Slow Codes are symptomatic of ethically and legally inappropriate CPR policies

Although cardiopulmonary resuscitation (CPR) was initially used very selectively at the discretion of clinicians, the use of CPR rapidly expanded to the point that it was required to be performed on all patients having in-hospital cardiac arrests, regardless of the underlying condition. This created problems with CPR being clearly inadvisable for many patients. Do Not Resuscitate (DNR) orders emerged as a means of providing a transparent process for making decisions in advance regarding resuscitation, initially by patients and later also by clinicians. Under hospital policies in many countries, however, CPR remains the default position for all patients having cardiac arrest in the hospital if there is no DNR order in place, regardless of whether CPR is medically indicated or in the patient's best interests. "Slow Codes" are the delayed or token efforts to provide CPR when clinicians feel CPR is futile or inappropriate. After giving a historical overview of the development and the changing use of CPR, we argue that more attention needs to be given to the cause of slow codes, namely, policies requiring CPR to be performed as the default action while simultaneously lacking implementing interventions such as advance care planning as a routine policy. This is ethically and legally inappropriate, and hospital policies should be modified to allow clinicians to consider whether CPR is appropriate at the time of arrest. Such a change requires a stronger emphasis on early recognition of patients for whom CPR is not in their best interests and to improve hospital emergency planning.