Slow Code
Wednesday, February 11, 1998 All Things Considered

Noah Adams talks with Dr. Gail Gazelle about the practice of "Slow Code" in hospitals. Also known as "Show Code," "Hollywood Code" and "Light Blue," a a Slow Code happens when a terminally-ill patient goes into cardiopulmonary failure. The medical staff goes through the motions of attempting resucitation but do not make a sincere attempt to revive the patient. Dr. Gazelle maintains this occurs because the attending physicans has not written a DNR order or the patients family has requested that "everything be done" to save the patient, but the doctor decides that the patient can not expect a quality of life that warrants sincere efforts at resuscitation. Gazelle writes in the Feb 12th issue of The New England Journal of Medicine that physicians have an olbligation to discuss a DNR with their patients and their families.

Read Dr. Gail Gazelle's article in the New England Journal of Medicine.

You can read the transcript:

ROBERT SIEGEL, HOST: This is All Things Considered. I'm Robert Siegel.

NOAH ADAMS, HOST: And I'm Noah Adams.

In tomorrow's issue of the New England Journal of Medicine, there's an article about something doctors and nurses know as "the slow code." It's also called "show code" or "Hollywood code" or "light blue."

The article was written by Dr. Gail Gazelle of Brigham and Women's Hospital in Boston. She describes a scenario in which a terminally ill patient suffers cardiac arrest, but medical personnel only go through the motions of trying to resuscitate the patient.

Dr. Gazelle writes the public is virtually unaware of the existence of the slow code, but she says it's well known to the house staff in every hospital in the country.

DR. GAIL GAZELLE, AUTHOR, "The Slow Code: Should Anyone Come To Its Defense?": Typically, they would take the cue from the attending physician. And a slow code would usually occur in a setting where the attending physician has not discussed what the patient would want done with the patient or their family. So, it's almost an unspoken procedure.

ADAMS: What if the family had said, "we want you to do everything that is practicable to keep our father alive?"

GAZELLE: In that type of setting, the physician is often put at a very difficult situation. If the physician knows that really there are no therapeutic options left that will help the patient or prolong the patient's life, sometimes the physician will make a decision to run a slow code, in an attempt to lessen the harm.

A code involves defibrillation, which is running a strong current of electric shock through the patient's chest, and a patient typically has major convulsion off of the table as a result of that. Chest compressions are performed, ribs are often cracked in the process.

Often a breathing tube is put down the patient's throat, and they're attached to a ventilator. There is no question that they are harmful.

ADAMS: In this case then, the physician is sort of saying there's a greater good here, and that's the comfort of the patient. And even though the family said do everything you can, I'm not going to.

GAZELLE: That is probably correct.

ADAMS: Is that legal?

GAZELLE: There is no law about slow codes. It is not an area that the profession has addressed. And it is certainly not an area that state legislatures have examined.

ADAMS: And they're not going to be -- the physicians are not going to be too happy that you're writing about it, probably?

GAZELLE: My hope is that in exposing this procedure to the light of day, that physicians may actually feel a burden taken off their shoulders, and may feel more of an impetus to have open communication with their patients.

ADAMS: Do you feel that is really the problem? The failure of the physician to communicate with a patient and the family?

GAZELLE: The failure on both the part of the physician and the patient to enter into open dialog about what is often a very difficult -- difficult issue.

ADAMS: Why is it, Dr. Gazelle, that it is so difficult for patients, family, and physician to talk?

GAZELLE: I think we live in a culture that is in a profound state of denial that death is a natural part of life. And as a result of that, physicians who are merely products of that culture have tremendous difficulty communicating about care of the end-of-life.

Physicians, furthermore, are taught to cure disease. They're not taught how to make the transition to comfort measures of care. And I think that this is a problem that we need to address both within the profession and in society at large.

ADAMS: But your article raises, near the end, this question that -- and I'll quote, "physicians are taught early in their training that even under the most dire of clinical circumstances, they must never take away a patient's hope."


ADAMS: So, how does that square with what you're saying?

GAZELLE: I think that in the setting of a terminally ill patient, we need to change the definition of hope. And we need to be thinking about death in the setting of dignity for the patient, in the setting of retaining connections to ones that the patient has been close to throughout their life.

And we need to also redefine hope as a way of avoiding unnecessary suffering. Unfortunately, there are cases where modern medicine cannot prolong life, and that is where the definition of hope needs to be redefined.

ADAMS: But I bet every physician you talk with has a story that says something like, "there was no hope, but I never gave up and I never told the patient. And that patient kept on fighting and something wonderful happened."

GAZELLE: I think that for every one of those stories, there are probably 10 more stories of a case where a physician knows all too well that death is inevitable. And in those cases, the physician has a duty to be honest with the patient, in as compassionate a manner as possible, about what the confines of medical realism really are.

And the focus of care needs to be directed on the patient's comfort, the patient's dignity, and on decreasing unnecessary suffering.

ADAMS: Dr. Gazelle, thank you very much for talking with us.

GAZELLE: Thank you.

ADAMS: Gail Gazelle is a doctor of Internal Medicine at Brigham and Women's Hospital in Boston. Her article on the slow code appears in tomorrow's issue of the New England Journal of Medicine.

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