The media is starting to cover a study saying that many people don’t get defibrillated fast enough in the hospital (by docs at my hometown hospital where I worked at the Heart Institute during the summer in college!), and Dr. Wes, our medblogging cardiologist, has already responded. I of course have my own take.
I wonder how many of these cases were slow codes? And what are slow codes?
I had never heard the term until a classmate gave an ethics talk on it last month–and didn’t know they even existed. (Yay Stanford.) From a great article discussing them:
Slow codes, also known as partial, show, light blue, or Hollywood codes, are cardiopulmonary resuscitative efforts that involve a deliberate decision not to attempt aggressively to bring a patient back to life. Either because the full armamentarium of pharmacologic and mechanical interventions is not used, or because the length of the effort is shortened, a full attempt at resuscitation is not made. Unlike a true code, in which time is critical and a state of medical emergency exists, a slow code may seem to occur in slow motion, with staff members stiffly going through the motions, then breathing a collective sigh of relief when the effort is terminated.
They are often done on patients who are thought to be severely terminal, or demented, or whatever else the people running the code view the patient to be. They are anything but ethical. They give false hope to a patient and his or her loved ones that the patient can (and should) be resuscitated–if the act was futile, why would the doctors be performing it at all? They are also certainly futile interventions, and not benign interventions, either.
Why are they done? A couple good lines from the article (which you should really read, it’s quick):
A different rationale is operative when end-of-life wishes have been discussed and the patient or family has stated a wish that “everything” be done to resuscitate the patient. Instead of hearing the request that everything be done as evidence of despair on the part of a patient or family faced with imminent loss, physicians often take such a request at face value. Indeed, the physician may believe that respect for the patient’s autonomy requires an unquestioning acceptance of the patient’s stated wishes. Rather than probing the patient’s fears and concerns and providing reassurance that the patient’s suffering will be treated and that he or she will not be abandoned, a physician may see a slow code as a way out of a dilemma — as having the appearance of respecting a patient’s wishes while lessening the consequent harm.
Patients’ autonomy is frequently cited as the most compelling reason for providing treatment that offers no medical benefit. While some view autonomy in the extreme, as a pure and independent statement of the patient’s wishes, a more encompassing view holds that true autonomy exists only in the context of the physician’s commitment to help a patient achieve that which is in his or her best interest.20 There is also controversy about whether respect for autonomy necessitates the provision of futile interventions. Furthermore, the offer of futile measures can serve to undermine, rather than support, the ability of patients to act autonomously.21
The gist? “Do everything” does not mean a physician must “do everything possible even if the ‘everything’ is going to be futile.” And talk to your patients about their code status, and make sure they and their family members know the severity of their illness. “Do everything” is probably often part of the grieving process (DENIAL), too.