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{{Short description|Deliberately delayed resuscitation attempt}}

{{Orphan|date=April 2013}}

{{About|the medical practice|the programming term|algorithmic efficiency}}

'''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 for which [[cardiopulmonary resuscitation]] (CPR) is thought to be of no medical benefit by the medical staff.{{sfn|New York Times|1987}} The related term '''show code''' refers to the practice of a medical response that is fakedmedically futile, but is attempted for the sakebenefit of the patient's family and loved ones. However, the terms are often used interchangeably.{{sfn|New York Times|1987}}

The practices are banned in some jurisdictions.

'''Slow code''' refers to the practice in a [[hospital]] to purposely respond slowly to a patient in [[cardiac arrest]]. The related term '''show code''' refers to the practice of a medical response that is faked for the sake of the patient's family.

==Background==

During a patient cardiac arrest in a hospital or other medical facility, staff may be notified via a [[Hospital emergency codes#Code Blue|code blue alert]],.{{sfn|Marks|2006}} to which aA medical response team, willbased on the institution's practices and policies, attends to the respondemergency.{{sfn|NBC News|2008}} The team will perform [[cardiopulmonarylife resuscitation]]saving measures, including (CPR), in order to re-establish both cardiac and pulmonary function.{{sfn|Braddock|1998|loc=When should CPR be administered?}}

Cardiopulmonary resuscitation may be withheld underin some circumstances. One is if the patient has a [[do not resuscitate]] ("no code") order,{{sfn|Braddock|1998|loc=When can CPR be withheld?}} such as one in whicha [[Advance health care directive|living will]].{{sfn|Braddock|1998|loc=What if the medicalpatient staffis deemsunable thatto CPRsay willwhat behis/her wishes are?}} Another is if the patient, family member, individual with [[power of noattorney]] clinicalprivileges benefitover tothe patient, or other surrogate decision maker for the patient, makes such a request of the medical staff.{{sfn|College of Physicians and Surgeons of Ontario|2006}} ThisSurrogate includesdecision amakers patientare considered in [[septica shock]],hierarchy: onelegal whoguardians haswith hadhealth ancare acuteauthority, [[stroke]]individual orwith whopower hasof [[metastaticattorney cancer]],for andhealth onedecisions, withspouse, severeadult [[pneumonia]]children, whichparents, alland have no probability ofadult successsiblings.{{sfn|Braddock|1998|loc=WhenWhat if the patient is CPRunable notto ofsay what his/her wishes benefitare?}}

A third situation is one in which the medical staff deems that CPR will be of no clinical benefit to the patient.{{sfn|College of Physicians and Surgeons of Ontario|2006}} This includes, among other cases: a patient in severe [[septic shock]] and/or [[multiple organ dysfunction syndrome]] whose organ damage cannot be contained and reversed any longer, one who has had an acute [[stroke]] that has irreversibly damaged vital brain functions needed for life beyond repair (i.e., in the brain stem), or who has advanced and incurable [[metastatic cancer]], and one with severe [[pneumonia]] which is no longer treatable with assisted ventilation methods and medication, which all have very little or no realistic probability of success.{{sfn|Braddock|1998|loc=When is CPR not of benefit?}} There is also a low probability of success for patients with severe [[hypotension]] that resulted from shock or severe illness or injury, and has not responded to treatment (and which was not induced), severe cases of acute or chronic [[kidney failure]] or [[end stage kidney disease]] (where dialysis and other renal replacement therapies either are no longer working or were not adequate, and where a transplant either cannot be found or is not an option), end-stage [[HIV/AIDS|AIDS]] and its accompanying severe opportunistic illnesses (which are not responding to antiretroviral and drug therapy and/or the white blood cell count is too low), or those who are older than about 70 and/or homebound (where they and/or their guardians, instead of a DNR order, have authorized such half measures and the law permits it).{{sfn|Braddock|1998|loc=When is CPR not of benefit?}}

==Practice==

Slow code is used in response situations for which CPR is of no medical benefit. The medical staff at the facility will purposely respond slowly or incompletely to a patient in cardiac arrest.{{sfn|New York Times|1987}} When a medical response is faked for the sake of the patient's family, it is referred to as a ''show code''.{{sfn|New York Times|1987}}

A patient may request, in an advance directive, to prohibit certain responses, including [[intubation]], chest compression, electrical [[defibrillation]], or [[Advanced cardiac life support|ACLS]].{{sfn|Dosha|Dhoblea|Evonicha|Guptaa|2009}} This is referred to as a ''partial code'' or ''partial resuscitation'' and such resuscitation "commonly violates the ethical obligation of nonmalfeasance".{{sfn|Berger|2003|p=2271}} It is regarded as medically unsound because partial interventions are "often highly traumatic and consistently inefficacious".{{sfn|ANA Center for Ethics and Human Rights|2012|p=6}}

==Ethics==

The practice is "controversial from an ethical point of view",{{sfn|DePalma|Miller|Ozanich|Yancich|1999}} as it represents a violation of a patient's trust and right "to be involved in inpatient clinical decisions".{{sfn|Braddock|1998|loc=What if the family disagrees with the DNR order?}}

In a [[position paper]], the [[American Nurses Association]] states that "slow codes are not ethical".{{sfn|ANA Center for Ethics and Human Rights|2012|p=6}}

[[New York]] became the first [[U.S. state|state]] in the [[United States]] to ban the practice in 1987.{{sfn|New York Times|1987}} The law also required medical staff to honour a patient's refusal of cardiopulmonary resuscitation.{{sfn|New York Times|1987}}

==Policy and legislation==

Some medical services centres have instituted policy banning the practice.{{sfn|Braddock|1998|loc=What about "slow codes"?}}

In 1987, [[New York (state)|New York]] became the first [[U.S. state|state]] in the [[United States]] to baneffectively end the practice inby 1987.{{sfn|Newenacting Yorklegislation Times|1987}} The law alsoto requiredrequire 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.{{sfn|New York Times|1987}}

==Notes==

{{reflist|2}}

==References==

{{refbegin|2}}

*{{cite web|url=http://depts.washington.edu/bioethx/topics/dnr.html|title=Do Not Resuscitate Orders|work=Ethics in Medicine|last=Braddock|first=Clarence H.|publisher=[[University of Washington]] School of Medicine|year=1998|accessdateaccess-date=2013-04-06|ref=harv}}

*{{cite journal|title=Ethical Challenges of Partial Do-Not-Resuscitate (DNR) Orders|last=Berger|first=Jeffrey T.|journal=Archives of Internal Medicine|volume=163|issue=19|pages=2270–2275|date=October 2003|doi=10.1001/archinte.163.19.2270|pmid=14581244}}

*{{cite journal|url=http://www.nursingcenter.com/lnc/journalarticle?Article_ID=437848|title="Slow" Code: Perspectives of a Physician and Critical Care Nurse|last1=DePalma|first1=Judith A.|last2=Miller|first2=Scott|last3=Ozanich|first3=Evelyn|last4=Yancich|first4=Lynne M.|journal=Critical Care Nursing Quarterly|volume=22|issue=3|pages=89–99|publisher=[[Lippincott Williams and Wilkins]]|yeardate=November 1999|month=November|issn=1550-5111|refdoi=10.1097/00002727-199911000-00014|pmid=10646457|url-access=harvsubscription}}<!--http://journals.lww.com/ccnq/Abstract/1999/11000/_Slow__Code__Perspectives_of_a_Physician_and.14.aspx -->

*{{cite web|url=http://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean|title="Code Blue", "Code Black": What Does "Code" Mean?|last=Marks|first=William J.|publisher=[[WebMD]]|date=1 January 2006|accessdate=2013-04-06|ref=harv}}

*{{cite journal|title=Analysis of limited resuscitations in patients suffering in-hospital cardiac arrest|last1=Dosha|first1=Kristofer|last2=Dhoblea|first2=Abhijeet|last3=Evonicha|first3=Rudolph|last4=Guptaa|first4=Amit|last5=Shaha|first5=Ibrahim|last6=Gardiner|first6=Joseph|last7=Dwamenaa|first7=Francesca C.|journal=Resuscitation|volume=80|issue=9|pages=985–989|date=September 2009|doi=10.1016/j.resuscitation.2009.05.011|pmid=19581039}}

*{{cite web|url=http://www.cpso.on.ca/policies/policies/default.aspx?ID=1582|title=Decision-making for the End of Life|others=Physician Advisory Service|publisher=[[College of Physicians and Surgeons of Ontario]]|year=2006|month=May|accessdate=2013-04-06|ref={{harvid|College of Physicians and Surgeons of Ontario|2006}} }}

*{{cite newsweb|url=http://www.nbcnewswebmd.com/ida-to-z-guides/23239084/ns/healthcode-blue-code-health_careblack-what-does-code-mean|title=Hospitals’"Code ‘codeBlue", blue’"Code mostBlack": deadlyWhat atDoes night"Code" Mean?|___locationlast=[[Chicago]]Marks|agencyfirst=[[AssociatedWilliam Press]]J.|publisher=[[NBC NewsWebMD]]|date=191 FebruaryJanuary 20082006|accessdateaccess-date=2013-04-06|ref={{harvid|NBC News|2008}} }}

*{{cite newsweb|url=http https://www.nytimesnursingworld.comorg/1987~4af287/08globalassets/22docs/opinionana/slowethics/ps_nursing-codescare-showand-codesdo-andnot-resuscitate--allow-natural-death.htmlpdf |title=SlowNursing Codes,Care Showand CodesDo Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions|newspaperformat=[[NewPDF|others=ANA YorkCenter Times]]for Ethics and Human Rights|publisher=New[[American YorkNurses Times CompanyAssociation]]|date=2212 AugustMarch 19872012|accessdateaccess-date=2013-04-06|ref={{harvid|NewANA Center for Ethics and YorkHuman TimesRights|19872012}} }}

*{{cite web|url=http://www.cpso.on.ca/policies/policies/default.aspx?ID=1582|title=Decision-making for the End of Life|others=Physician Advisory Service|publisher=[[College of Physicians and Surgeons of Ontario]]|yeardate=May 2006|month=May|accessdateaccess-date=2013-04-06|ref={{harvid|College of Physicians and Surgeons of Ontario|2006}} }}

*{{cite news|url=http://www.nbcnews.com/id/23239084/ns/health-health_care|archive-url=https://web.archive.org/web/20160305095046/http://www.nbcnews.com/id/23239084/ns/health-health_care|url-status=dead|archive-date=March 5, 2016|title=Hospitals' 'code blue' most deadly at night|___location=[[Chicago]]|agency=[[Associated Press]]|work=[[NBC News]]|date=19 February 2008|access-date=2013-04-06|ref={{harvid|NBC News|2008}} }}

*{{cite news|url=https://www.nytimes.com/1987/08/22/opinion/slow-codes-show-codes-and-death.html|title=Slow Codes, Show Codes and Death|newspaper=[[New York Times]]|date=22 August 1987|access-date=2013-04-06|ref={{harvid|New York Times|1987}} }}

{{refend}}

[[Category:Medical slang]]

[[Category:Medical ethicscontroversies]]