Monday, November 26, 2012

THE SLOW CODE


A friend sent me an article from the Toronto Star (http://www.thestar.com/news/canada/article/1292712--half-hearted-medical-care-for-hopeless-cases) that examines a behind-the-scenes medical practice called the “slow code.” The phrase awakened a dusty memory in me, a list of sarcastic phrases we medical smartasses spoke to one another but were careful never to mention around patients. Like “Five-P Syndrome,” meaning Piss-Poor Protoplasm Poorly Put Together. Or, when some troublesome patient departed, “AMF,” meaning, to put it delicately, “Adios, My Friend.” A “slow code” was cardiopulmonary resuscitation done so desultorily it was sure to fail.

In most hospitals the call for CPR comes over the PA system as “Code Blue” or “Code Three:” a patient is in cardiac arrest, so all hands on deck, stat. The bedside becomes a frightfully dramatic scene, a whirlwind of doctors, nurses, techs, gloved hands, potent drugs slammed through tubing, electric gadgets hooked up.

When I was an ER doc, I participated in plenty of these, and went at each full-bore, even when survival was unlikely. (In fact, unlikely survival is the most likely outcome. A study of ninety-nine thousand CPR attempts found that only two hundred twenty-eight patients, a fifth of one percent, were pulled from death into a normal life. That doesn’t mean we shouldn’t try, only that our expectations need trimming.)

Sometimes the patient is known in advance to be unsalvageable, being too old or frail or irreversibly sick even to survive the trial of CPR. In those instances, the staff would like to have a “DNR,” or do-not-resuscitate, order on the chart, but that’s not always the case, as end-of-life conversations are too seldom conducted. The practitioners who find themselves suddenly at these bedsides do their job, but half-heartedly, hence the “slow code.”

These scenarios aren’t just wasted energy. They can generate gratuitous suffering for everyone involved, especially the staff, who, while cleaning up the post-code mess, wonder what they’re doing in this profession. This all might be avoided were doctors to routinely discuss end-of-life issues with patients and their families. 

One reason they often don’t is that they’re not paid to do so. They’d earn thousands for a brain operation, but not a cent for helping guide people through their darkest hour. A provision in an early version of the Affordable Care Act of 2010 (“Obamacare”) specified paying doctors to hold such conversations. No sooner was this made public than millions interpreted it as “death panels” intent on pulling Grandma’s plug, and the provision was dropped.

As long as we keep end-of-life issues locked in the closet, we’ll continue to slow-code and act in other ways that would make a visiting anthropologist wonder about our mental health.

1 comment:

  1. As part of my surgical residency, I did six months as a resident on the anerthesia service. Between that and spending plenty of time in the ER, I did a lot of CPR.

    There is no doubt in my mind that "saving" some patients makes no sense from one of the several points of view on this important subject.

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