DNR — Is A “Slow Code” Acceptable?

One of the more remarkable articles I have read for my course on Bioethics is one by Lantos and Meadow in The American Journal of Bioetehics, 11 (11): 8-12, 2011 on the ethics of the “Slow Code”.

As they quickly point out there is much in the medical literature and via established medical ethics texts to renounce any effort to resuscitate a patient which is less than 100%. Yet Lantos and Meadow offer their suggestion that there are times, perhaps many times, when it is the ethically preferred method for dealing with the end-of-life.

The article correctly discusses that cultural symbolism associated with CPR and the intense confict which grips families when they are requested to authorize a DNR.  For some families, even those well aware of the futility of performing one and the inevitability of their loved-ones death, the act of agreeing NOT to do something to prolong their life is a decision that they just cannot make.  In those situations the physicians involved may attempt to continue to push the family to agree, unilaterally and willingly confront the family by asserting the right to write a DNR order on their own, or accede to the family’s lack of decision by performing a full code despite their own strong beliefs in its futility.

The fourth possibility which the /authors advocate is the “slow code”.  It is a half-way or partial procedure which may be only symbolic in nature.  It may only last a minute, or less.  It is an act of futility with the emotional and psychological status of the family in mind. It is purposefully an ambiguous act for those patients who are dying but for whom any overt decision by loving family members is heart-rending.

 It becomes a ritual associated with dying, one hospital based and perhaps unsavory from a scientific perspective.  It is ultimately a powerful acknowledgement that physicians should be cognizant of the emotional trauma that the death of a loved-one has on their relatives.  The authors summarize the criticisms of this action.

 I, for one, believe it has a place in the hospital setting under appropriate conditions.  I believe that the options of DNR need to be offered to the authorized health-care proxy/family member when physicans believe it appropriate.  Discussion of palliative care and Hospice should not be avoided when deemed the correct choice.  But when family members cannot bring themselves to make those decisions, this alternative option should be considered.

 Family members should not be brutalized or beaten into submission when they clearly are unable to make the decision to order the DNR.  The “slow code” may be the ethically and morally right choice under such circumstances and I applaud the efforts of Lantos and Meadow to discuss it. 

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