Are slow codes uniquely deceptive?

Abstract

"Sham codes" or "slow codes"-defined here as resuscitative efforts undertaken only to the extent necessary to convey the impression that "everything was done," rather than to achieve return of spontaneous circulation (ROSC)-have been almost universally condemned for the past five decades. To facilitate an examination of this practice, we consider how the clinician's obligations and prerogatives differ under four scenarios, all of which involve conflict between the physician who desires to withhold cardiopulmonary resuscitation (CPR) and the family who does not. Under two scenarios, involving quality of life considerations and quantitative futility ("long shots"), we argue that slow codes are ethically impermissible. Under two other scenarios, however, we maintain an agnostic view on the moral permissibility of slow codes. We observe that where the case for impermissibility is predicated on considerations of honesty and professional integrity, commonly practiced and commonly defended alternatives to the slow code, such as non-initiation of CPR after bedside assessment, limited trials of CPR, and futile CPR, are typically undertaken for beneficent reasons and, like the slow code, entail non-lying deception. Finally, we offer recommendations for care delivery reform that work "upstream" to prevent the conflicts and crises of trust that give rise to intractable conflicts surrounding CPR.