While I generally agree that North American physicians should have a freer hand to not provide non-indicated treatment (specifically full-bore CPR, my sense is that Canada and the U.S. both vest this decision with patients/families) from my perspective as an EM/CCM physician and medical educator, slow codes are worse. As leaders of a resuscitation team, we should bear the weight of the decision making that says "No - we're not doing this" and "we're stopping now."
1 - We practice how we play. Ideally, IHCA should be rare. Each time the resuscitation team gathers and performs ACLS, we should be doing it in a standardized way (allowing for variation in treatment based on most likely cause of the arrest). Every time we deviate from this practice we are showing that standardization doesn't matter. Like Yoda said, "Do, or do not. There is no try."
2 - Slow codes are basically lying to the family. We're trying to show them "hey, we did everything" when, in fact, we did not. We should have the courage of our convictions to say we did not because, from a physiologic perspective, it would not have changed anything.
Finally, I have found utility (and healthcare system support from risk management/legal) in focusing on the concept of "physiologic futility", at least for maximally supported ICU patients. If a patient is already intubated, on high dose pressors, and is going to arrest from a cause that is not immediately reversible (like, we've already verified there's no pneumothorax or cardiac tamponade, etc.), my system has supported documentation in that moment of 1) the patient was already being resuscitated with the support they were receiving, 2) the cause of the arrest would not be addressed in the timeframe afforded by ACLS, and 3) that CPR would be merely performative. This started during COVID but has persisted and has been helpful.
Great comments, thanks. I'm very curious to learn how these slow codes actually go. I remember seeing one in training, but that was a long time ago. Is the point to give shallow CPR to avoid breaking ribs, but you still do it for 10 minutes or longer? Or does one cut it short, and if so, what is documented? Are drugs still given, or just pretended and discarded?
I know the distress of being compelled to give CPR to a very elderly, frail, dying person, and slow codes appear to be more common than I had realized, so I am not passing judgment. I agree the inherent deceit could create a new set of problems, though.
Very interesting—thanks for sharing this. Will be interested to learn the process- is the family / patient informed, is there a debate, protocol, etc, or is it mostly an ad hoc physician decision. What if physicians disagree- how is that handled. Can talk to you offline. Appreciate your insights.
Laws vary subtly state by state, but in general no legal requirement to provide futile and non-beneficial treatment. Can withhold cpr, or colonic lavage, equally even if patient or family ask for that treatment.
HOWEVER just because can legally do that, doesn’t mean won’t be a huge headache, potential complaints and law suits etc. so in practice always get the patient and family on board, and if significant disagreement seek broader and broader medical consensus and government/legal backing. So while the laws differ from US, the resus conversations follow very similar format I suspect - except perhaps we are more leading here in saying “if despite all these active measures, their heart stops naturally we won’t attempt artificially restart it with CPR - does that sound reasonable?”
I am perplexed to learn that “slow CPR” is even a thing, let alone to realize that it is normalized in North America.
I am also perplexed to learn, if I understood it correctly, that patients’ families ultimately decide on the appropriateness of performing CPR, because doctors could judge worst than the suffering, lay families. That’s insane.
I see a tendency here in Brazil, mostly among young doctors, to ask the family whether doctors should intubate a patient. I explicitly advise against it in my mentoring.
In my opinion, the family perceives it as an act of omission where the doctors try to dump the responsibility for the results (dysthanasia and death) on the family.
My father is a retired geriatrician. He always said that the patient and family must feel you have assumed the responsibility for the case. They must understand you are conducting it for the better, and then they will become relaxed and acceptant of the outcome.
I don’t know if it’s even possible in a society where everyone is afraid of litigation… anyway, thank you for the insightful post.
I wouldn't say it's normalized, but based on the results of the survey, sounds like close enough.
Families, especially affluent educated families, have an enormous influence over all care provided in the U.S., and absolutely make the decision as to whether CPR will be provided. The physician "gets" the DNR directive from the family, or the family "makes" the patient DNR (in the local medical dialect).
Fear of litigation is involved, but it's more a takeover of healthcare by consumerism and corporate interests in my opinion.
A common phrase U.S. physicians use is "do you want everything done?" Said to a patient in extremis, or their bewildered and frightened family. This is the fastest way to a) avoid actually having hard conversations and b) being able to claim that you did, while honoring 'patient autonomy'.
I think you got the point there when you mentioned it’s more a consumerism culture take over.
Unfortunately, we have imported it from the US, specially in the private health sector. There, health services are sold as shelf products, of course, because everyone has to pay the bills.
There’s a very prominent hospital in my state that is seen among the country’s best private hospitals. Their slogan is “redefining the impossible”, that is, they explicitly sell dysthanasia.
In the country with the world’s largest income gap, “doing everything” also means you are a member of the higher class. This is the rich’s way of dying.
I see the “do everything” approach as a curse. We have the power to keep a heart beating at any amount of suffering. One day the “consumer” will realize that we must be very wise when using such a power. Hopefully, the market will find a way to make a reasonable end of life care as a marketable product.
I’ve chosen the word “curse” to emphasize there is something of a displaced religious belief in to it. One day I’ll be brave enough to write about it on Substack.
I've never participated in, nor requested a "slow code" as you describe it. I will look forward to seeing what your ethicists have to say about deceit. I'm unable to think of the circumstance in which "benign deceit" is appropriate with patients or their families.
I would imagine that I am an attending "of a certain age", and I have ranted before; I don't any more. I think, perhaps, I have actually aged and experienced myself out of it. But along with my ranting (and now, in its absence), I have always held crucial conversations with patients, when they are awake, and families, when they are not. I do not ask, per se, whether I can enter a DNR order. I explain the circumstance to them, teach them what CPR/ACLS was invented for, what it can do and what it cannot do. I then tell them that I am going to enter a DNR order, for the reason that it does not have any chance of even returning the patient to their pre-hospital state of health and with high probability will not even return them to the state of health they are in at this very moment. I assure them that this does not mean that we are backing down in anything else we are doing to try and restore their/their family's health. Patients and family all understand that there is an end to each of us, whether we like it, or not. When they understand that we are all in there fighting together to stave off the end until we no longer can, the withholding of futile CPR is something that almost everyone understands, once they understand what it can do and what it can't do. We do have to understand that their background knowledge of CPR before we explain it comes from ER, The Pit, Grey's Anatomy, etc. No wonder they would want it - you get up and go home when it's over.
This is a different conversation from converting to comfort measures, by a degree or two. The two conversations have in common that families are often relieved that this is an option. The DNR conversation is one that is held when it is clear that we are losing the battle and that CPR would literally be futile. I will admit that if families strongly object, I will back down. We do, as you say, live in a society where CPR is considered the norm, and most patients and families do not have any experiences other than their own or those of family members on which to base their understanding of the world or of medicine and its limitations. Sometimes people come back after sleeping on it and discussing with family and/or clergy and ask for the DNR.
I think it's important to emphasize that this particular DNR conversation is not based in quality of life assessment, as might be the baseline conversation that one has with every patient as they enter the hospital. Every patient is entitled to judge for themselves the quality of life they will tolerate. Some patients are fine withholding CPR, because they are ready if the time comes; what they want is to not suffer or be in pain, because of the acute illness they are currently experiencing.
Sometimes, patients tell me that they understand what I have said, but that they want to "go down swinging". I understand this way of thinking, and when that is what they want, I can participate with them. In that circumstance, I don't order a "slow code"; if I am going to be their partner, they will get the best I have to offer, and I will abet their swinging.
Something I hope also that there is more discussion of is the idea that it harms patients to spend extra days on life support, teetering on the edge of death before succumbing to it because we provided CPR/ACLS. It doesn't seem like something I would want for myself, but I think we assume that it's bad for patients, and I don't have certain knowledge that it is.
As you can probably surmise, I feel like running a "slow code" is dishonest and not in keeping with any pact that we have with our patients. The fact that some ethicists find it OK won't likely change that for me. I'll be interested in hearing the arguments for when it's ethical to deceive patients and families. I wouldn't be able to look them in the eye, which is something that I find important to be able to do.
I am realizing, Matt, that your comments section allows me to, essentially, write blog entries without having the pressure of making a new one every week. I get to decide what I'll write about, and when. I believe I will indulge myself this way for a while.
Its a tough grey area for all. The most important thing to do as alluded in this article is consent. CPR is a procedure with clear harms and benefit. The code discussion often is simplified (often by non-CC providers) into some form of "do you want us to do everything to save your life?".....
Be as graphic as possible about CPR when discussing with patients and family. Tell them that ribs are broken and we may even use a device analogous to a jackhammer to perform CPR. Discuss the survival to functionality statistics you summarized so well in your other article. Tell them specifically when you would stop if there's no ROSC. Consent them like a surgeon would consent a patient for a surgery that the surgeon knows there lies a <5% chance of survival.
Patient autonomy is fine and dandy but they need to know what we know to a certain extent to exercise that autonomy to their best interests. If after all that they ask "what would you recommend doc?", Ill tell them what I think.
While I generally agree that North American physicians should have a freer hand to not provide non-indicated treatment (specifically full-bore CPR, my sense is that Canada and the U.S. both vest this decision with patients/families) from my perspective as an EM/CCM physician and medical educator, slow codes are worse. As leaders of a resuscitation team, we should bear the weight of the decision making that says "No - we're not doing this" and "we're stopping now."
1 - We practice how we play. Ideally, IHCA should be rare. Each time the resuscitation team gathers and performs ACLS, we should be doing it in a standardized way (allowing for variation in treatment based on most likely cause of the arrest). Every time we deviate from this practice we are showing that standardization doesn't matter. Like Yoda said, "Do, or do not. There is no try."
2 - Slow codes are basically lying to the family. We're trying to show them "hey, we did everything" when, in fact, we did not. We should have the courage of our convictions to say we did not because, from a physiologic perspective, it would not have changed anything.
Finally, I have found utility (and healthcare system support from risk management/legal) in focusing on the concept of "physiologic futility", at least for maximally supported ICU patients. If a patient is already intubated, on high dose pressors, and is going to arrest from a cause that is not immediately reversible (like, we've already verified there's no pneumothorax or cardiac tamponade, etc.), my system has supported documentation in that moment of 1) the patient was already being resuscitated with the support they were receiving, 2) the cause of the arrest would not be addressed in the timeframe afforded by ACLS, and 3) that CPR would be merely performative. This started during COVID but has persisted and has been helpful.
Great comments, thanks. I'm very curious to learn how these slow codes actually go. I remember seeing one in training, but that was a long time ago. Is the point to give shallow CPR to avoid breaking ribs, but you still do it for 10 minutes or longer? Or does one cut it short, and if so, what is documented? Are drugs still given, or just pretended and discarded?
I know the distress of being compelled to give CPR to a very elderly, frail, dying person, and slow codes appear to be more common than I had realized, so I am not passing judgment. I agree the inherent deceit could create a new set of problems, though.
“So let’s see you refuse to provide it”… highlights another difference between countries, as we can do just that in Australia.
Very interesting—thanks for sharing this. Will be interested to learn the process- is the family / patient informed, is there a debate, protocol, etc, or is it mostly an ad hoc physician decision. What if physicians disagree- how is that handled. Can talk to you offline. Appreciate your insights.
Laws vary subtly state by state, but in general no legal requirement to provide futile and non-beneficial treatment. Can withhold cpr, or colonic lavage, equally even if patient or family ask for that treatment.
HOWEVER just because can legally do that, doesn’t mean won’t be a huge headache, potential complaints and law suits etc. so in practice always get the patient and family on board, and if significant disagreement seek broader and broader medical consensus and government/legal backing. So while the laws differ from US, the resus conversations follow very similar format I suspect - except perhaps we are more leading here in saying “if despite all these active measures, their heart stops naturally we won’t attempt artificially restart it with CPR - does that sound reasonable?”
And that’s just it…. What if they so no?
I am perplexed to learn that “slow CPR” is even a thing, let alone to realize that it is normalized in North America.
I am also perplexed to learn, if I understood it correctly, that patients’ families ultimately decide on the appropriateness of performing CPR, because doctors could judge worst than the suffering, lay families. That’s insane.
I see a tendency here in Brazil, mostly among young doctors, to ask the family whether doctors should intubate a patient. I explicitly advise against it in my mentoring.
In my opinion, the family perceives it as an act of omission where the doctors try to dump the responsibility for the results (dysthanasia and death) on the family.
My father is a retired geriatrician. He always said that the patient and family must feel you have assumed the responsibility for the case. They must understand you are conducting it for the better, and then they will become relaxed and acceptant of the outcome.
I don’t know if it’s even possible in a society where everyone is afraid of litigation… anyway, thank you for the insightful post.
I wouldn't say it's normalized, but based on the results of the survey, sounds like close enough.
Families, especially affluent educated families, have an enormous influence over all care provided in the U.S., and absolutely make the decision as to whether CPR will be provided. The physician "gets" the DNR directive from the family, or the family "makes" the patient DNR (in the local medical dialect).
Fear of litigation is involved, but it's more a takeover of healthcare by consumerism and corporate interests in my opinion.
A common phrase U.S. physicians use is "do you want everything done?" Said to a patient in extremis, or their bewildered and frightened family. This is the fastest way to a) avoid actually having hard conversations and b) being able to claim that you did, while honoring 'patient autonomy'.
I think you got the point there when you mentioned it’s more a consumerism culture take over.
Unfortunately, we have imported it from the US, specially in the private health sector. There, health services are sold as shelf products, of course, because everyone has to pay the bills.
There’s a very prominent hospital in my state that is seen among the country’s best private hospitals. Their slogan is “redefining the impossible”, that is, they explicitly sell dysthanasia.
In the country with the world’s largest income gap, “doing everything” also means you are a member of the higher class. This is the rich’s way of dying.
I see the “do everything” approach as a curse. We have the power to keep a heart beating at any amount of suffering. One day the “consumer” will realize that we must be very wise when using such a power. Hopefully, the market will find a way to make a reasonable end of life care as a marketable product.
I’ve chosen the word “curse” to emphasize there is something of a displaced religious belief in to it. One day I’ll be brave enough to write about it on Substack.
Thank you again. Have a nice weekend.
I've never participated in, nor requested a "slow code" as you describe it. I will look forward to seeing what your ethicists have to say about deceit. I'm unable to think of the circumstance in which "benign deceit" is appropriate with patients or their families.
I would imagine that I am an attending "of a certain age", and I have ranted before; I don't any more. I think, perhaps, I have actually aged and experienced myself out of it. But along with my ranting (and now, in its absence), I have always held crucial conversations with patients, when they are awake, and families, when they are not. I do not ask, per se, whether I can enter a DNR order. I explain the circumstance to them, teach them what CPR/ACLS was invented for, what it can do and what it cannot do. I then tell them that I am going to enter a DNR order, for the reason that it does not have any chance of even returning the patient to their pre-hospital state of health and with high probability will not even return them to the state of health they are in at this very moment. I assure them that this does not mean that we are backing down in anything else we are doing to try and restore their/their family's health. Patients and family all understand that there is an end to each of us, whether we like it, or not. When they understand that we are all in there fighting together to stave off the end until we no longer can, the withholding of futile CPR is something that almost everyone understands, once they understand what it can do and what it can't do. We do have to understand that their background knowledge of CPR before we explain it comes from ER, The Pit, Grey's Anatomy, etc. No wonder they would want it - you get up and go home when it's over.
This is a different conversation from converting to comfort measures, by a degree or two. The two conversations have in common that families are often relieved that this is an option. The DNR conversation is one that is held when it is clear that we are losing the battle and that CPR would literally be futile. I will admit that if families strongly object, I will back down. We do, as you say, live in a society where CPR is considered the norm, and most patients and families do not have any experiences other than their own or those of family members on which to base their understanding of the world or of medicine and its limitations. Sometimes people come back after sleeping on it and discussing with family and/or clergy and ask for the DNR.
I think it's important to emphasize that this particular DNR conversation is not based in quality of life assessment, as might be the baseline conversation that one has with every patient as they enter the hospital. Every patient is entitled to judge for themselves the quality of life they will tolerate. Some patients are fine withholding CPR, because they are ready if the time comes; what they want is to not suffer or be in pain, because of the acute illness they are currently experiencing.
Sometimes, patients tell me that they understand what I have said, but that they want to "go down swinging". I understand this way of thinking, and when that is what they want, I can participate with them. In that circumstance, I don't order a "slow code"; if I am going to be their partner, they will get the best I have to offer, and I will abet their swinging.
Something I hope also that there is more discussion of is the idea that it harms patients to spend extra days on life support, teetering on the edge of death before succumbing to it because we provided CPR/ACLS. It doesn't seem like something I would want for myself, but I think we assume that it's bad for patients, and I don't have certain knowledge that it is.
As you can probably surmise, I feel like running a "slow code" is dishonest and not in keeping with any pact that we have with our patients. The fact that some ethicists find it OK won't likely change that for me. I'll be interested in hearing the arguments for when it's ethical to deceive patients and families. I wouldn't be able to look them in the eye, which is something that I find important to be able to do.
I am realizing, Matt, that your comments section allows me to, essentially, write blog entries without having the pressure of making a new one every week. I get to decide what I'll write about, and when. I believe I will indulge myself this way for a while.
Its a tough grey area for all. The most important thing to do as alluded in this article is consent. CPR is a procedure with clear harms and benefit. The code discussion often is simplified (often by non-CC providers) into some form of "do you want us to do everything to save your life?".....
Be as graphic as possible about CPR when discussing with patients and family. Tell them that ribs are broken and we may even use a device analogous to a jackhammer to perform CPR. Discuss the survival to functionality statistics you summarized so well in your other article. Tell them specifically when you would stop if there's no ROSC. Consent them like a surgeon would consent a patient for a surgery that the surgeon knows there lies a <5% chance of survival.
Patient autonomy is fine and dandy but they need to know what we know to a certain extent to exercise that autonomy to their best interests. If after all that they ask "what would you recommend doc?", Ill tell them what I think.