Slow codes without regret

“Slow codes have been nearly universally decried as unethical in the literature for at least three decades.” So began the invitation for these essays. But my story begins in the mid-1980s, way more than three decades ago. Back then I was in training, first as an internal medicine intern, then a resident, then a fellow, and always in large teaching hospitals. As an intern and resident, I carried the code beeper, so anytime a patient arrested, I knew right away to drop everything and sprint to the room. By early in my first year, I hated that beeper. Not because I didn't know how to run a code—but because I was sick of codes. Almost nobody died back then without being coded, and it seemed like everybody who coded died. I was sick of running codes where everyone died. I don't remember ever coding a patient when I was in training and hearing they later walked out of the hospital. Or even just left the hospital alive. Ever. The mid-1980s were sandwiched between the late 1970s, when cardiopulmonary resuscitation (CPR) became standard for all in-house arrests, and 1990, when the Patient Self Determination Act (PSDA) passed. Before the PSDA, patients had no easy way to request, let alone demand, a do not resuscitate (DNR) status. Did we talk about DNRs in the 80s? Hardly ever. Did we give patients the option? Almost never. Did we run lots of codes? Every day. But for context, other huge changes were also happening in medicine back then. Medicare was created in 1965 but did not add a hospice benefit until 1982. By 1979 CPR was standard for all in hospital arrests, and by 1981, CPR was standard for all out of hospital arrests as well. The American Heart Association and Citizen CPR Foundations rushed to teach CPR to everyone in the 1980s, ignoring that CPR was originally developed for patients in the peri-operative areas,1 and was never intended for all patients, especially not for those who were terminally ill. Yet, inexorably, CPR became the default for all arrests unless there was a previously written DNR. This meant that all patients—including the terminally ill and dying—received CPR unless a DNR order was in place. What else happened in the 1980s? AIDS (acquired immunodeficiency syndrome) was blowing up—especially in the large city where I trained. We couldn't save these (mostly young people) at the end of their lives, but we coded them. We also couldn't save the patients in multi-organ failure, or with terminal cancer, or those with end-stage heart disease—but we coded them too. We coded them all. Every day. And especially at night. Just think what it was like for young trainees (most of us were in our 20s) to participate in failed codes every day and night—during work weeks that routinely lasted 100 h or more (no work hour limits back then). But even as young and inexperienced as we were, we knew it was wrong to subject dying patients to the brutality of CPR. And no, it wasn't less brutal back then—it was more brutal. We didn't have specialized code teams, lines teams, bedside ultrasound, or anesthesia readily available. It was just us—mostly interns—trying to intubate, putting in the central lines, compressing the chest while breaking the fragile ribs, and calling for rounds of drugs. And at the end, we usually also tried a blind pericardiocentesis—meaning we stuck a long, large bore needle directly into the pericardium (blindly, we just hoped we entered the pericardium) “just in case” there was cardiac tamponade. Needles flying, blood squirting, broken bones, and, at the end, a naked, battered dead body and mentally and emotionally battered young physicians. Not coincidentally, the term moral distress was first coined in 1984 by Jameton2 as occurring “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.” So how did we live with what we were doing? With ourselves? Slow codes provided one way out of the impossible morass for us. Not “show codes”—pull the curtain, scream and yell and “pretend” to do something; we never did that. Slow codes—where you were slow to push the code button, slow to walk to the room, slow to open the code cart. Slow. When we checked out our soon-to-code and dying patients to the covering trainee colleague before we left, we'd say—when he codes, do not run to the room, walk. When the situation was especially dire or imminent, we said—walk as slow as possible. It was understood that “walk, don't run” really meant “we have no business coding this poor soul, but we have to because this is a hospital and that is what we have been told we must do.” And if the patient was dead when we arrived it was easy to “call” (stop) the code the nurses had started. The patient suffered less, we suffered less, and nobody talked much about it. Families were told “we did everything,” and theoretically we all felt better… except those of us who didn't. The toll on the nurses who had to start the code whether we walked slow or fast must have been horrendous, though I am ashamed to say I don't remember conversations with them about this. We interns—the youngest, least trained, least experienced, and most vulnerable—were on our own during those bleak nights (and days). So, we either invented or adopted the slow code as the best we could do at the time to do the least amount of harm while being required to honor the full code status. And they were done all over the country back then. I don't know any physicians from that era who, if they are honest, will deny running “slow codes.” You see, conversations about CPR between trainees (or even attendings) and patients were rare— if they happened at all. We weren't taught to have conversations—we weren't even taught that we should have conversations—and anyway, it was our job to “save” patients by whatever means possible—including CPR. Our training mirrored attitudes in our country; death was an enemy to be vanquished or cheated. I am over four decades out from those days, but sometimes, in nightmares, can still feel the ribs cracking, can still see the eyes glazing over, and the lights going out on a life in a brutal, senseless, painful way. Forward to the mid-2010s. No longer an intern, I was at a leading institution taking part in a multi-disciplinary discussion about slow codes in a clinical ethics setting. The speaker had just reviewed the horrors of slow codes. Lying! Deceit! Dereliction of duty in not obtaining a DNR before the code event! Terrible physicians! Unethical behavior! Absolutely intolerable! Unbelievable! The small group was piling it on—trying to fathom slow codes—when I piped up: “We did them all the time in training.” Silence. Not a word. No questions about “why.” But there was a pretty quick judgment that we must have been unethical physicians since I'd just admitted to a practice that “everybody knew” was wrong. My explanation of physicians in the 1980s choosing the least bad pathway fell flat. Interestingly, other physicians in the room from my era remained silent as the moment passed. Forward to now, 2024. I am the director of clinical ethics at a different (large) system. I am (and have been) immersed in the world of codes. I know about slow codes and show codes, no codes, fast codes, and partial codes. I know about Hollywood codes and cafeteria style codes. Codes witnessed by families and those not witnessed. Codes using all the blood products in the entire facility on a patient with a non-survivable injury. Codes that aren't stopped until a surrogate finally agrees to stop. Codes where the wrong treatment was tried because a surrogate demanded it. I've been in hospitals where a DNR cannot be written without consent of the patient/surrogate and hospitals with a unilateral DNR policy (DNR written despite patient/surrogate objection). I've had full code patients not coded and DNR patients undergo CPR. I've reviewed patients coded for a very long time just because they were “young” even though the team said there was a zero percent chance of success. I have seen ICU patients maxed out on pressors and ventilator settings who were coded even though CPR was physiologically futile. I've seen codes on patients over 100 with terrible osteoporosis, and I've seen brain dead patients (not organ donors) stay in the ICU for days with a Full Code status. I won't say I've seen it all—but I have seen a lot. Too much. And I wonder how on earth we justify this? What hubris—or fear—leads us to perform CPR we know is physiologically futile? Perhaps Daly was right when she suggested DNR instead of full code as the default status for inpatients3; at least that might have forced conversations. I find many physicians simply don't want to have a code status conversation—I ask them how they will feel if they subject a particular patient to CPR, knowing that it cannot help. Some say they will feel bad; others say it doesn't matter because “the patient is dead anyway.” Many do not see it as a problem, perhaps because they themselves never actually perform the codes, which are now done by specialized teams who rarely know anything about the patient. Many of those physicians have never once felt ribs crack under their own hands. I teach communication—the hows and the whys. I urge physicians to have conversations about code status with all inpatients. And I advocate for codes to be done correctly or not at all. So, no, I don't condone slow codes in 2024, but I understand too well why they were so common decades ago. I teach that it's better to withhold CPR with a DNR order on the chart. But if there is no DNR on the chart for a patient who should not be coded—I remind physicians their obligation in an emergency is to evaluate the situation and do what needs to be done. We all know the rule about having no obligation to code a patient (despite a full code order) who already has rigor mortis or is decapitated. The same applies to the ICU patient maxed on pressors and ventilator settings. Even if that patient is full code, and even if the surrogate wants CPR, when that patient codes due to hypotension or hypoxemia that are already maximally treated—the physician on site should not start CPR. The physician off-site should stop CPR as soon as they arrive at the scene. To do otherwise injures the patient, the medical teams, the nurses, the code teams, and the medical profession. Our primary obligation primum non nocere (first, do no harm) ought to prevail over surrogate demands in such a case. Am I right? I don't know. I do know many physicians disagree with me as they find it easier to allow a futile code than to have a tough conversation. But I think even they agree with me in theory—they just aren't willing or able to follow through. Are there still situations where a slow code remains the “least bad” option? No, I can't think of one. I am lucky to work in a system that gives physicians the option of writing a “unilateral DNR,” so that if CPR cannot work, we can write a DNR order even if the patient/surrogate disagrees. Other physicians are not so lucky and may work in situations where a unilateral DNR is never allowed. In those cases, a short code (full attempt but not prolonged) is a better option than either a slow code or a long and fruitless code. So I don't regret a single slow code from all those years ago because the slow code was too often “the least bad” option. But that is no longer the case, so I join my colleagues in condemning slow codes today. Patricia A. Mayer is board-certified in internal medicine, rheumatology, and hospice and palliative medicine. She holds a master of science degree in bioethics, completed a 2-year Clinical Ethics Fellowship at the Cleveland Clinic, and founded the Clinical Ethics Service at Cleveland Clinic Florida. She served as Medical Director of the Hospice of Northern Colorado and holds faculty positions at the Cleveland Clinic, Mayo Clinic, Case Western University, Clarkson University, and the University of Arizona College of Medicine-Phoenix. She currently serves as the Director of Clinical Ethics for Banner Health, headquartered in Phoenix, Arizona.