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Palliative Care Network of Wisconsin (PCNOW)
Board of Directors Position Statement: Partial or Slow Codes
 
July 13, 2017
 
In response to the recent JAMA article by Rousseau (2), PCNOW has written a position statement on the issue of "partial or slow" CPR attempts.  We encourage you to distribute this to your hospital ethics and intensive care committees. The full position statement is provided below.

PCNOW Position Statement on Partial or Slow Codes: PCNOW discourages the use of partial or slow codes. We urge Wisconsin health care institutions to review/revise their CPR/DNAR policies to explicitly oppose partial and slow codes. We urge Wisconsin health care institutions to provide DNAR communication training in parallel to existing CPR skill training programs.

Background: Respect for patient autonomy and a shared medical decision-making process enable patients to align treatment plans with their personal goals and values. When patients are unable to make decisions for themselves, surrogates can express patient values, if known. However, certain medical interventions must be offered as an entire procedure in order to work effectively.  Cardiopulmonary resuscitation (CPR) is an example of such an intervention, which must be performed as a whole in order to provide the optimal possibility of patient benefit (1,2,3). In circumstances in which patients and families are unable to agree to a do not attempt resuscitation (DNAR) order, some authors have advocated the use of “partial codes” (some resuscitative efforts are done while others are withheld) or “slow codes” (a deliberate, but half-hearted attempt at CPR in a medical situation in which CPR is highly likely to be ineffective). The use of partial or slow codes is typically performed when clinicians view the full procedure as extremely unlikely to be effective (i.e. futile), but the patient or family continues to request CPR. This process has been justified by invoking preservation of patient autonomy, minimizing treatment bias regarding pre-cardiac-arrest conditions, and fostering the grieving process of surviving loved ones (4).

Evidence suggests there is a near-certainty of death within days when partial codes are performed (5). Partial or slow codes can expose patients to substantial risk of suffering, can increase family suffering, and cause clinician moral distress (2,3,6,7). Lastly, performing partial or slow codes, that is, deliberately performing a medical procedure with no intended benefit, undermines clinician professionalism.  Since the bioethical principle of patient autonomy is not absolute, and clinicians should also adhere to the principles of beneficence (“act to benefit the patient”) and non-maleficence (“do no harm”), there is no ethical mandate that clinicians perform requested medical treatments, which expose patients to significant harm without a meaningful chance of benefit (8,9).   

Managing CPR Conflicts: Requests for a slow or partial code by a patient, surrogate, or medical treatment team typically represents a breakdown in communication. The following steps are advised:
  • A goals of care conference (a.k.a. Family Meeting) involving the medical treatment team, surrogate and/or patient.  Such a conference should entail:
    • A discussion of the underlying medical condition and prognosis;
    • When the use of CPR is deemed medically inappropriate, a clear recommendation is made that CPR not be done at the time of natural death, rather than offering a choice: “do you want us to try to restart the heart”; (see Fast Fact #24)
    • Presentation of the best available medical evidence regarding success rates of CPR;
    • Reflective listening, exploratory questions and guided discussion aimed to better allow clinicians to understand the underlying reason for persistent requests for CPR;
    • When one or more conferences fail to achieve resolution, seek out specialist palliative care consultation and/or an ethics consultation.
Hospital Policy Considerations:
  • DNAR orders should only direct clinicians in the case of cardiopulmonary arrest and should not be confused with treating pre-cardiopulmonary-arrest conditions such as respiratory distress or cardiogenic shock.
  • Code status orders and forms should offer the choice of full code or DNAR with no menu CPR procedure components (e.g. mechanical ventilation, pacemaker).
  • Health care institutions should avoid medical orders or advance directives, which confuse DNAR orders with the appropriate treatment of pre-cardiac arrest conditions such as incipient respiratory failure.
  • The performance of slow codes or partial codes should be considered a sentinel event which should be reviewed and utilized to foster system-based quality improvement.
  • Health care institutions should involve key stake-holders (e.g. clinicians, nurses, social workers, chaplains, ethics committee members) to develop a clearly delineated policy and process for resolving CPR futility concerns.
  • Health care institutions should develop educational programming that provide opportunities for clinicians to practice discussing CPR/DNAR with patients and surrogates.
Resources

PCNOW Fast Facts: 
  • #23-24: DNR Orders
  • #179: CPR Survival in the Hospital Setting
  • #183-4: Conflict Resolution Parts 1 and 2
  • #222-227: Family Meetings (Goal of Care Conference)
PCNOW Member Portal
  • DNR Lecture
  • Communication Curriculum Guide
  • Communication Trigger Video-good/bad examples of DNR Discussion
References:
  1. Perbedy MA, Kaye W, et al.  Cardiopulmonary resuscitation of adults in the hospital: a report 14,720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58(3):297-308.
  2. Rousseau  P.  Partial codes—when “less” may not be “more.” JAMA Intern Med. 2016; doi:10.1001/jamainternmed.2016.2522.
  3. Sanders  A, Schepp  M, Baird  M.  Partial do-not-resuscitate orders: a hazard to patient safety and clinical outcomes? Crit Care Med. 2011;39(1):14-18.
  4. Lantos  JD, Meadow  WL.  Should the “slow code” be resuscitated? Am J Bioeth. 2011;11(11):8-12.
  5. Dumot  JA, Burval  DJ, Sprung  J,  et al.  Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of “limited” resuscitations. Arch Intern Med. 2001;161(14):1751-1758.
  6. Morrison  W, Feudtner  C.  Quick and limited is better than slow, sloppy, or sly. Am J Bioeth. 2011;11(11):15-16.
  7. American Association of Critical Care Nurses, Moral Distress Resources:http://www.aacn.org/wd/practice/content/ethic-moral.pcms?menu=practice
  8. AMA Futility Policy: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page
  9. AMA DNR Policy: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion222.page?






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