Slow Code Research Articles

The Resuscitation of “Slow Codes”: Fraud, Lies, and Deception

The Resuscitation of “Slow Codes”: Fraud, Lies, and Deception

Why Not a Transparent Slow Code?

Lantos and Meadows (2011) argue that in some end-of-life situations limiting resuscitative measures by using a “slow code,” one limited in intensity and duration, is morally justified and, in fact,...

Nurses’ perceptions of attempting cardiopulmonary resuscitation on oldest old patients

This paper is a report of a study to explore nurses' thoughts and attitudes about cardiopulmonary resuscitation of oldest old patients. Although it is recognized that nurses and doctors have different approaches to resuscitation, little is known about nurses' attitudes towards attempting resuscitation of the oldest old (85+ years). Ten nurses working in three hospitals participated in in-depth interviews during 2009-2010. The data were analysed according to a constructivist-grounded theory tradition. The appropriate availability of 'do not attempt resuscitation' orders was important to the participants. Participants experienced stress in end-of-life care situations when resuscitation status was not decided for patients they considered should have a 'do not attempt resuscitation' order. Participants acknowledged the difficulties in end-of-life decision-making, but stated that 'do not attempt resuscitation' orders are underused and sometimes delayed. Participants were sceptical about attempting resuscitation. Nevertheless, respect for patient autonomy was strong, and participants were adamant about the necessity of following the legal requirements governing resuscitation. Five of the participants had been asked by physicians to use 'slow codes', cardiopulmonary resuscitation efforts that intentionally are conducted too slowly for resuscitation to occur, and agreed this was unethical. Some participants described the information on cardiopulmonary resuscitation and 'do not attempt resuscitation' given by physicians to patients as inadequate. End-of-life decisions impact on nurses' comfort in their working situation as they face ethical dilemmas and anxiety about performing cardiopulmonary resuscitation. Greater collaboration between all stakeholders might reduce these. Nurses may need additional education or updates about laws about end-of-life treatment, as participants were unaware of current legislation concerning end-of-life decision-making.

Cognitive dissonance theory applied to CPR, DNAR, and the practice of slow codes

Cognitive dissonance theory holds that inconsistencies in our thinking or between beliefs and actions generate mental discomfort. This motivates efforts to reduce the inconsistencies by adapting behaviours or thoughts to make them more consistent with one another. This article demonstrates how the theory can be applied as a framework to understand internal conflicts which health professionals may experience when they encounter inconsistencies between their principles and practice, in the implementation of cardiopulmonary resuscitation and ‘do-not-attempt-resuscitation’ orders. The author suggests that the discomfort generated by these conflicts has been a motivating factor in the emergence of so called ‘slow codes’ (cardiopulmonary resuscitation efforts intentionally conducted too slowly or not long enough to be successful). Interventions are suggested that may help prevent the occurrence of slow codes.

Nurses' and Doctors' Perspectives on Slow Codes

The aim of this study was to ascertain nurses' and doctors' perspectives on the practice of slow codes, which are cardiopulmonary resuscitative efforts that are intentionally performed too slowly for resuscitation to occur. A Heideggerian phenomenological study was conducted in 2005, during which data were gathered in the Republic of Ireland from three nurses and two doctors (via unstructured interviews) and analysed using Colaizzi's reductive procedure. Slow codes do occur in Ireland and are intended as beneficent acts. However, slow codes were identified as pointless and undignified when intrusive measures were employed. There is a need for discussion on the topic of slow codes in Ireland, and for aids to cardiopulmonary resuscitation decision making to be developed, such as advance directives, communication training, clinical guidelines and an explanatory leaflet for patients and families.

Literature review: decision‐making regarding slow resuscitation

Applying ethical principles as a framework, a review of the literature will be presented regarding the decision-making process of slow codes. Slow codes are cardiopulmonary resuscitative efforts intentionally conducted too slowly for resuscitation to occur. While some authors argue that a slow code is a non-maleficent and beneficent act towards the hopelessly ill patient, others believe that this practice is harmful and deceptive, that it disregards patient and surrogate autonomy and deprives the patient of a peaceful death. Literature review. Decision-making surrounding cardiopulmonary resuscitation receives considerable attention in the literature. However, data relating to the decision-making process in slow codes is sparse. One ethnographic study described the practice of slow codes as doing good and preventing harm to the patient. It was evident from the literature review that slow codes, even in the most limited form, are invasive and undignified and that they prolong death and suffering. Further research is needed to examine why slow codes happen despite the availability of a do-not-resuscitate order. Decision-making regarding cardiopulmonary resuscitation is increasingly problematic in Ireland. The literature review suggests that clinical guidelines regarding decision-making and cardiopulmonary resuscitation should be introduced to reduce the likelihood of slow codes occurring, but also that nurses and doctors endeavour to communicate more effectively with patients and family.

Dynamically extending the Corral with native code for high-speed packet processing

By combining the Open Kernel Environment, a Click-like software model known as Corral and basic concepts of active networking, we allow third-party code to control the code organisation of a network node at any level, including kernel and network card. We show how an active network environment was implemented and how this environment allows slow active code to control the code organisation of the fast path. The underlying code is structured much like components in a 'Click'-router that may be connected or disconnected at runtime. Not only are active packets permitted to reconfigure predefined native components in the networking code, by using the safe programming model of the open kernel environment they are also able to load and link their own native components at any place in the datapath and at any level in the processing hierarchy.

Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan.

The purpose of this study was to survey physicians attitudes toward DNR of terminally ill cancer patients in Taiwan. A total of 7626 structured questionnaires were sent by mail to physicians who were members of the Taiwan Society of Internal Medicine and the Surgical Association of Taiwan, and 1328 valid responses were received. The response rate was 17.6%. The instrument, a structured questionnaire, was composed of one scenario and six questions. A majority (77.6%) of the physicians under investigation would tell a terminally ill cancer patient or his family about the possibility of DNR and ask them to consider signing a consent form. Over one half of the physicians (58.4%) did not know whether the Medical Law in Taiwan permits natural death, and 96.1% of the subjects felt they would need legal protection for agreeing patient s autonomy to decide DNR. Unfortunately, 41.2% of the respondent admitted that they did not have a formal Informed Consent Form that could be used for DNR. Even of those who had such a form, only 27.4% had clear guidelines given by their institutions. Among 623 physicians whose institutions had an formal Informed Consent Form for DNR, 63.7% agreed that it was reasonably used. Surprisingly, 67.9% of the physicians had used Slow Codes. The findings of this study served as a solid base. The investigator and other colleagues used it to convince legislators to pass a Natural Death Act in Taiwan. Since some legislators disliked the term death and the main promotes were people engaged in hospice palliative care, the new law entitled Hospice Palliative Act was passed on May 23, 2000. The DNR order finally gained its legal base for medical practice. The limitation of this study was the low response rate. However, since the subjects, physicians, had a busy work load, this was still an acceptable response rate.

Frequency Hopping Code Division Multiple Access for Wireless Local Access

In this paper, the suitability of Slow FrequencyHopping Code Division Multiple Access (SFHCDMA) isevaluated for wireless local access applications.Investigations of the wireless channel indicate that frequency hopping mitigates the poorpropagation characteristics associated with low mobilitycommon to fixed wireless applications. Employingstatistical analysis and simulation models, it is shownthat the frequency hopped channel displays inherentfrequency diversity. Consequently, an FH architecture isresilient to the effects of intersymbol interferencearising from significant time dispersion frequently experienced in the wireless channel.Furthermore, interference diversity of SFH-CDMA resultsin a robust air interface technique. With simulationtechniques it is demonstrated that SFH-CDMA can support the medium rate service bearers (approximately1 Mbps) required for wireless local access, whilstproviding high capacity.

The slow code--should anyone rush to its defense?

The past two decades have witnessed dramatic changes in professional values and social expectations regarding medical care and decision making at the end of life. Increased emphasis on patients' autonomy and participation have made open discussion, both in the medical and popular literature and at the bedside, the new norm. The seemingly final taboo, euthanasia, is now the topic of frank public, intellectual, and legal debate. Although Wanzer et al., in their 1989 second look at “The Physician's Responsibility toward Hopelessly Ill Patients,” wrote that the “entire subject is now discussed openly,”1 there remains a practice that has received little . . .

Nurses’ perceptions of normative and nonnormative clinical codes for critically ill patients

This is a study of the treatment of patients who are in severe medical distress. A code refers to the designation that stands for the range of treatments that the patient will be given. Code blue involves the full range of medical treatment to prevent death. No code involves denial of life‐extending treatments. Previous research has documented that social factors are related to the treatment of terminally ill patients. This study uses interviews with registered nurses and secondary sources to address the nature of patient codes (their location in the hospital, the perceptions of nurses relative to these codes, the interaction among health care professions relative to codes, etc.). It is suggested that there are normative (code blue) and nonnormative (slow code) codes given to these patients. The normative practices are outlined. Then some social, psychological, and medical factors that conflict with these normative codes are addressed (e.g., the physician's view of death as a failure). Finally, the non‐normative practice of slow code is analyzed. In the slow code, the medical staff goes through the rituals of a code blue, but in a deliberate manner. Nurses’ perceptions of nonnormative codes are explored. Some alternatives to the use of slow codes are discussed.

DNR Orders and Medical Futility

To the Editor. —In the Editorial 1 regarding the study by Dr Curtis and colleagues, 2 Ms Alpers and Dr Lo note that the study may underestimate problems experienced at institutions without the bioethical experience of the setting of Curtis and colleagues. Specifically, I believe this to be true: in hospitals where physicians are not experienced with futility decisions, the becomes the predominant method of limiting the inappropriate use of CPR. A slow code is distinguished from other attempts at CPR by its purpose: to appear as a resuscitative effort but without the intention of therapeutic benefit for the patient. A slow code feigns medical therapy and serves nonmedical purposes such as avoiding the perceived legal risks of writing a DNAR order based on futility. During my residency training in internal medicine, completed in 1993 in New York City, the use of slow codes was common, while

Limiting but not abandoning treatment in severely mentally impaired patients: a troubling issue for ethics consultants and ethics committees.

On many occasions, care givers are faced with problems in which “drastic” types of treatment seem clearly inappropriate but “lesser” interventions still appear to be advisable, if not indeed mandatory. In the hospital setting, examples are frequent: the demented elderly patient, still very much capable of brief social interactions and still able to enjoy at least limited life, who although clearly not a candidate for coronary bypass surgery is, nevertheless, a patient in whom an intercurrent pneumonia deserves treatment; the severely retarded youngster in whom appendectomy seems clearly warranted but for whom long-term dialysis seems ill-advised. The examples are legion, and their variety defies an easy, stereotypical solution. Why, one may ask, is the treatment of intercurrent pneumonia or operating on an acute appendix “clearly indicated” while coronary bypass and long-term dialysis “clearly” are not? The reactions of care givers in the past have often consisted of attempts to give half-hearted treatment or to treat fully even against their better judgment. The lack of conceptual guidelines that might help sort out such problems has inevitably led either to an inflexible absolutism in which all possible treatment to sustain life or no treatment at all is given or has resulted in a pathetic attempt to act but act minimally (the “slow code” or to give what seems to be an ineffective dose of antimicrobials) with the hope that such actions will be ineffective.

Profoundly Diminished Life The Casualties of Coercion

A war of words is being waged about whether physicians can refuse, unilaterally, to provide support for patients who are hopelessly or terminally ill. For many years one scenario predominated: the patient or his family said, Stop this treatment and let me die, while the physician said, cannot stop lest I be sued, or indicted for murder. Physicians coped by inventing slow codes and show codes until time and the courts freed them to write codes. And families, once excluded along with patients from making decisions, gradually won the right to speak for a loved one who no longer could. Suddenly we see a reversal. A patient or family says, Do everything, while the physician says, Stop. In Minnesota, Helga Wanglie's physicians and hospital objected to sustaining indefinitely a woman in a persistent vegetative state while her family admonished that only God can take a life.[1] In Washington, D.C., the physicians caring for Baby Rena, an eighteen-month-old in constant pain with AIDS, hydrocephalus, respiratory distress, heart failure, and kidney dysfunction, believed that medicine must not be used to torture the dying and made plans to go to court Her foster parents insisted that all treatment be continued, because God would surely work a miracle.[2] In these new scenarios, physicians typically argue that it is not only permissible, but morally mandatory to cease aggressive treatment. The treatment is futile, they argue, or pointlessly cruel. The families of these patients, however, do not agree that their loved one would be better off dead. They may hold a vitalism that all is of value, regardless of its quality. Or they may believe that personhood is not lost just because one can no longer think. I will argue that this dispute about whether physicians ethically can, or ought, unilaterally to refuse to provide support revolves around fundamentally irresolvable moral conflicts concerning our most deeply held beliefs about the value of life, especially profoundly diminished life. Thus the futility debate is itself largely futile. The fundamentally intractable nature of this dispute, in turn, prompts coercion and the threat of coercion: where a dispute cannot be resolved by rational argument or persuasion, then believers of one side can only prevail on dissenting others by force. This, not the dispute about the value of diminished life, provokes the practical moral dilemmas. Physicians do not wish to be coerced into providing care that they believe is medically or morally wrong. Families do not want to be precluded from supporting the lives of their loved ones by the veto of physicians who have monopoly control over the means to those patients' survival. And the people who pay the taxes and insurance premiums that fund such care may object where they see social hijacking committed by patients and families pursuing private goals at common expense. If the central moral challenge concerns coercion in the face of an irresolvable value conflict, then a proper solution must inquire how best to preserve freedom for each party to honor its own values without coopting unwilling others. Despite the acrimony and divisiveness often surrounding these cases, I will suggest that considerable freedom can be preserved for all. The Standard Arguments Profoundly diminished life refers to patients whose condition is irreversibly very poor. Two scenarios predominate. First, like Nancy Cruzan, Karen Quinlan, or Helga Wanglie, the patient maybe permanently unconscious, or perhaps deeply demented. Many of these patients are not terminally ill, in that they can survive many years with proper nutrition and nursing care. Second are the terminally ill who will die soon no matter what medical interventions are provided. They may be awake and aware, but they have no realistic prospects for enjoyment or personal fulfillment in what remains of their lives. …

Do not resuscitate policies of New Jersey hospitals.

The do not resuscitate (DNR) policies of 100 New Jersey hospitals were investigated using a questionnaire to evaluate hospital characteristics, DNR documentation, decisionmaking, consent, satisfaction with present policies, and revision plans. Among responding hospitals, 78% indicated they had a policy, with--61% being established between 1984 and 1987. Twenty-two percent of hospitals with a DNR policy accepted oral orders, 39% accepted telephone orders, and 36% required written consent from a competent patient. Forty-nine percent of hospitals with a policy accepted qualified orders such as, "do not intubate." Sixty-two percent of responding hospitals were satisfied with their current policy. For 22 hospitals without a policy, 80% indicated dissatisfaction with their current practice. When hospitals with a DNR policy were compared to those without a policy, government supported hospitals were less likely to have a DNR policy than non-governmental hospitals (P = .04). Hospitals without a policy were more likely to perform "slow codes" than those with a policy (P = .007). A two-year follow-up survey found seven hospitals without DNR policies.

Indoor radio communications using time-division multiple access with cyclical slow frequency hopping and coding

The authors describe and analyze a flexible, robust, multichannel time-division-multiple-access (TDMA) radio communications system that is ideally suited for portable as well as mobile indoor use. It uses noncoherent signaling and incorporates slow cyclical frequency hopping and burst-error-correcting coding to provide low-error communications at aggregate rates of several megabits per second without the need for antenna diversity or adaptive equalization. The system can be implemented in a small building using a centralized architecture or in a large building using a distributed antenna system. The TDMA protocol allows the various users the flexibility of choosing their own desired rates of data communications. Moreover, the capability of using different levels of coding gives the users the option of selecting their own error performance. The ability to combat interference is one of the salient features of this system. >