Slow code
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.
Background
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]
Ethics
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
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]
Notes
- ^ a b c New York Times 1987.
- ^ Marks 2006.
- ^ NBC News 2008.
- ^ Braddock 1998, When should CPR be administered?.
- ^ Braddock 1998, When can CPR be withheld?.
- ^ a b Braddock 1998, What if the patient is unable to say what his/her wishes are?.
- ^ a b College of Physicians and Surgeons of Ontario 2006.
- ^ a b Braddock 1998, When is CPR not of benefit?.
- ^ Dosha et al. 2009.
- ^ Berger 2003, p. 2271.
- ^ a b 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"?.
References
- Braddock, Clarence H. (1998). "Do Not Resuscitate Orders". Ethics in Medicine. University of Washington School of Medicine. Retrieved 2013-04-06.
{{cite web}}: Invalid|ref=harv(help) - 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.
{{cite journal}}: Invalid|ref=harv(help) - DePalma, Judith A.; Miller, Scott; Ozanich, Evelyn; Yancich, Lynne M. (November 1999). ""Slow" Code: Perspectives of a Physician and Critical Care Nurse". Critical Care Nursing Quarterly. 22 (3). Lippincott Williams and Wilkins: 89\u201399. doi:10.1097/00002727-199911000-00014. ISSN 1550-5111.
{{cite journal}}: Invalid|ref=harv(help) - 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.
{{cite journal}}: Invalid|ref=harv(help) - Marks, William J. (1 January 2006). ""Code Blue", "Code Black": What Does "Code" Mean?". WebMD. Retrieved 2013-04-06.
{{cite web}}: Invalid|ref=harv(help) - "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.
{{cite web}}: CS1 maint: others (link) - "Decision-making for the End of Life". Physician Advisory Service. College of Physicians and Surgeons of Ontario. May 2006. Retrieved 2013-04-06.
{{cite web}}: CS1 maint: others (link) - "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.
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