# Slow code

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Deliberately delayed resuscitation attempt

This article is about the medical practice. For the programming term, see [algorithmic efficiency](/source/Algorithmic_efficiency).

**Slow code** refers to the practice in a [hospital](/source/Hospital) or other medical centre to purposely respond slowly or incompletely to a patient in [cardiac arrest](/source/Cardiac_arrest), particularly in situations for which [cardiopulmonary resuscitation](/source/Cardiopulmonary_resuscitation) (CPR) is thought to be of no medical benefit by the medical staff.[1] The related term **show code** refers to the practice of a medical response that is medically futile, but is attempted for the benefit of the patient's family and loved ones. However, the terms are often used interchangeably.[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](/source/Hospital_emergency_codes#Code_Blue).[2] A medical response team, based on the institution's practices and policies, attends to the emergency.[3] The team will perform life saving measures, including CPR, 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](/source/Do_not_resuscitate) ("no code") order,[5] such as in a [living will](/source/Advance_health_care_directive).[6] Another is if the patient, family member, individual with [power of attorney](/source/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, among other cases: a patient in severe [septic shock](/source/Septic_shock) and/or [multiple organ dysfunction syndrome](/source/Multiple_organ_dysfunction_syndrome) whose organ damage cannot be contained and reversed any longer, one who has had an acute [stroke](/source/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](/source/Metastatic_cancer), and one with severe [pneumonia](/source/Pneumonia) which is no longer treatable with assisted ventilation methods and medication, which all have very little or no realistic probability of success.[8] There is also a low probability of success for patients with severe [hypotension](/source/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](/source/Kidney_failure) or [end stage kidney disease](/source/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 [AIDS](/source/HIV%2FAIDS) 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).[8]

A patient may request, in an advance directive, to prohibit certain responses, including [intubation](/source/Intubation), chest compression, electrical [defibrillation](/source/Defibrillation), or [ACLS](/source/Advanced_cardiac_life_support).[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](/source/Position_paper), the [American Nurses Association](/source/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](/source/New_York_(state)) 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

1. ^ [***a***](#cite_ref-FOOTNOTENew_York_Times1987_1-0) [***b***](#cite_ref-FOOTNOTENew_York_Times1987_1-1) [***c***](#cite_ref-FOOTNOTENew_York_Times1987_1-2) [New York Times 1987](#CITEREFNew_York_Times1987).

1. **[^](#cite_ref-FOOTNOTEMarks2006_2-0)** [Marks 2006](#CITEREFMarks2006).

1. **[^](#cite_ref-FOOTNOTENBC_News2008_3-0)** [NBC News 2008](#CITEREFNBC_News2008).

1. **[^](#cite_ref-FOOTNOTEBraddock1998When_should_CPR_be_administered?_4-0)** [Braddock 1998](#CITEREFBraddock1998), When should CPR be administered?.

1. **[^](#cite_ref-FOOTNOTEBraddock1998When_can_CPR_be_withheld?_5-0)** [Braddock 1998](#CITEREFBraddock1998), When can CPR be withheld?.

1. ^ [***a***](#cite_ref-FOOTNOTEBraddock1998What_if_the_patient_is_unable_to_say_what_his/her_wishes_are?_6-0) [***b***](#cite_ref-FOOTNOTEBraddock1998What_if_the_patient_is_unable_to_say_what_his/her_wishes_are?_6-1) [Braddock 1998](#CITEREFBraddock1998), What if the patient is unable to say what his/her wishes are?.

1. ^ [***a***](#cite_ref-FOOTNOTECollege_of_Physicians_and_Surgeons_of_Ontario2006_7-0) [***b***](#cite_ref-FOOTNOTECollege_of_Physicians_and_Surgeons_of_Ontario2006_7-1) [College of Physicians and Surgeons of Ontario 2006](#CITEREFCollege_of_Physicians_and_Surgeons_of_Ontario2006).

1. ^ [***a***](#cite_ref-FOOTNOTEBraddock1998When_is_CPR_not_of_benefit?_8-0) [***b***](#cite_ref-FOOTNOTEBraddock1998When_is_CPR_not_of_benefit?_8-1) [Braddock 1998](#CITEREFBraddock1998), When is CPR not of benefit?.

1. **[^](#cite_ref-FOOTNOTEDoshaDhobleaEvonichaGuptaa2009_9-0)** [Dosha et al. 2009](#CITEREFDoshaDhobleaEvonichaGuptaa2009).

1. **[^](#cite_ref-FOOTNOTEBerger20032271_10-0)** [Berger 2003](#CITEREFBerger2003), p. 2271.

1. ^ [***a***](#cite_ref-FOOTNOTEANA_Center_for_Ethics_and_Human_Rights20126_11-0) [***b***](#cite_ref-FOOTNOTEANA_Center_for_Ethics_and_Human_Rights20126_11-1) [ANA Center for Ethics and Human Rights 2012](#CITEREFANA_Center_for_Ethics_and_Human_Rights2012), p. 6.

1. **[^](#cite_ref-FOOTNOTEDePalmaMillerOzanichYancich1999_12-0)** [DePalma et al. 1999](#CITEREFDePalmaMillerOzanichYancich1999).

1. **[^](#cite_ref-FOOTNOTEBraddock1998What_if_the_family_disagrees_with_the_DNR_order?_13-0)** [Braddock 1998](#CITEREFBraddock1998), What if the family disagrees with the DNR order?.

1. **[^](#cite_ref-FOOTNOTEBraddock1998What_about_"slow_codes"?_14-0)** [Braddock 1998](#CITEREFBraddock1998), What about "slow codes"?.

## References

- Braddock, Clarence H. (1998). ["Do Not Resuscitate Orders"](http://depts.washington.edu/bioethx/topics/dnr.html). *Ethics in Medicine*. [University of Washington](/source/University_of_Washington) School of Medicine. Retrieved 2013-04-06.

- Berger, Jeffrey T. (October 2003). "Ethical Challenges of Partial Do-Not-Resuscitate (DNR) Orders". *Archives of Internal Medicine*. **163** (19): 2270–2275. [doi](/source/Doi_(identifier)):[10.1001/archinte.163.19.2270](https://doi.org/10.1001%2Farchinte.163.19.2270). [PMID](/source/PMID_(identifier)) [14581244](https://pubmed.ncbi.nlm.nih.gov/14581244).

- DePalma, Judith A.; Miller, Scott; Ozanich, Evelyn; Yancich, Lynne M. (November 1999). [""Slow" Code: Perspectives of a Physician and Critical Care Nurse"](http://www.nursingcenter.com/lnc/journalarticle?Article_ID=437848). *Critical Care Nursing Quarterly*. **22** (3). [Lippincott Williams and Wilkins](/source/Lippincott_Williams_and_Wilkins): 89–99. [doi](/source/Doi_(identifier)):[10.1097/00002727-199911000-00014](https://doi.org/10.1097%2F00002727-199911000-00014). [ISSN](/source/ISSN_(identifier)) [1550-5111](https://search.worldcat.org/issn/1550-5111). [PMID](/source/PMID_(identifier)) [10646457](https://pubmed.ncbi.nlm.nih.gov/10646457).

- 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): 985–989. [doi](/source/Doi_(identifier)):[10.1016/j.resuscitation.2009.05.011](https://doi.org/10.1016%2Fj.resuscitation.2009.05.011). [PMID](/source/PMID_(identifier)) [19581039](https://pubmed.ncbi.nlm.nih.gov/19581039).

- Marks, William J. (1 January 2006). [""Code Blue", "Code Black": What Does "Code" Mean?"](http://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean). [WebMD](/source/WebMD). Retrieved 2013-04-06.

- ["Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions"](https://www.nursingworld.org/~4af287/globalassets/docs/ana/ethics/ps_nursing-care-and-do-not-resuscitate--allow-natural-death.pdf) (PDF). ANA Center for Ethics and Human Rights. [American Nurses Association](/source/American_Nurses_Association). 12 March 2012. Retrieved 2013-04-06.{{[cite web](https://en.wikipedia.org/wiki/Template:Cite_web)}}: CS1 maint: others ([link](https://en.wikipedia.org/wiki/Category:CS1_maint:_others))

- ["Decision-making for the End of Life"](http://www.cpso.on.ca/policies/policies/default.aspx?ID=1582). Physician Advisory Service. [College of Physicians and Surgeons of Ontario](/source/College_of_Physicians_and_Surgeons_of_Ontario). May 2006. Retrieved 2013-04-06.{{[cite web](https://en.wikipedia.org/wiki/Template:Cite_web)}}: CS1 maint: others ([link](https://en.wikipedia.org/wiki/Category:CS1_maint:_others))

- ["Hospitals' 'code blue' most deadly at night"](https://web.archive.org/web/20160305095046/http://www.nbcnews.com/id/23239084/ns/health-health_care). *[NBC News](/source/NBC_News)*. [Chicago](/source/Chicago). [Associated Press](/source/Associated_Press). 19 February 2008. Archived from [the original](http://www.nbcnews.com/id/23239084/ns/health-health_care) on March 5, 2016. Retrieved 2013-04-06.

- ["Slow Codes, Show Codes and Death"](https://www.nytimes.com/1987/08/22/opinion/slow-codes-show-codes-and-death.html). *[New York Times](/source/New_York_Times)*. 22 August 1987. Retrieved 2013-04-06.

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Adapted from the Wikipedia article [Slow code](https://en.wikipedia.org/wiki/Slow_code) by Wikipedia contributors ([contributor history](https://en.wikipedia.org/wiki/Slow_code?action=history)). Available under [Creative Commons Attribution-ShareAlike 4.0 International](https://creativecommons.org/licenses/by-sa/4.0/). Changes may have been made.