical units where such codes are most frequently performed. A nursing manager related that she does everything possible to prevent "slow" codes. She coordinates discussions with physicians about code status and is assertive about bringing the physician and family together. She has made it her mission that no "slow" codes will occur in her intensive care unit because she objects to them so strongly on an ethical basis.

REFERENCES