Doctors or nurses will never utter it in discussions with patients or family members.
But in quiet hospital corners, the words are whispered among medical professionals.
Certain that no recording devices are turned on, doctors and nurses will quietly admit that “slow code” — a lackadaisical approach to sustaining life for those who demand aggressive treatment but are thought to be beyond hope — is an element of end-of-life care in this country.
Medical experts interviewed for this story say they never engage in slow codes. But some researchers and bioethicists suggest it’s making a resurgence.
Dr. John Lantos, director of the Children’s Mercy Bioethics Center in Kansas City and co-author of a journal article titled “Should the ‘slow code’ be resuscitated?” says the clandestine practice is happening far more than medical professionals openly concede.
Standard medical guidelines, he notes, suggest cardiopulmonary resuscitation (CPR) on a patient in cardiac arrest continue for between 10 and 15 minutes.
“People say, ‘We’d never do a slow code. But they also say they stop resuscitation after three or five minutes.
“I think it’s appropriate to do that. I just think it’s politically incorrect to admit the real rationale. They’re stopping because CPR is futile and inhumane.”
Slow codes are simply wrong, counters Doreen Ouellet, course director at the University of Toronto’s Joint Centre for Bioethics, who retired in the spring after a 40-year career as a nurse, educator, administrator and bioethicist in a number of Toronto hospitals.
“It’s how we dealt with patients in the ’70s and ’80s when families said they wanted everything done and the medical team thought it was hopeless. It went away in the ’90s because there was widespread agreement that it wasn’t honest or ethical.
“But there’s talk of bringing it back.”
When doctors and nurses decide to operate under a slow code — also referred to as “blue,” “partial” or “Hollywood” code — their intent is not to save a life.
The typical scenario, based on interviews with dozens of health-care providers, goes like this:
A patient or their family members, informed of dire medical prospects, request heroic measures be maintained in the hope of beating the odds.
The patient’s heart stops, a cardiac arrest is called.
Rather than racing to the scene to commence CPR, medical staff assume a leisurely saunter towards the patient’s room. Once there, a half-hearted resuscitation effort commences.
“You walk towards the patient’s room like this,” says Ouellet, demonstrating a slow-code dawdle across the floor.
“There’s a perception, right or wrong, that the public are demanding too much, so the medical team are stuck — they know the patient is not going to survive, so how can they let a patient die without disagreeing with family members and perhaps end up getting sued.”
When families of patients with little hope of recovery demand so-called “full-code” treatment that would keep their loved ones on life-sustaining treatment against the wishes of medical staff, contentious life-vs.-death conflicts can ensue.
Challenging the wishes of patients and families can be a treacherous path for those wary of endless meetings, formal complaints from families or legal proceedings.
Conflict aversion is the most compelling argument for slow codes.
They are a path of least resistance, accomplishing the same ultimate effect without controversy.
A patient surreptitiously marked for slow code who enters a cardiac emergency, for example, would still get the CPR treatment demanded by family members. But, assuming it takes place when family isn’t present, the effort would be far less vigorous or sustained.
It is a kind of begrudging acknowledgement of the caregivers’ professional obligations, a work-to-rule charade, critics allege.
“It’s still in the air,” says Dr. Michael Evans, an emergency-room physician who has practised medicine in Ontario and Nova Scotia for 25 years. “It’s never written on the chart because it’s never a legal order, and it could certainly get you into legal trouble if you ever did that.”
Evans’ view of the practice is categorical: “It is malpractice. If you’re called to a code, you go. You do it as if it’s a 2-year-old, a 20-year-old or a 100-year-old. It doesn’t matter the age of the person that has an urgent medical need.”
The public is largely unaware of the practice. It is imposed upon patients without their consent or knowledge.
There are no laws governing it. And researchers have collected no data. Its detection is shrouded by the collusion of a tight group of hospital colleagues who take part, insiders say.
Some medical insiders believe slow codes are making a comeback in part because modern technology has provided new options for aggressive care that can sustain a life for months or years.
Most medical professionals and bioethicists believe the deliberate holding back of medical firepower is deceptive, giving unwitting patients and families false hope.
“You do something to achieve a goal or you don’t,” says Dr. Neil Lazar, director of the intensive care unit at Toronto General Hospital and a leading Canadian advocate for patient-centred health care.
“Slow codes are to hide something. It’s not transparent.”
University of Toronto bioethicist Kerry Bowman calls the practice “a backhanded way of dealing with a complex ethical situation. It’s a lie. And anytime a health-care worker is purposely deceiving a patient and/or their family, a huge red flag goes up.”
Hold on, says Lantos.
The much-maligned slow code “may be appropriate and ethically defensible in situations in which (CPR) is likely to be ineffective, the family decision-makers understand and accept that death is inevitable, and those family members cannot bring themselves to consent or even assent to a do-not-resuscitate (DNR) order,” reads the article he co-authored last year, published in the American Journal of Bioethics.
Whether they speak openly about it or not, most doctors are quietly aware that, for some families, the death of their loved one following a less-than-standard resuscitation is a relief, says Lantos.
“The point here is to say, ‘C’mon guys, admit that even though slow codes are unethical, you’ve all been doing them. Sort of.’ ”
Doctors may best serve the patient and the family by having “a carefully ambiguous discussion about end-of-life options and then providing resuscitation efforts that are less vigorous or prolonged than usual.”
Dr. Peter Singer, a University of Toronto professor of medicine and former director of the Joint Centre for Bioethics, chafes at the ambiguity argument.
“I’m more in favour of honest — if difficult — conversations than avoidance and maybe duplicity.”
Lantos acknowledges that many in the medical community have called his defence of slow codes a paternalistic endorsement of cloak-and-dagger secrecy.
“It’s a nice argument,” he says. “But why is honesty so obviously the only moral consideration? There’s an argument against the brutal-honesty approach. Families might be better off if you do a little CPR and say, ‘I’m very sorry but your loved one died.’ ”
There are other methods for disguising true medical intentions from a patient’s family members, say medical experts.
Among the most troubling for Ouellet is a practice called “no escalation in care.”
Family members, clear with doctors that their loved one be given aggressive care, are reassured by medical staff that the present treatment plan in place will not be decreased or altered.
While that may sound reassuring to the untrained medical ear, it really means that the patient will receive no additional medical care, says Ouellet.
“People think if you continue with the medication, the patient will go on forever. Of course they won’t.”
If a patient’s condition changes — urine output decreases, heart rate increases or they acquire an infection and need antibiotics — the treatment plan remains unchanged under a no-escalation protocol, she says.
“The family understands one intent, and the practice and intention of the medical team is different than what the family believes is happening,” she says. “The dishonesty for me is that you’re pretending you’re still providing care. But you’re not responding to changes in the person’s condition. You’re just maintaining all the interventions as is until he dies.”
In her experience, Ouellet says, the practice is “very prevalent. It’s everywhere.”
In cases where family members are purposely made to believe their loved one could turn the corner, the practice is unethical, she declares.
“It seems like sleight of hand on the part of the medical profession and the health-care team,” she says. “It’s got to be made clear. You are leaving everything the way it is, you are not withdrawing medical care, but you will not add medical care in response to changes in the patient’s condition.”
Beyond transparency and ethics lies the serious question of patient dignity, she says.
“The problem is the patient dies incrementally, a little at a time.”
Original Article
Source: the star
Author: Robert Cribb
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