The Slow Code: Is It Ethical?

Dr. John Lantos

Slow codes, defined as half-hearted efforts to resuscitate patients, have been called deceptive, dishonest, unethical and deplorable. But is it time to reconsider that point of view? Can slow codes be appropriate and ethically defensible? Dr. John Lantos thinks so, and he joins us now on the Bioethics Channel, a production of the Center for Practical Bioethics. For more information about the Center and its programs, visit practicalbioethics.org. Practicalbioethics.org. Dr. Lantos is director of the Children's Mercy Bioethics Center. He and William Meadow of the McLean Center for Clinical Medical Ethics have written an article in the November 2011 edition of the American Journal of Bioethics entitled, Should the Slow Code Be Resuscitated? Dr. Lantos, you state in the article that the slow code has been misunderstood. Explain why you think this is so.

Dr. John Lantos

Sure. The question is, Here is what do people mean by a full resuscitation and what would they mean by a somehow less than full resuscitation? In the past, a less than full resuscitation has been disparagingly nicknamed a slow code, and it can mean anything from CPR that's done with full vigor but for a shorter period of time to to a complete sham or charade attempt at resuscitation, even, for example, injecting the cardiac meds into the mattress rather than into the patient. So it covers a range of alternatives, some prettier than others.

Dr. John Lantos

So this is a scenario where a DNR order, a do not resuscitate order, is not agreed to by the family. And that causes some situations to develop with the doctors as they try to make the decision, correct?

Dr. John Lantos

Exactly. So to set the stage for the argument that we made, you have to understand a little bit about how end-of-life decisions are made in general. If doctors think that a patient is dying... Or if families think that medical treatment is no longer appropriate, they initiate a discussion with each other about what sort of limitations they would like to place on which treatments are offered. Families can have living wills or advanced directives. Doctors can bring up discussions of do not. or do not intubate or other limitations on treatment. And in the vast majority of cases, these discussions eventually lead to an agreement. Treatment is limited. Patients seek palliative care and die according to their wishes and preferences in ways that doctors and nurses find appropriate and non-distressful. Sometimes those discussions don't go well. it's a small minority of cases, but they're deeply troubling cases where either the families don't want treatment that the doctors think is in the patient's best interest and what the patient would have wanted, or the other way around, that families insist on continued aggressive life-sustaining treatment, including cardiopulmonary resuscitation, when the doctors think the patient is clearly dying and the treatment will be futile. So it's that small subset of intractable disagreements that we're talking about. In those circumstances, we argue that under current bioethical and legal norms, there are only three options. One, family says, do CPR, and the doctor thinks it's futile. The doctor can just say, no, we're not going to do that. We don't do that here. It's futile. You have no right to demand that of us. And if you don't like it, tough, go find another doctor or another hospital. That's the approach advocated by John Paris in his response to us. A second alternative is for the doctors to say, well, okay, we don't have the right to make this decision. Families have the right to make the decision. And so we're going to do full CPR knowing or believing deep in our hearts that it's likely to be ineffective, almost certainly will be ineffective. and at the same time will cause the patient pain and suffering since CPR involves invasive procedures, intubation, chest compressions that may crack ribs, etc., etc., and so it's not a benign set of interventions. This causes a lot of doctors and nurses severe moral distress. They're being asked to torture patients for no benefit, and so they don't like to do that. Or the third alternative is continued counseling, as it's benignly called, But counseling in these circumstances is usually somewhat coercive, involves browbeating, repeated efforts by multiple professionals to lean on the families to get them to ultimately accede. to a plan that limits treatments. Families universally say they hate this. They start to avoid health care professionals. They stop visiting their loved one because they don't want to continue these unpleasant, coercive, and ultimately, to their minds, unnecessary and futile conversations.

Dr. John Lantos

Sounds like a lot of this, then, could be addressed with an education of what CPR is, the general public, including all of us. are educated too often, I would suspect, by TV programs that give a more benign, using your word, a more benign representation of what CPR involves, and the results that come from that are a lot more positive than in actual life.

Dr. John Lantos

A nice, hopeful, and optimistic dream, but simply wrong by the way I've set this up. That conversation has already taken place. That's the conversation that doctors have when they first approach patients and explain why they think resuscitation would be inappropriate. And you're right. That conversation works the vast majority of the time. Many people have misimpressions of what CPR is. Many people believe it to be far more effective than it is. And when doctors sit down with them and explain how ineffective it is likely to be in the particular circumstances that their loved one is facing, say metastatic cancer, multisystem organ failure, chronic degenerative disease, Alzheimer's, et cetera, et cetera, many families, most families get it. agree to limit treatment. A DNR order is written. Hospice and palliative care is consulted, and everybody's happy. The cases we're talking about are after that conversation has already taken place, and the family says, yes, doctor, thank you. We understand. We disagree. We want it anyway.

Dr. John Lantos

So you're suggesting that perhaps the name should be changed and have it be more of a tailored resuscitation.

Dr. John Lantos

Right. So among the responses to our paper, and there were six or eight of them, as is common in the format that the American Journal of Bioethics has pioneered, the open peer commentary format, which is a wonderful thing. Most of the physicians who responded, although interestingly not the philosophers, priests, and lawyers, most of the physicians who responded acknowledged that it is entirely appropriate and quite common to tailor the vigor or duration of their resuscitative efforts based on the circumstances of the case. so that many people said, yeah, we do resuscitation for three minutes or five minutes or sometimes even one minute, but we do it with integrity. We do it with vigor. We do it with the hope that it will be successful. But if after a minute or two minutes or three minutes it's unsuccessful, then we, in our professional integrity, have the discretion to call the code that is... given order for CPR to stop, and we can then in good conscience go look the family members in the eye and say, we did everything we could. Meadow and I argue they're kidding themselves. The data on CPR that's available from all the evidence-based medicine shows that

Dr. John Lantos

the prognostic value of one or two or three minutes of CPR is minimal. If you're going to give CPR a full chance of succeeding, you probably have to go at least 10 minutes and some people would say 20 before deciding that it is not going to be effective. So these short codes, these tailored codes, these codes that are modified based on the circumstances of the patient's particular clinical condition and the family's wishes are are in essence the same thing that we're talking about. It's just that the term slow code has become an unacceptable term in today's discourse, and perhaps tailored code or appropriate code would be a better way to move forward.

Dr. John Lantos

Taking what you just said, though, it sounds like slow codes happen informally, almost. rather than being upfront about it. And maybe that's what points you're trying to bring across.

Dr. John Lantos

Again, it would partly be semantic or definitional. I think the people who make this argument say, no, no, no, we are not doing a slow code. A slow code means you move more slowly. You do inadequate CPR. We are doing... full CPR. We're just not doing it for as long. So that is, by definition, not a slow code. And therefore...

Dr. John Lantos

The question sounds like it depends on how vigorous you are and how you, in your own mind as a medical professional, make that connection that you're being vigorous and that you're doing all you can, but at the same time you're recognizing that... This won't do as much good as what people hope.

Dr. John Lantos

Or to put it another way, and the way Bill Meadow and I tend to think about it, assuming that you've done everything possible to communicate with the family and to try to get an agreement that CPR is not going to be effective and assume that you've failed, that the disagreement is simply intractable. At that point, the question is, is the harm to the patient by doing two minutes or three minutes or even five minutes of chest compressions a greater harm in some absolute sense than the psychological harm to the family of not letting them direct the circumstances in which their loved one dies? And we say that's a real ethical tension that can't be sort of shoved under the rug or explained away by saying obligations to the patient always trump any sort of obligations to family members we call for a balance

Dr. John Lantos

it sounds like that balance just simply is not easy to achieve

Dr. John Lantos

well to read the physicians commentaries it may be more easy to achieve in practice than it is in principle that is People seem to recognize the necessity of doing this and to do it when it is necessary, as long as they don't explain it to themselves in terms that would violate the principles by which they're trying to live.

Dr. John Lantos

So if we're up front about

Dr. John Lantos

slow codes...

Dr. John Lantos

Which we

Dr. John Lantos

must not be, as it turns out.

Dr. John Lantos

Right. How will that improve the care? If we do that, of the seriously ill. It sounds like, Dr. Lantos, we're both kind of struggling with this. It's the idea of let's not play any more games. Let's be up front about this. And if we are up front, how do we think that will improve the care of the seriously ill and the dying among us?

Dr. John Lantos

The goal is to always do what's best for the patient. But sometimes what's best for the patient includes considerations of what's best for the family. Patients, all patients, live within some social structure or another, and so considerations of what's good for their loved ones often are also valid considerations for the patient. Most people acknowledge that there are situations where the patient themselves would say, look, if my family wants me to have CPR, even though I think it won't work, do it for them because their well-being is important to me.

Dr. John Lantos

How will patient care improve if this happens? Family members won't be insulted or confronted by doctors who are refusing to provide care to a loved one according to the family's deeply held values and preferences. Patients won't be subjected to the indignity and possible harm or pain associated of a full-blown 20-minute CPR episode. And doctors and nurses won't have to live with the moral distress caused by imposing that sort of indignity and suffering. So it seems to us, in the small set of cases where good communication can't lead to an agreement that avoids the need for this sort of compromise, This sort of compromise is the least worst alternative.

Dr. John Lantos

Dr. John Lantos is director of the Children's Mercy Bioethics Center. The article is entitled, Should the Slow Code Be Resuscitated? It can be found in the November 2011 edition of the American Journal of Bioethics. For more information, visit bioethics.net. That's bioethics.net. I'm Laurel LeBue. Thanks for listening to the Bioethics Channel.