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{{Short description|Deliberately delayed resuscitation attempt}}
{{About|the medical practice|the programming term|algorithmic efficiency}}
'''Slow code''' refers to the practice in a [[hospital]] or other medical centre to purposely respond slowly or incompletely to a patient in [[cardiac arrest]], particularly in situations for which [[cardiopulmonary resuscitation]] (CPR) is thought to be of no medical benefit by the medical staff.{{sfn|New York Times|1987}} The related term '''show code''' refers to the practice of a medical response that is medically futile, but is attempted for the benefit of the patient's family and loved ones. However, the terms are often used interchangeably.{{sfn|New York Times|1987}}
 
The practices are banned in some jurisdictions.
 
==Background==
During a patient cardiac arrest in a hospital or other medical facility, staff may be notified via a [[Hospital emergency codes#Code Blue|code blue alert]].{{sfn|Marks|2006}} A medical response team, based on the institution's practices and policies, attends to the emergency.{{sfn|NBC News|2008}} The team will perform life saving measures, including CPR, in order to re-establish both cardiac and pulmonary function.{{sfn|Braddock|1998|loc=When should CPR be administered?}}
 
Cardiopulmonary resuscitation may be withheld in some circumstances. One is if the patient has a [[do not resuscitate]] ("no code") order,{{sfn|Braddock|1998|loc=When can CPR be withheld?}} such as in a [[Advance health care directive|living will]].{{sfn|Braddock|1998|loc=What if the patient is unable to say what his/her wishes are?}} Another is if the patient, family member, individual with [[power of attorney]] privileges over the patient, or other surrogate decision maker for the patient, makes such a request of the medical staff.{{sfn|College of Physicians and Surgeons of Ontario|2006}} Surrogate decision makers are considered in a hierarchy: legal guardians with health care authority, individual with power of attorney for health decisions, spouse, adult children, parents, and adult siblings.{{sfn|Braddock|1998|loc=What if the patient is unable to say what his/her wishes are?}}
 
A third situation is one in which the medical staff deems that CPR will be of no clinical benefit to the patient.{{sfn|College of Physicians and Surgeons of Ontario|2006}} This includes, among other cases: a patient in severe [[septic shock]] and/or [[multiple organ dysfunction syndrome]] whose organ damage cannot be contained and reversed any longer, one who has had an acute [[stroke]] that has irreversibly damaged vital brain functions needed for life beyond repair (i.e., in the brain stem), or who has advanced and incurable [[metastatic cancer]], and one with severe [[pneumonia]] which is no longer treatable with assisted ventilation methods and medication, which all have very little or no realistic probability of success.{{sfn|Braddock|1998|loc=When is CPR not of benefit?}} There is also a low probability of success for patients with severe [[hypotension]] that resulted from shock or severe illness or injury, and has not responded to treatment (and which was not induced), severe cases of acute or chronic [[kidney failure]] or [[end stage kidney disease]] (where dialysis and other renal replacement therapies either are no longer working or were not adequate, and where a transplant either cannot be found or is not an option), end-stage [[HIV/AIDS|AIDS]] and its accompanying severe opportunistic illnesses (which are not responding to antiretroviral and drug therapy and/or the white blood cell count is too low), or those who are older than about 70 and/or homebound (where they and/or their guardians, instead of a DNR order, have authorized such half measures and the law permits it).{{sfn|Braddock|1998|loc=When is CPR not of benefit?}}
 
A patient may request, in an advance directive, to prohibit certain responses, including [[intubation]], chest compression, electrical [[defibrillation]], or [[Advanced cardiac life support|ACLS]].{{sfn|Dosha|Dhoblea|Evonicha|Guptaa|2009}} This is referred to as a ''partial code'' or ''partial resuscitation'' and such resuscitation "commonly violates the ethical obligation of nonmalfeasance".{{sfn|Berger|2003|p=2271}} It is regarded as medically unsound because partial interventions are "often highly traumatic and consistently inefficacious".{{sfn|ANA Center for Ethics and Human Rights|2012|p=6}}
 
==Ethics==
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Some medical services centres have instituted policy banning the practice.{{sfn|Braddock|1998|loc=What about "slow codes"?}}
 
In 1987, [[New York (state)|New York]] became the first [[U.S. state|state]] in the [[United States]] to effectively end the practice by enacting legislation to require medical staff to honour a patient's refusal of cardiopulmonary resuscitation or a do not resuscitate order, and to grant civil and criminal immunity to those who do so or those who perform CPR without knowledge of the order.{{sfn|New York Times|1987}}
 
==Notes==
{{reflist|2}}
 
==References==
{{refbegin|2}}
*{{cite web|url=http://depts.washington.edu/bioethx/topics/dnr.html|title=Do Not Resuscitate Orders|work=Ethics in Medicine|last=Braddock|first=Clarence H.|publisher=[[University of Washington]] School of Medicine|year=1998|accessdateaccess-date=2013-04-06|ref=harv}}
*{{cite journal|title=Ethical Challenges of Partial Do-Not-Resuscitate (DNR) Orders|last=Berger|first=Jeffrey T.|journal=Archives of Internal Medicine|volume=163|issue=19|pages=2270–2275|date=October 2003|doi=10.1001/archinte.163.19.2270|ref=harv|pmid=14581244}}
*{{cite journal|url=http://www.nursingcenter.com/lnc/journalarticle?Article_ID=437848|title="Slow" Code: Perspectives of a Physician and Critical Care Nurse|last1=DePalma|first1=Judith A.|last2=Miller|first2=Scott|last3=Ozanich|first3=Evelyn|last4=Yancich|first4=Lynne M.|journal=Critical Care Nursing Quarterly|volume=22|issue=3|pages=89–99|publisher=[[Lippincott Williams and Wilkins]]|date=November 1999|issn=1550-5111|ref=harv|doi=10.1097/00002727-199911000-00014|pmid=10646457}}<!--http://journals.lww.com/ccnq/Abstract/1999/11000/_Slow__Code__Perspectives_of_a_Physician_and.14.aspx -->
*{{cite journal|title=Analysis of limited resuscitations in patients suffering in-hospital cardiac arrest|last1=Dosha|first1=Kristofer|last2=Dhoblea|first2=Abhijeet|last3=Evonicha|first3=Rudolph|last4=Guptaa|first4=Amit|last5=Shaha|first5=Ibrahim|last6=Gardiner|first6=Joseph|last7=Dwamenaa|first7=Francesca C.|journal=Resuscitation|volume=80|issue=9|pages=985–989|date=September 2009|doi=10.1016/j.resuscitation.2009.05.011|refpmid=harv19581039}}
*{{cite web|url=http://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean|title="Code Blue", "Code Black": What Does "Code" Mean?|last=Marks|first=William J.|publisher=[[WebMD]]|date=1 January 2006|accessdateaccess-date=2013-04-06|ref=harv}}
*{{cite web|url=http https://www.nursingworld.org/dnrposition~4af287/globalassets/docs/ana/ethics/ps_nursing-care-and-do-not-resuscitate--allow-natural-death.pdf |title=Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions|format=PDF|others=ANA Center for Ethics and Human Rights|publisher=[[American Nurses Association]]|date=12 March 2012|accessdateaccess-date=2013-04-06|ref={{harvid|ANA Center for Ethics and Human Rights|2012}} }}
*{{cite web|url=http://www.cpso.on.ca/policies/policies/default.aspx?ID=1582|title=Decision-making for the End of Life|others=Physician Advisory Service|publisher=[[College of Physicians and Surgeons of Ontario]]|date=May 2006|accessdateaccess-date=2013-04-06|ref={{harvid|College of Physicians and Surgeons of Ontario|2006}} }}
*{{cite news|url=http://www.nbcnews.com/id/23239084/ns/health-health_care|archive-url=https://web.archive.org/web/20160305095046/http://www.nbcnews.com/id/23239084/ns/health-health_care|url-status=dead|archive-date=March 5, 2016|title=Hospitals' 'code blue' most deadly at night|location=[[Chicago]]|agency=[[Associated Press]]|publisherwork=[[NBC News]]|date=19 February 2008|accessdateaccess-date=2013-04-06|ref={{harvid|NBC News|2008}} }}
*{{cite news|url=https://www.nytimes.com/1987/08/22/opinion/slow-codes-show-codes-and-death.html|title=Slow Codes, Show Codes and Death|newspaper=[[New York Times]]|publisher=New York Times Company|date=22 August 1987|accessdateaccess-date=2013-04-06|ref={{harvid|New York Times|1987}} }}
{{refend}}
 
[[Category:Medical slang]]
[[Category:Ethically disputed medical practices]]
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