The Slow Code Dilemma: When Life-Saving Efforts Cause Moral Distress

You're a doctor or a nurse working in an intensive care unit (ICU). A very sick patient's heart stops. You know that trying to resuscitate them would be futile - their underlying illness can't be cured, and cardiopulmonary resuscitation (CPR) is unlikely to restart their heart for more than a few minutes. But the family insists you "do everything" to try to save their loved one. What do you do?  

This difficult situation is all too common in ICUs across America. A recent study surveyed doctors, nurses and other providers at two hospitals in Chicago about their experiences with "slow codes" when medical teams pretend to do CPR but don't try their hardest to save the patient.  

The results show slow codes are surprisingly widespread: 69% of participants had cared for a patient who received a slow code, with an average of more than one per provider over the past year. That's despite opinions on whether slow codes are ethical. Only about half think they're acceptable if CPR is futile; the rest said no code should be done or that full, guideline-consistent CPR should be attempted.   

When asked open-endedly why slow codes happen, the most common answer was that they serve as a compromise between the family's wishes and the medical team's judgement. But many respondents also cited poor communication as a factor, and said slow codes are done to avoid legal liability or preserve trust with families. 

Most troublingly, three-quarters of participants reported feeling moral distress when forced to take part in slow codes or other perceived medically futile resuscitation attempts. This distress was highest among nurses and trainees, who are more likely to be carrying out slow codes ordered by physicians.   

Moral injury from practices like slow codes has been linked to burnout, job dissatisfaction and clinicians leaving the field - contributing to the critical staffing shortages we're now facing. Some bioethicist are saying that the slow code may help families more than it helps patients.

So, what's the answer? There are no easy solutions, but clearly more open communication and policies that protect providers' rights of conscience are needed. Discussing goals of care early on could also help avoid some heart-wrenching 11th-hour decisions. 

Slow codes may seem like a humane compromise. But this study reveals the ethical dilemmas and moral toll they exert on medical staff. It's time we had an honest conversation about how to handle futile end-of-life resuscitation - for everyone's wellbeing.