Ethical Considerations When Nurses Perform ‘Slow Codes’ at End of Life
Nurses might perform limited resuscitation efforts (known as “slow codes”) with no intended benefit of patient survival, often to avoid harming a dying patient with overly aggressive, unwanted end-of-life care.
Slow codes still are not talked about openly. The controversial practice “is often considered deceitful and unethical; therefore, the practice is shrouded in secrecy. Yet, it is still occurring in practice,” says Liz Stokes, JD, MA, RN, a Washington, DC-based nurse, attorney, and bioethicist.
To better understand this practice, Stokes and a colleague interviewed 24 ICU nurses in 2018 and 2019.1 In some cases, they found nurses conduct limited resuscitation efforts with direction from physicians. It happens with or without a medical order.
“There are medical orders that allow some parts of CPR but not others. This is done with patient and family consent — sometimes, at their request,” Stokes explains.
End-of-life care medical orders may reflect a patient’s decision to choose one resuscitation method, but not another (e.g., opting out of chest compressions). “However, researchers found that is not always the case,” Stokes says.
On some occasions, limited resuscitation efforts occurred without the family’s knowledge. Not all resuscitation measures are medically beneficial, and clinicians often must decide in the moment if they are clinically appropriate to perform. “This is an ethically complex area of medicine,” Stokes notes.
Through their interviews with ICU nurses, Stokes believes the understanding of “slow code” appears to have evolved over time. “Because limited resuscitation is not well researched, the terms associated with it are unclear and misunderstood,” Stokes says.
Initially, “slow code” meant CPR that is performed slowly. The nurses interviewed understood it differently. In their view, a “slow code” meant CPR performed swiftly, but key components for survival are eliminated (e.g., chest compressions or defibrillation).
“The historical intent of slow codes, that the patient would not survive the CPR attempt, remained the same,” Stokes says.
Most nurses interviewed felt compelled to perform CPR when families demanded it, even if it was not clinically beneficial (or even harmful) to the patient. This practice contradicts guidance from specialty organizations indicating clinicians are not obligated to perform medically inappropriate care.2
“Only one nurse described a culture where the healthcare team would not even offer CPR to families unless it was medically indicated,” Stokes reports.
Every scenario varies. “Therefore, it is critical for the healthcare team to have frequent, transparent, and culturally sensitive conversations with patients and families around end-of-life preferences to establish mutual goals of care,” Stokes says.
Some interviewees expressed support for slow codes because the tactics used to mitigate conflict between clinicians and families regarding end-of-life goals of care were ineffective. Such conflict causes a strong emotional and moral response in many nurses.
“It is important to address these issues as we continue to see nurses face tremendous challenges due to many constraints outside of their control,” Stokes offers.
Ethicists play a critical role in conflict resolution at the end of life. “Ethicists are neutral stakeholders who possess communication skills to create a safe and trustworthy space for patients and families to discuss their values for care,” Stokes notes.
While taking a neutral stance in the conflict, ethicists can support nurses experiencing moral distress by providing an avenue for the nurse’s perspectives to be heard, acknowledged, and addressed. The problem is ethicists are not always readily available. “Most health organizations are critically under-resourced,” Stokes laments.
Some hire only one or two ethicists to staff the entire organization. “This is a substantial gap that hospitals must close by providing resources to support ethics consultation, to mitigate conflict with patients and families — but also to provide support mechanisms for clinicians dealing with repeated exposure to death and dying,” Stokes explains.
It also is critical that slow codes are not performed secretly. Clinicians should be performing end-of-life efforts openly and transparently with families. “This fosters trust and reliance in the nursing profession and healthcare organizations,” Stokes says.
Overall, clinicians must acknowledge slow codes do occur. “We can no longer ignore that this happens,” Stokes says. “We must accept that it occurs to better understand the motivation and strive for a solution.”
- Stokes F, Zoucha R. Nurses’ participation in limited resuscitation: Gray areas in end of life decision-making. AJOB Empir Bioeth 2021;12:239-252.
- Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 2015;191:1318-1330.
On some occasions, limited resuscitation efforts occurred without the family’s knowledge. Not all resuscitation measures are medically beneficial, and clinicians often must decide in the moment if they are clinically appropriate to perform.
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