(376) Ethical Implications of the Slow Code: A Systematic Review of Ethics of Slow Codes in US Hospitals

Introduction: Introduction
The lack of consensus regarding code status during cardiopulmonary arrest can lead to physicians performing a “slow code”, which involves appearing to provide advanced cardiac life support without full resuscitation efforts. The ambiguous space between “full code” and “comfort measures” in situations of medical futility presents significant ethical challenges. This systematic review aims to explore the ethical implications of slow codes and the factors influencing their practice.

Methods: Methods
We performed a qualitative systematic literature review of slow codes in the hospital setting in the United States. A librarian searched MEDLINE, Embase, CINAHL, and Web of Science databases for terms including but not limited to CPR, ACLS, PALS, termination, futility, and ethics. The search was originally conducted on 05/16/2024. After the removal of duplicates, 12,863 articles underwent dual, independent screening. We identified 28 studies meeting inclusion criteria, which were reviewed for argument quality and analyzed for ethical position and concepts.

Results: Results
The ethics involving slow codes remain controversial. It is commonly performed in cases of medical futility in which a decision maker does not consent to a Do Not Resuscitate order. The ethical issues that arise in these situations include a question of deceit, paternalism, and lack of informed consent. Some argue that slow codes can be useful in specific clinical situations to demonstrate medical futility.

Conclusions: Conclusion
The overwhelming response to performing slow codes is that they are not ethically sound. Often, the decision to perform a slow code stems from a lack of understanding from the patient or patient’s family to perform CPR. Initiating a discussion to ascertain what a patient would want in the event of cardiopulmonary arrest is paramount. In medically futile cases, this line can be difficult to draw for those involved in decision making. The options of “do nothing” and “do everything” can be distressing for family members making medical decisions. Furthermore, performing a slow code can be equally distressing to the medical team who may feel they have no other option. This review has found that physicians remain divided in the choice to perform slow codes, despite the ethical implications.