A Walker and Avant concept analysis of slow code practice in end-of-life resuscitation

The slow code is a complex and ethically sensitive phenomenon in cardiopulmonary resuscitation (CPR), referring to a deliberately partial or delayed resuscitation attempt in patients with poor prognosis or terminal conditions. Although it is recognized in clinical practice, the concept remains ambiguous and ethically controversial. Clarifying its defining attributes, antecedents, and consequences is essential for ensuring ethical and responsible end-of-life decision-making in healthcare.

This study applied Walker and Avant's (2019) concept analysis method to clarify the concept of slow code in CPR. A comprehensive literature review was performed using PubMed, Scopus, Web of Science, CINAHL, ProQuest, and SID databases. The search covered studies published up to 2025 in both English and Persian. The following keywords and their combinations were used with Boolean operators AND and OR: slow code, symbolic resuscitation, code status, do not resuscitate, end-of-life decision-making, nursing ethics, and CPR ethics. Relevant literature was screened and analyzed to identify defining attributes, antecedents, and consequences of the concept.

The analysis revealed that the slow code represents a symbolic and ethically complex clinical act, performed when resuscitation is deemed clinically futile but ethical, cultural, or familial expectations pressure healthcare teams to act. Defining attributes include partial or intentionally delayed resuscitation, symbolic compliance with clinical or institutional norms, and an underlying intent to reconcile professional ethics with contextual constraints. Antecedents include patient-related factors (terminal illness, poor prognosis, low probability of return of spontaneous circulation), team-related factors (moral distress, perception of futility, prior ethical conflict), and organizational factors (absence of DNR policies, ambiguous end-of-life care guidelines, hierarchical team culture, and time pressure). Consequences include prolonged patient suffering, family misunderstanding or loss of trust, moral distress and emotional burden among healthcare providers, and organizational ethical dilemmas. However, transparent management guided by ethical frameworks can facilitate constructive discussions about end-of-life care, improve communication with families, and inform institutional policy development.

This concept analysis clarifies slow code as a distinct yet ethically controversial phenomenon characterized by intentionally limited or symbolic resuscitation despite perceived medical futility. Clarifying this concept does not endorse its clinical use; rather, it provides a clearer conceptual framework for distinguishing slow code from related end-of-life practices, supporting ethical education, informing institutional policies, and guiding future empirical research. The findings further highlight the importance of advance care planning, transparent communication, and documented do-not-resuscitate (DNR) decisions as ethically appropriate alternatives to slow code in end-of-life care.