Correspondence
The Slow Code
N Engl J Med 1998; 338:1921-1923June 25, 1998
- Article
To the Editor:
We would like to take issue with the call for the demise of the slow code (Feb. 12 issue).1 Decisions concerning the intensity, duration, and appropriateness of the procedures performed during a code are made all the time. When the family requests that “everything be done” for a dying patient, it is the physician's duty to provide the family with the feeling and knowledge that indeed everything appropriate was done. The slow code should not be seen as an attempt to cheat the patient, or more frequently his or her family, but rather as a way of allowing the family to accept that the outcome of death was inevitable, even though aggressive measures were used. In our experience, many people do take comfort in knowing that their loved one's death occurred despite an attempt by the doctors to prolong the patient's life. When viewed in this manner, the slow code can be seen as a ritualistic comforting hand on the shoulder of a grieving family member, rather than as an aggressive, deceitful show. In truth, the slow code does not cause pain or suffering in a patient who is without a pulse and therefore any consciousness, and may alleviate some anguish on the part of a family. In appropriate circumstances, it probably still has a place in the care of terminally ill patients.
1 ReferencesEran Segal, M.D.
Chaim Sheba Medical Center, Tel-Hashomer 52621, IsraelTalia Halamish-Shani, LL.B.
Medical Risk Management, Tel Aviv 63402, Israel1
Gazelle G . The slow code -- should anyone rush to its defense? N Engl J Med 1998;338:467-469
Full Text | Web of Science | Medline
To the Editor:
The very patients on whom the slow code is performed are almost always the ones least likely to benefit from, or survive, cardiopulmonary-resuscitation efforts. We need to change the default position. Although the failure to discuss cardiopulmonary resuscitation with a patient dying of disseminated cancer might be considered paternalistic, is it not just the application of good clinical judgment?
Doctors should accept the notion that cardiopulmonary resuscitation is not an effective therapeutic option for certain subgroups of patients.1,2 If it were no longer considered a part of the therapeutic armamentarium for these patients, we might be able to move on to the most important task: preparing patients and their families (and even house officers and nursing staff) for a dignified, comfortable, quiet death. If we continue believing that cardiopulmonary resuscitation must be offered to all patients, I am afraid that the slow code will never go away.
2 ReferencesHarlan Rich, M.D.
Providence Veterans Affairs Medical Center, Providence, RI 02908-47991
Blackhall LJ . Must we always use CPR? N Engl J Med 1987;317:1281-1285
Full Text | Web of Science | Medline2
Hansen-Flaschen JH . When life support is futile. Chest 1991;100:1191-1192
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To the Editor:
Although Gazelle notes that physicians cannot be compelled to offer inappropriate treatment, she also acknowledges that the prevailing standard of practice in the United States is to perform resuscitation in all cases of cardiopulmonary arrest in which do-not-resuscitate orders have not been written. Even in the absence of a legal requirement, the physician who fails to attempt resuscitation is sometimes seen by the family as having abandoned the patient, withheld lifesaving therapy, or even caused the patient's death. The fear of legal retribution is real. The anger experienced in the grieving process can easily be focused on the physician, and the resulting lawsuit may be far more painful to both parties than the “white lie” of a slow code. If physicians conveyed the futility of resuscitation in terminal illness more effectively to patients and their families, they in turn might have more realistic expectations.
L. John Greenfield, Jr., M.D., Ph.D.
University of Michigan Medical Center, Ann Arbor, MI 48104-1687To the Editor:
Gazelle refers to the poor survival rate for older people after in-hospital resuscitation. However, might it not be possible that this poor survival rate is due in part to these older people's being recipients of slow codes? No study has examined the adequacy of resuscitation as a predictor of its success. This at least raises the possibility that the poor outcome of resuscitation associated with certain patient characteristics is confounded by an increased likelihood of receiving a short code.
We believe that a study we performed provides support for this hypothesis.1 We defined a “short code” as one that provided fewer than the minimal number of interventions required by any presenting rhythm as outlined in the advanced-cardiac-life-support guidelines. Among 87 people who died of cardiopulmonary arrest, 17 (20 percent) received a short code. The patients older than 75 years were significantly more likely than those 75 or younger to receive a short code (32 percent vs. 11 percent). Impaired functional status showed a trend toward an association with receiving a short code, but age continued to predict the receipt of a short code after adjustment for functional status. In addition, short codes were not associated with primary diagnoses of chronic renal failure or cancer, both of which have been shown to predict poor survival after advanced cardiac life support.2
It is likely that the majority of slow codes are administered to patients whose outcomes would be the same regardless of the adequacy of the resuscitation attempt. Nonetheless, we worry about outcome assessments based on factors, such as age, that are also associated with the adequacy of care. For selected patients, the appropriate alternative to the slow code may be a full resuscitation attempt.
2 ReferencesTerri R. Fried, M.D.
Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516Tom J. Wachtel, M.D.
Rhode Island Hospital, Providence, RI 029031
Fried TR ,Miller MA ,Stein MD ,Wachtel TJ . The association between age of hospitalized patients and the delivery of advanced cardiac life support. J Gen Intern Med 1996;11:257-261
CrossRef | Web of Science | Medline2
Bedell SE ,Delbanco TL ,Cook EF ,Epstein FH . Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 1983;309:569-576
Full Text | Web of Science | Medline
To the Editor:
When a patient or the family cannot be persuaded to forgo life-sustaining procedures, a physician who feels resuscitation is futile is faced with a conflict that cannot be resolved without resorting to paternalism, futile and harmful treatment, or fantastic powers of persuasion. The assumption that patients and families with “unrealistic” requests are simply grieving and can be persuaded by adequately addressing their fears is simplistic and naive. It fails to acknowledge as valid views that differ from the physician's own.
Christopher Ish, M.D.
University of Maryland Medical System, Baltimore, MD 21201To the Editor:
Although Gazelle presents a compelling ethical picture of slow codes and why they still happen, I believe there is one aspect that she failed to address.
In our society today there is a stark lack of rituals and rites of passage. Historically, at the juncture of major life events people gathered and said or did something meaningful. Until recently in Western society a priest, pastor, or rabbi would be at the bedside performing an appropriate rite and saying appropriate words. In other societies at other times, shamans, healers, or clergy would perform similar rites and say similar words. It could very well be that something in us longs to respond to junctures in life, such as birth and death. It would not be odd then to find medical practitioners, at a person's last moments of life, in a society largely devoid of ritual, being called by the person's family and from within themselves to fill the gap with the only magic and rituals they possess. If we as a society and as a medical culture deem that slow codes are inappropriate, then we are still left with the important issue of what we are to do at these junctures.
Robert G. Krause, R.N.
Yale University School of Nursing, New Haven, CT 06536Author/Editor Response
Dr. Gazelle replies:
To the Editor: The key to improving the care of the dying lies in providing comprehensive palliative care and in increasing communication that clarifies patients' values, provides reassurance regarding the alleviation of suffering, and informs patients about what if any life-prolonging measures are available. The lack of such communication is one of the major drivers behind the use of cardiopulmonary resuscitation as what Rich aptly decries as the “default.” I think it is unfortunate that some believe that fears of legal retribution may outweigh the “white lie” of a slow code. In response to Ish, I agree that there will be patients and families who, despite the best communication and exploration of the rationale behind their request for “everything,” will still insist on medically unrealistic interventions. Multi-institutional task forces at Harvard and in the city of Houston are developing guidelines for the management of disagreements between patients or families and medical professionals regarding futile interventions1 (and Truog RD: personal communication); these guidelines might provide a model for more productive modes of conflict resolution than either lawsuits or slow codes.
Like Krause and Segal and Halamish-Shani, some ethicists have written about the importance of cardiopulmonary resuscitation as an end-of-life ritual.2,3 We live in a society that fails to acknowledge not only that death is inevitable but also that the last phase of a person's life can be a time of great richness and meaning. Rituals that pay tribute to that richness should be encouraged. I would hope that our profession, however, could lead society in establishing rituals that are more likely to promote human connection and meaning than performing chest compressions, delivering jolts of electric current, and infusing epinephrine.
3 ReferencesGail Gazelle, M.D.
Brigham and Women's Hospital, Boston, MA 021151
Halevy A ,Brody BA . A multi-institution collaborative policy on medical futility. JAMA 1996;276:571-574
CrossRef | Web of Science | Medline2
Lantos JD . Bethann's death. Hastings Cent Rep 1995;25:22-23
Web of Science | Medline3
Nolan K . In death's shadow: the meanings of withholding resuscitation. Hastings Cent Rep 1987;17:9-14
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- Citing Articles (3)
Citing Articles
1
William Lawrence Allen. (2011) Let's Do Not Resuscitate Placebo Cardiopulmonary Resuscitation. The American Journal of Bioethics 11:11, 24-25
CrossRef2
M. H. Ebell, A. M. Afonso. (2011) Pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a meta-analysis. Family Practice 28:5, 505-515
CrossRef3
Michael S. Ewer, Susannah K. Kish, Charles G. Martin, Kristen J. Price, Thomas W. Feeley. (2001) Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer 92:7, 1905-1912
CrossRef
