The Use of Slow Codes and Medically Futile Codes in Practice

Slow codes, which occur when clinicians symbolically appear to conduct advanced cardiac life support but do not provide full resuscitation efforts, are ethically controversial.

To describe the use of slow codes in practice and their association with clinicians' attitudes and moral distress.

We conducted a cross-sectional survey at Rush University and University of Chicago in January 2020. Participants included physician trainees, attending physicians, nurses, and advanced practice providers who care for critically ill patients.

Of the 237 respondents to the survey (31% response rate, n = 237/753), almost half (48%) were internal medicine residents (46% response rate, n = 114/246). Over two-thirds of all respondents (69%) reported caring for a patient where a slow code was performed, with a mean of 1.3 slow codes (SD 1.7) occurring in the past year per participant. A narrow majority of respondents (52%) reported slow codes are ethical if the code is medically futile. Other respondents (46%) reported slow codes are not ethical, with 19% believing no code should be performed and 28% believing a full guideline consistent code should be performed. Most respondents reported moral distress when being required to run (75%), do chest compressions for (80%), or witness (78%) a cardiac resuscitation attempt they believe to be medically futile.

Slow codes occur in practice, even though many clinicians ethically disagree with their use. The use of cardiac resuscitation attempts in medically futile situations can cause significant moral distress to medical professionals who agree or are forced to participate in them.