Rethinking Slow Codes: Gina Piscitello, Parker Crutchfield, Jason Wasserman

Eric 01:03

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 01:05

This is Alex Smith.

Eric 01:07

And Alex, we are going to be talking about slow codes today. You may heard of a partial code show codes, light blue codes, placebo codes, Hollywood codes. We’re going to talk about what that is. But before we do, who do we have on with us to talk about this great subject?

Alex 01:22

We are delighted to welcome Gina Piscitello, who’s a palliative care doc at the University of Pittsburgh. Gina, welcome to the GeriPal Podcast.

Gina 01:32

Thanks for having me.

Alex 01:33

And we’re delighted to welcome Parker Crutchfield, who is a bioethicist at the Western Michigan University Homer Stryker School of Medicine. Parker, welcome to the GeriPal Podcast.

Parker 01:44

Hi there. Glad to be here.

Alex 01:46

And we’re delighted to welcome Jason Wasserman, who is also a bioethicist at Oakland University’s William Beaumont School of Medicine. Jason, welcome to GeriPal.

Jason 01:56

Hey, thanks. Great to be here.

Eric 01:58

So we’ve got a lot to talk about. The ethics of slow codes, are they ever. Okay, maybe a little defense of the slow code. But before we go into that, Jason, do you have the song request, or is it Parker who has a song request for Alex?

Jason 02:12

Parker?

Eric 02:13

Parker?

Parker 02:14

Yep.

Eric 02:15

What song are you going to request today?

Parker 02:18

Stop in the Name of Love by the Supremes.

Eric 02:21

Why did you decide to pick this song?

Parker 02:25

Well, I thought of it from the perspective of the patient who, instead of a slow code, might be getting a. A full, sincere code that they don’t want and might eventually break their heart as well.

Alex 02:38

I love it and I love The Motown. Having grown up in Michigan and East Lansing and went to Michigan, I love a little bit of the Supremes. So here’s a little bit.

Alex 02:59

(singing)

Parker 03:58

That’s a perfect song.

Eric 04:00

I love it.

Eric 04:06

Well, we’re going to think over slow codes, whether we should stop doing how often we’re doing them. But before we get into that, maybe we can actually define what is a slow code. Again, you may have heard of this as partial codes, show codes, Hollywood codes. Jason, what is a slow code?

Jason 04:26

Yeah, so there’s kind of two uses of the term. I mean, technically speak, like in a. In a narrower sense, a slow code is a situation in which a team takes its sweet time responding to an arrest because they’re motivated by or they have a reticence to resuscitate the patient. So they kind of take their time because they don’t really want to engage in full board cpr.

Alex 04:50

The walk, don’t run there.

Jason 04:52

Yeah, exactly. Right. So one of my colleagues earliest experiences in medical school, his first code blue, he comes running out of the room, running towards the stairwell, busting through the door, and he looks over and his attending is, you know, reading a paper and waiting on the elevator, you know, and it’s like. And it was kind of a, you know, that hidden curriculum and a little bit of an education. And so that’s technically the narrower definition of a slow code.

But the term is often used as an umbrella term to capture any kind of insincere effort at CPR that’s motivated by that sort of resistance to actually wanting to do those things on a patient, usually in whom CPR would be futile or medically inappropriate in the estimation of the team. And it can therefore capture these other kinds of things which have, again, their more particular meanings. So a Hollywood code or a show code is when you do the attempt, you might hurry to the bedside and you might look like you’re doing the attempt, but your compressions are too shallow. I’ve. I’ve been told by a resident that they’ve seen epinephrine injected into the mattress and not the patient.

Alex 05:59

Oh, boy.

Eric 06:01

Really?

Parker 06:02

Wow. Okay.

Jason 06:03

And. And then there are other things. Right. A family code, indic. And these intersect. But a family code might indicate that the CPR attempt is being done perfunctorily for the. But for the family, it kind of calls out those motivations and so forth. So there’s just a range of kinds of insincerity. And slow code is one type in a narrow sense, but an umbrella term for all of these insincere types as we.

Eric 06:27

Yeah. So kind of we’re doing, you know, you get these medical professionals, they’re kind of symbolically appearing to do ACLs in the hospital, but we’re not really doing full ACLs. We may be doing, you know, light chest compressions. We may do a bill for a very short period of time. Just. Let’s just do three cycles and we’ll call it a day. So already setting a time limit at the start, moving slower, shooting. Epidemic mattress is one thing.

Jason 07:03

Yeah, that was a good one. I will say there is another kind of thing that’s generally seen as distinct from a slow code or an insincere code, which is a time limited or in one article at least referred to as an appropriate code. And that is when you engage in a CPR attempt to protocol, knowing that it’s likely futile or inappropriate that you wouldn’t otherwise do, and then you cut it short.

Parker and I are actually working on a piece because we don’t see how that sometimes people say you engage in a sincere but time limited CPR attempt in response to a situation where it’s actually futile. And, you know, we have questions about whether that’s actually sincere. Like you’re not actually being sincere when you do that. But there is another thing out there that people try to say is an alternative to a slow code, which is a time limited or a quote unquote, appropriate code that we can even talk about.

Eric 07:52

Yeah. What do you think about that, Parker? Because that kind of feels like you’ve already set. Like it kind of feels a little showy to me. Performative, like you’ve already set a time or a number of cycles that you’re going to do, knowing that is not going to work. And you’re kind of just. It feels like I often see that in performance for the family members to show them that we’re trying to follow their wishes.

Parker 08:15

Yeah. My view is that it might actually be the worst of all options because. So I’m. I’m motivated by trying to avoid harm. Harm is a. As the sort of A moral fundamental that we want to prevent in as much as we can. And a short code might cause all of the harms that are associated with futile cpr, but with zero chance of actually doing anything. So if, if.

Let’s just suppose, and I don’t think there, there’s some evidence, maybe not, maybe not as strong as we like, but it’s admittedly difficult to gather that the harms to the patient from cpr, much of them are, upon commencement or within the first few minutes of performing it, they aggregate as, as it continues. But it’s not like the, the first few minutes are harm free.

Alex 09:03

The harms you’re talking about, like intubation, chest compressions where you might fracture ribs, those sorts of harms that happen immediately. Upfront harms.

Parker 09:14

Yep, exactly. So if, if we care about avoiding harm, the short code might be the worst of all options. It might be worse than harming the family by unilaterally refusing the request. And it harms the patient in ways that are avoidable by, for example, the slow code.

Jason 09:30

That’s particularly important, I think, because people offer it as a counter to the slow code, which fundamentally is a harm reduction attempt. Whether you think it’s ethical or not, that’s the goal is to do this thing, avoid aggrieving the family, but also avoid or mitigate the harms that might be associated to the patient. And some people say, well, this time limited code is sincere because it’s to.

To protocol, but it’s also harm reductive because we just do it for a little while. And I think we take issue with the fact that a, it doesn’t seem sincere if you don’t believe it can be therapeutic and the family is holding onto that hope. That’s not engaging in sincerity, in my view. And then as Parker said, it’s not actually harm reductive or certainly not as harm reductive as a, as a slick code.

Eric 10:13

Because it is interesting. And I love your thoughts about this, Gina. Like, I think about, like, when do we call a code, like in somebody who we think it’s not futile, we think that there is a chance that it may help. It’s when, like, we’re out of ideas of what can make this reversible anymore. They’re irreversibly dead. So we call them, we call the code, and we pronounce them as dead because we don’t think that there’s anything else. And that could happen at 45 minutes. That can happen at 30 minutes. Heck, that can happen at like 30 seconds.

The example or even two seconds. The example I always give is like, if there was an industrial saw accident, like, my head gets chopped off. My head’s on one side of this room, my body is on the other side. A minute ago I was adamant, I want to be full code. I don’t know of anybody who would do a show code or slow code or any code on me if my body and my head were separated. And we often see that. We don’t see that, but we see like people with metastatic cancer dying in the icu, septic on three presses already basically getting two weeks of a code.

Blood pressure drops, heart rate drops, and then they code like that’s pretty close to saw happening. Cutting off my head, body over there, head over there. What do you think about that, Gina?

Gina 11:32

Yeah, I think that’s a really good point. And when we’ve looked at this in the past about why are people doing slow codes to begin with? So some people say it’s like to help support the family. But a lot of people are saying it’s for legal reasons that they feel that their state laws are obligating them to perform cpr.

So even in that situation that you mentioned about like your head being in one spot, your body being in another, you know, like, could people interpret that to be like, oh, I need, you know, if your EMS arriving at the site, do I need like the medical director to tell me not to do a code in this situation? So I think a lot of it is legal. And the doctors and the who are deciding to do these flow codes, they’re doing it because they feel like they are obligated to do it by their state law.

Eric 12:08

Are there state. I know New York, I think, had one for a while, but got rid of it. Are there any state laws or laws saying that you have to do? I don’t know of any that says you have to do cpr. I know like in places like the va. So there’s hospital policies where we can’t unilaterally change somebody’s code status. But they’re also very explicit that you don’t have to provide non beneficial care. So you have to keep them full code, but you have to make an assessment and then you can call the code at any time.

Gina 12:38

Yeah, I recently worked on a study that looked at unilateral decision making that would include physicians. When are they allowed to say, I’m not going to provide CPR in every state? They are wildly different in how they approach these things. Sometimes it has to be totally like physiologically futile. For you to be able to withhold cpr. Others, it’s more broad. It’s like for your conscience. If the physician’s conscience goes against your conscience to provide cpr, they can withhold it.

But there are some states, like North Carolina, they do not have anything in their statute saying that it’s okay for a clinician to withhold or withdraw, like there’s any treatment like cpr. So physicians in those settings, they might feel very uncomfortable doing it. And I’ve heard, I mean nationally, I’ve heard many clinicians say we are doing this for this purpose. It is because of our state law. That’s why we are doing the slow code.

Jason 13:22

And if I could just tag onto that, the ambiguity and how some of, even some of those laws that are in states where it’s theoretically permissive of clinician judgment in these ways, sometimes the wording of healthcare law is so poor that it gives physicians a lot of hesitancy. In the state of Michigan, for example, there’s a guardian law that while CPR is a medical order and therefore in theory is up to the clinician, there’s also language in our guardianship law that says that guardians have the power to initiate, revoke or amend a DNR order.

Now, if you put that together with other elements of the law, it doesn’t mean that patient consent is, or family consent is required for dnr. But I’ve seen judges who are had particular political persuasions interpret it that way. And so I think physicians are rightly worried about how the law is written and how it’s going to be interpreted in court.

Eric 14:13

So it’s interesting because there’s this concept of unilateral dnr, whether or not we can do a unilateral dnr. And that may change by state, it may change by hospital.

Jason 14:24

My judge, our judge.

Eric 14:26

Right, but then let’s just imagine if, if we can’t change, somebody’s just, just like in the VA system, you can’t change. You can’t go against families. A decision around codes. F they want to be full code, they have to stay full code. But even in the va, they’re very specific that you don’t actually have to perform like chest compressions. You don’t have to provide interventions that are non beneficial. So you can, you can call the code, you can end the code at any point where you no longer think it is beneficial.

Alex 15:00

Eric wants you to tell him his approach is okay and it’s okay to push back on Eric and say, eric, you’re deluding yourself that is also a slow code.

Eric 15:13

It is, right?

Alex 15:14

It’s a short code, poorly problematic.

Eric 15:16

It’s super short. It’s 0 sec, 1 second long.

Parker 15:20

Well, so I’ll happily push back because I think what gets. One of the common arguments against the slow code is this, that you have these policies that permit unilateral decision making. And although that may be the best medicine for the patient, it also neglects the harms that are going to inevitably occur when you refuse a family. So if we, if you view, if we view a harm as just something that makes a person’s life worse than it otherwise would have been, when you tell a family, no, we are not going to do what you want to your loved one that harms them and the degree of harm could vary case to case, but it’s, it’s a frustration of their desires and a diminishment of their well being.

Eric 16:11

So any empirical evidence around whether or not seeing a family member go through CPR and die is worse than telling them we’re not going to do CPR from a harms perspective. Do you think it’s worth it or do you think like it’s so individual it doesn’t really matter to do those studies?

Parker 16:33

So it’s that. But also, how could you. I mean it, it just seems like a study that’s impossible to conduct because.

Eric 16:39

Like the, the, the randomize some slow code. Well, let’s talk about that. Like, you know, I’ve read a lot of articles in preparation for this. Most of the articles are not in defense of slow codes. It’s. Slow codes are morally abhorrent. They’re ethically wrong that we should never do them because multiple different reasons, including lying to family members, is bad. So pretty much it’s all over the place. I’m assuming that a lot of the teaching is don’t do that. How often are slow codes happening? Like in real life? Are people following these, you know, bioethicists and thought leaders?

Alex 17:26

Sounds like. Is that a question for Gina about how often is this happening?

Eric 17:29

You did a study looking at this, right?

Alex 17:31

Yeah, Gina, right. Before we get to there, I just want to comment on something else Eric said about what people say in journals. And Parker and Jason, you wrote a beautiful commentary that I’m going to link to on our show Notes associated with this podcast where you said, decisive moral positions are easy to come by when sitting in the cheap seats of academic journals, but a troubling ambivalence is naturally characteristic of live dilemmas.

Speaker 6 17:59

I love that sentence.

Alex 18:02

I love that sentence because that’s why.

Parker 18:04

We’Re talking about this right here. Right?

Alex 18:06

Like we’re moving from this. Like, like, you know, it’s easy to say this argument, that argument, but hey, this is happening as Gina is about to tell us, and this is a problem.

Eric 18:15

Well, is it happening?

Jason 18:17

Yeah. Well, Gina’s work actually gave rise to our project in a, in a, in one very significant way. I’m sorry for jumping in, but like on the one hand, as you point out, the literature over the past 40 years has been incredibly dogmatic on the issue. It’s just like, don’t do them. Lying is wrong, it’ll hurt public trust and we don’t have to do them if we just improve communication and strengthen our non beneficial care policies. We don’t think any, we don’t, we disagree with the first two premises at least as kind of unilateral statements and not sure about the second two, that they’re accurate, that those are going to resolve all those situations.

So while the literature had been dogmatically against SLOCOS for the past 40 years, there had been one notable article kind of making a little sliver of an exception to. And all 14 commentaries or 13 commentaries on that article were against. Like, there wasn’t one that was like, hey, they got it right, even a little. And at the same time, so we see this dogmatic literature and then at the same time we come across Gina and her colleague’s article that shows a pretty significant prevalence of these, at least one that complicates the ethics view.

Eric 19:24

Gina, what did, what did you do in your article? Let’s hear how are these happening at all in real life?

Gina 19:31

They are. And the reason I did this article was because people didn’t believe me. Like I didn’t believe this was a thing until I saw it as a resident, I thought, holy crap, what is this? So people didn’t believe me outside of medicine. So I had to, you know, prove it. So with colleagues, we looked at two different medical centers. We interviewed or we surveyed internal medicine residents.

Eric 19:49

And what year was this? This is like in 2020. 2020, not long ago. We can’t say. Like this is recent. Okay.

Gina 19:59

You interviewed, we surveyed internal medicine residents, nurses, critical care nurses, pulmonary critical care physicians, cardiology physicians, fellows, about how often are these happening at their hospital? First are they happening and then how often are they happening? And what we found is that about 69% they said that they are happening at their hospital and that they have been involved in one slow code in the past year. Some people said, though up to 10. They’ve been involved in 10 slow codes in the past year. So it varied by participant. But many people have been actively involved in these slow codes.

Alex 20:35

And what did you find out about that? They’re thinking about the ethics of these slow codes.

Gina 20:40

That’s what I think. That shocked me to the core, because over half of the people we surveyed, they thought that they can be ethical even in situations where you think, well, the case that we gave was a situation where the patient is perceived to be medically futile. CPR is not going to really help this patient in those situations. Is it ethical to perform it? And about 52% said, yes, it is. And the other people said, no, it’s not.

Alex 21:05

Perform it, meaning perform a slow code.

Gina 21:07

Perform a slow code. Yeah. And I think, you know, we. We explained to them, we gave them a definition of the slow code. Many of the people who said it’s ethical. Perform. They said that if you are going to perform it, you need to tell the patient’s family that you’re performing a slow code, which. That goes against the slow code. The slow code is a performance. It’s a trick. You’re tricking the family to think that you’re actually doing the work and you’re not. So that’s, you know, that’s part of.

Eric 21:32

Nobody in real life actually tells the family about a show code.

Alex 21:36

Yeah, I’m doing a performative cp. I’ve never heard. That’s. That’s weird.

Eric 21:41

Yeah, I guess you could say. So this is the problem with definitions, right? Like if, like Jason was talking about, there’s a wide definition. Right, Jason, that could include. We are going to do 2 minutes, 5 minutes, 3 rounds. So maybe like this partial slow or short code.

Jason 22:01

Yeah. There is a thing called a transparent or transparent slow code. Transparent code or transparent slow code.

Eric 22:07

We’re going to read our paper up on the elevator and take a while. They’re probably not saying that. Right.

Jason 22:11

Well, so we actually had a case in our system that gave rise to our colleague Abe Brummet’s piece that’s forthcoming on this. But it was a case where a family was insisting on cpr, but the patient was still capacitated and just couldn’t bring himself to confront the family about his decision to want to be dnr. And so one option, which we didn’t need to pursue in the end, but was an agreement with the patient to slow code him.

Eric 22:36

Well, I gotta ask Gina. I’m gonna go back to you. So before you did this study, nobody believed you. After you did the study, you have this survey. Do they believe you now?

Gina 22:47

They do and they’re very upset about it. The people that I talk to, like in the community, they’re very upset that why are doctors doing this? Like, this is totally not what we would want our doctor to be. To be doing to us.

Alex 22:57

Oh, interesting.

Eric 22:59

Well, if I remember correctly, Parker, you also cited a study that asked the lay public about was it. I read so many articles, I don’t remember if it was Parker or Jason’s or somebody else’s article that there was a brief survey. It was like a convenience sample survey of the lay public. Jason, you’re nodding your head like this sounds familiar. I’m not making this up.

Jason 23:19

Right.

Parker 23:20

One of the entries in the special issue is a survey of laypeople and the level of trust they would have or mistrust they would have in the event of a slow code. And one argument against slow codes is that they erode public trust. And this, this article provides some bit of evidence that. Well, maybe that’s not the case.

Eric 23:41

Yeah, a higher than expected proportion of people thought it was okay to do a slow coat.

Parker 23:47

Yeah. Yeah.

Jason 23:49

A significantly higher. You know, it’s, it’s certainly the general public doesn’t seem to be as uniform and homogeneous in their view of this as the bioethicists have been.

Parker 24:00

Yeah, yeah.

Eric 24:01

Well, maybe we can also just summarize, like roundtable discussion, like what are the, what are the clear arguments against a slow code? And then we’ll talk about kind of lightning round. What are the, what are the arguments for a slow code? Is it over? Okay, so what are the main arguments against a slow code?

Parker 24:18

It’s dishonest.

Eric 24:19

Number one, we are lying to people and lying is bad. Okay, what else?

Jason 24:26

You know, as is pointed out by, in another article in our special issue, and I think is somewhat obvious when you think about it, we are deceptive in all sorts of ways throughout health care and in sometimes that decision.

Eric 24:37

Wait, wait, wait.

Alex 24:38

We’re doing. Aren’t we doing first?

Eric 24:40

Yeah, you got to get back to. We’ll get back to. Is it. Okay, we’ll get to that.

Alex 24:43

Jason, lightning round.

Eric 24:46

Everybody just throw in ideas why slow codes are bad, lying is bad, we’re hurting trust. They will not trust us. If the New York Times publishes an expose that, you know, 50% of doctors are doing slow codes, the public may actually react to that. And how would we feel about that?

Jason 25:04

Yeah. So there’s the argument that lying is wrong just in a sort of a patient care setting. And then there’s the argument that lying has bad consequences for the profession and decreases in public trust. I think a more convincing argument actually that is in our special issue as well, is that slow codes treat the patient as an object, as a means to an end, to sort of either satiate the worry and anxiety about conflict that might be held on the part of the medical team or to sort of acquiesce to the unrealistic expectations of the family on the other. But it’s not about the patient, it’s about others in one way, shape or form. And that. That’s disrespectful.

Alex 25:43

That’s a good one.

Jason 25:44

That’s actually an argument I find rather convincing.

Parker 25:48

One of the more frustrating arguments, at least for me, is that slow codes are wrong because you should have done otherwise. You should have done better.

Eric 25:55

You should have been a better communicator.

Parker 25:57

About a better communicator.

Alex 25:59

Well, we’ll get to why that’s frustrating.

Jason 26:02

We’re strengthening our non beneficial care policies in response especially to our op ed that we put out in concert with the special issue of so many people. There was a TikTok video from some healthcare tiktoker was like, well, we just need to do a better job showing families how unrealistic CPR is. And you know, it’s like, it’s a bit insulting actually because like I think a lot of our physicians do a really good job of that and it sometimes just doesn’t get us all the way there. It just doesn’t. And it’s not going to all the time.

Alex 26:33

Gina, you got one?

Gina 26:34

Yeah, and I’ll say this has already been discussed, but I think harms to the patient and especially bringing up the point like I remember CPR when we’ve been doing it and the patient’s awake, they are awake during the compressions, we stop for the pulse and rhythm check, they’re no longer awake. People can feel it. And I think that’s the concern. Another one is true harms of the patient physically.

Parker 26:52

Yeah.

Jason 26:53

And also can I add to that, I’ve had so many clinicians who wanted to just say, I’m not going to argue with the family. I’m just going to do the full cpr. They want it. And by the way, if the patient’s dead, they’re not going to feel it anyway. And it turns out this is actually not accurate. Even in patients that are unconscious, there’s like 1 to 2%. There’s some evidence that there’s about a 1 to 2% CPR induced consciousness rate. Now maybe that’s small, but it’s not zero harm just because they’re dead, so to speak. And I hear that a lot.

Alex 27:23

Eric, you got one?

Eric 27:24

Yeah, I’m going to bring up my other one. That there is no requirement to do non beneficial interventions. Like if somebody asks for ivermectin for their cancer or chemotherapy to treat their pneumonia, we don’t have to do it if we don’t think it’s beneficial. Even in settings where you can’t change their unilaterally change their code status.

Alex 27:47

I have one, and this is that slow codes are built on a premise of futility. And futility is not an agreed upon ethical argument. In fact, most bioethicists would argue that futility is not a practical concept that’s actionable and that reasonable people will disagree about what constitutes futile treatment. And then often when we initiate CPR or not often, not infrequently, if we initiate CPR in a patient for whom we think it’s futile, sometimes there will be return of circulation.

Eric 28:26

Wow.

Alex 28:27

Okay. So who are we to judge when something’s futile?

Parker 28:31

So for some of these arguments, can I just add that some of them don’t undermine the slow code. They undermine in some case the unilateral decision. So in your example, Alex, that would undermine unilaterally using the patient. And your example, Eric, of you don’t, you don’t have to do it, that would undermine the performance of sincere cpr. So these don’t necessarily rebut the position that slow codes are permissible. They rebut more forcefully the other options that a physician faces.

Eric 29:05

Yeah, well, I would argue that even if we do full CPR and we don’t think it’s going to work, we’re doing a performative. Performative, A rite, a ritual at the end of life.

Parker 29:17

Yep.

Jason 29:18

That’s our point about this claim that time limited codes in the context of futile or inappropriate CPR are sincere but short. There doesn’t seem anything sincere about doing a code if you don’t believe it’s therapeutic.

Parker 29:34

One of the something you just said, Eric, maps onto one of the narrative pieces in the special issue from a physician who was a resident in the 80s. And it talks exactly about this idea that everyone who dies gets coded and no one who gets coded leaves the hospital. So it’s just like something. It’s just part of the culture of dying in a hospital that you get.

Eric 29:57

And the moral distress that we face doing these interventions to people knowing that it is not going to help them. But like you said, Parker, Harm. There is going to be harms. Harms not just the patient. Maybe harms to the family, certainly harms to the medical team.

Alex 30:15

Have we transitioned into our slow codes ever?

Eric 30:19

Okay, right.

Jason 30:20

Can we respond to some of those arguments, please?

Eric 30:23

You can attack every single one of them.

Jason 30:25

Well, so let’s start with the idea that we just don’t have to do it. My article, which is on slow codes as a form of ethical disobedience, was motivated by a case in which a probate judge issued a temporary restraining order against our hospital for its DNR orders, where we had done good communication, bent over backwards to work with the family on a compromise for a month or more and run through our policy exactly where we thought it was inappropriate and harmful to a patient. And a judge comes along and says, nope, temporary restraining order. So now we have a choice. In theory, we don’t have to do it. But as our lawyer friend said, the master of the law in a courtroom is a judge. So whether it conforms to the statute or not is almost irrelevant. We’ve been ordered by a judge.

Eric 31:18

But it’s interesting. You’ve been ordered to keep them full code.

Jason 31:21

Right.

Eric 31:21

So now becomes the ethical dilemma. Do you do a performative code for the judge and the family, or do you just call the code 5 seconds and do it if their ET tube didn’t fall out or there was no reversible clause, Just end it. Because you can end it. It’s up to the doctors in the room when to end the code.

Jason 31:43

I think technically, but I think that that sort of ignores too much about the legitimate worries. And Lia, in that situation and the practice in that situation, I’m like, hey, I’m not going to put all this to the test with this judge. They clearly have a view here. And I’m not going to be on the.

Eric 32:00

I’m not going to risk my own job, my. My performance.

Jason 32:03

Yeah, why wouldn’t they? And let me say, also, like, it’s not just the legal system. It’s even where the laws may favor clinical judgment. The specter of liability is real, and I think we need to be sensitive to that. And then additionally, as Parker alluded to the culture around cpr, it’s a default. There’s a prevailing public belief that it’s a relatively innocuous and super effective intervention. And you just get it after nearly drowning on the beach, and then you get back to your surfboard, and we.

Eric 32:35

Teach people how to do it mannequins.

Jason 32:38

And it’s a default presumption. So I don’t think sociologically, while, while ethically it may be, I don’t think sociologically it’s like other non beneficial interventions like Ivermectin. I think there are a lot of other sociological factors that complicate the picture.

Gina 32:53

Yeah, and I was going to add to that. You know, Eric, I think to your point like that the doctor could stop in, in five seconds. Well, where is the doctor? The doctor could be at home in bed. You know, it’s the nurse who has to implement the doctor’s order that’s going to be there on the body doing these chest compressions until the doctor shows up. And like, how awful for them to have to go through that and hear the attending doctor say, hey, I know this code isn’t gonna work, but you need to physically get on that body and do that.

Eric 33:19

That’s a great point.

Jason 33:20

So then on the veracity point, I’ll just. Now, since we’re at the, at the time when it. We can do this defense.

Eric 33:29

What was that?

Jason 33:30

Yeah, we do, we do a lot of deceptive stuff in medicine. Some of it we think is ethically justified. Well, we withhold information from patients for therapeutic purposes. Sometimes we withhold information from surrogates when we think we’re protecting a patient. You know, we may not explain all the options.

Eric 33:48

Hey, there’s this thing called ECMO that we haven’t tried yet.

Jason 33:52

Right. Especially when we’re not offering those options. Right. Like, you know, the idea that like we, we refuse to offer and even explain an infinite set of possible interventions every single clinical encounter.

Parker 34:07

Yeah.

Eric 34:09

So omissions happen all the time.

Alex 34:11

Yeah, and he does some direct patients.

Jason 34:15

Are routinely deceived for their own good. I mean, there’s all sorts of deception. My colleague, again, Abe Brummett, has a whole litany of examples of ethical deception in medicine. So the burden on people who want to say the slow code is wrong because it’s deceptive is to show why it’s deceptive in ways that are impermissible. Just merely saying it’s deceptive is not enough because there’s lots of things that are deceptive and ethically permissible.

Eric 34:43

Well, Gina, I got a question for you. What do you think makes code so special then CPR so special? Because you ask a surgeon, I see this all the time, so. And so has cancer of the liver, but it’s also metastasized everywhere. Family wants the surgeon to take the liver out and they just say no, they’re not going to do it, or they’re too high risk for a particular surgery, even if the cancer is localized, they’re just not going to offer it or they’re not going to do cabg because they’re too high risk. They will just say no. Why do you think it’s that doctors don’t say no around, like, we’re just not going to offer CPR to someone?

Gina 35:22

Yeah, I think part of it’s legal. I think part of it is, you know, learning the history of cpr. CPR was never intended to be done on every patient. It was done in the operating room on patients that they thought could medically benefit from it. And somehow it got extrapolated to everyone. And I think one of my teachers in my ethics fellowship, Dan Bronner, he’s wrote a lot about this. And, you know, some people say that because there’s a billable diagnosis, we can bill for cpr, Therefore it went wide to everyone. Other people say because, like, the law has come down and people.

Doctors are so worried about getting sued. That’s why everyone gets it. So I think there’s a lot of reasons why it’s happening. Why does it happen? And surgeons are able to say no, and other doctors aren’t. From my perspective, and I’m internal medicine trained, I really think it’s like I was just trained differently. When I hear the surgeon speak about informed consent and offering procedures, I was just fundamentally trained different. We provide that care to patients, and I wonder if that’s part of the training of it. It’s just like, for me, as an internal medicine doctor, this is just. You don’t have the right to say no to people.

Alex 36:19

Yeah, it’s like, normative within internal medicine. Whereas there are a different set of ethical standards in surgery. For example, Parker, you look like you want to jump in here.

Parker 36:29

So two things. One, Dan Browner is now my colleague, and he’s got a wonderful book on. On this about the history of CPR and its relation to. To billing codes, but also for other procedures and treatments. They aren’t on the banner in epic. And so there’s no, like, default cabbage on the banner or ECMO by default or dialysis by default. There is CPR by default, although the presence of it in the medical record in that specific location might be new. I think it reveals something special about CPR that we think about it differently than we. Whatever the explanation is, it indicates the fact that we do think about it differently. And I think. I think it is, as Gina said, along with many others.

Eric 37:14

I read one article. I love this line, recognizing this symbolic Importance might allow us to better understand some of the inexplicable quirkiness in the way we talk about and perform cpr. Like it is quirky. It’s a, it’s a weird, weird because we’re not doing informed consent. Like we’re, it’s just odd.

Alex 37:34

It’s a ritual that is taken on added significance in our culture because of the ways in which it’s portrayed. In which, you know, James Tulsky article Miracles and Misinformation watched all of er, Chicago Hope and found success rates were like 2/3 when in reality they’re much lower.

Parker 37:53

So also, also consider that of most other treatments it’s extremely personal and close. So it requires a lot of personal force with an individual who you are very close to. And both of those factors have been shown repeatedly in the moral psychology literature to alter our moral judgments. And so you don’t get that with other treatments.

Alex 38:17

So when you say close you mean like your physically pumping on the patient’s.

Parker 38:22

Chest and doing so with a lot of vigor if you’re doing it sincerely.

Alex 38:27

And so this is the potential to create moral distress in the provider because of the closeness and force with which they’re acting upon the body?

Parker 38:37

Yes. Yeah. And not, not just distress but it alters sort of the cognitive or I guess emotional response to the task.

Eric 38:46

Okay, I want to go back to. So we’ve refuted some of the arguments against slow codes. Like what’s the argument that a slow code is actually maybe preferable.

Alex 38:58

Are we going trolley problem?

Jason 39:00

Let’s start with.

Parker 39:01

That’s what my article is. It uses the trolley problem.

Alex 39:04

Let’s go to trolley problem. I know we only have eight minutes left.

Eric 39:07

Yeah. So we got to keep it short.

Alex 39:08

We’re going to go fast trolley problem.

Parker 39:10

Fast trolley problem. You got, you’re an observer at a switch. People go on a runaway trolley. If you do nothing, trolley’s going to run off the cliff, everyone’s going to die. If you pull the switch, it’s going to divert the trolley into another track. And however you explain the problem, it’s going to hit a track worker, kill them, but everyone on the trolley will be safe. And so if you take slow cut out of the situation, that’s the dilemma between, or maps onto the dilemma between unilateral refusal of CPR or sincere cpr.

But there’s also pretty good evidence from moral psychology that if you include a third option that is basically a third track, so you pull a different switch and it, it’s a harm free track variety of ways you can talk. Talk about it. But say a sloping spur track. So it sloped, it slopes gently up a hill, comes to a rest, and no one ends up being hurt.

Eric 40:00

No harm track.

Parker 40:01

No harm. No harm. Everybody’s going to choose that track and everyone does. And so except for the, I think, you know, 93% of the psychopaths are like, so weird.

Alex 40:12

7% don’t choose that track.

Parker 40:14

Yeah. So either they were incompetent survey takers or psychopaths.

Eric 40:21

And there’s no right answer to the first two. Right. If you just have those two tracks. Is that right answer?

Parker 40:27

I. I think there is. And. And pretty consistently 85% of the people will pull the switch.

Eric 40:32

Oh, yeah. So they’ll be an actor, one worker.

Alex 40:34

In save the most people.

Eric 40:36

Yeah.

Parker 40:36

Yeah. And so my view is that the slow code is like that sloping spur track. And so if the sloping spur track is the best option in the this probably problem trilemma, then it’s the best option.

Eric 40:47

And really is that because there’s no harm?

Parker 40:49

Because it’s the least. It’s the most harm reductive. Yeah.

Eric 40:52

Tell me why.

Parker 40:54

Because it prevents harm to the patient. It prevents harm primarily to the family, once we take their well being into account, and it harms, to a lesser degree, the staff. So there’s no, I guess, I guess there’s no harm free option in these situations, but it’s the least harmful option.

Eric 41:12

Because there’s still the harm that you may lose trust with family if they find out or if the public finds out. Or like we did a podcast nationally about slow codes and people listen to it and they say, oh my God, slow codes happen all the time.

Parker 41:26

Yeah. Or maybe it violates sort of the social cohesion of the team.

Eric 41:31

Gia, what are your thoughts on that? Yeah, this, this idea. It’s the least harmful.

Gina 41:36

Yeah. I don’t buy it. I really appreciate the thought experiment. I love hearing people argue for the slow code. I don’t buy it. Personally, I cannot think of one situation where slow code is a better option.

Alex 41:48

Oh, say more.

Gina 41:50

I think if for me, the reason why I became decided to become a physician is I want to have honesty and integrity. And if people can’t trust me in like one realm of what I do in my practice, like, why would you trust me in any realm of that? So I think for me, you know, we’re going to have a patient where we think that CPR will not benefit them. I think it’s important to be honest and say either we’re going to do this code full out or we’re not going to do it at all. I think those are the options. This low code option for me is just, it’s not honest. And if anyone found out that I did that, why would you trust me in any other realm of what I’ve been doing in my professional career if I’m willing to, you know, be disingenuine in that way?

Eric 42:30

Parker, Jason, rebuttal.

Parker 42:31

Well, so I appreciate the comment and I’m not sure it’s a resolvable disagreement because if you listen to Gina’s justification, my justification, they boil down to ultimately the disagreement between utilitarianism and deontology, which.

Eric 42:45

If you can summarize that in one.

Parker 42:47

Sentence, because I didn’t understand that Gina, Gina cares about rules and I care about benefits, so.

Jason 42:55

Or the.

Eric 42:56

Or avoidance of harms, it sounds like.

Parker 42:58

Yeah, well, I care about welfare. She cares about principles, both well known ways of making moral decisions, but also notoriously difficult to reconcile.

Eric 43:10

So it seems like the main, like the reason to do a slow code is this is symbolic expression that we are, we are in this together. We’re not going to give up. It’s giving the family that. That feeling that we are going to do everything for their loved one to keep them alive. Even if we’re not really doing it, they’ll think we’re doing it. And Parker, my reading it right, that that minimizes harms to the family because they’ll feel like we’ve done everything. It minimizes harms to us because we’re not really doing everything. So we’re not having the moral distress and it minimizes harms to the patient because we’re not really doing real chest compressions.

Parker 43:48

Yeah, correct. And the cost of that is non maleficence violating that principle.

Eric 43:53

Jason, you’ve been quiet. What do you think about all this?

Jason 43:55

Well, so I think there’s other considerations. As I mentioned, I think sometimes we effectively face mandates from state law or judges. That’s what I mentioned my article is about. But what I wanted to say, and I think it ties to what I said before, even though there’s a fundamental disagreement that has really just emerged in this conversation about the ethicality of slow codes. I think we’re not as far apart necessarily. I mean, maybe Parker’s harms analysis moves him a little further away, but for me at least we’re not as far apart on the question.

Even if you think slow codes are wrong. And I think that they can be permissible from my point of view. And again, I Write about this. Slow codes are permissible in the context of state and judicial overreach at least. And what I say is it’s a response to a non ideal situation. So I actually am supportive of most of the arguments against slow codes in a vacuum. Right. In principle, I don’t think that those people are wrong. But we don’t live in principle. We live in reality. And we can be forced into bad situations. And I think a non ideal bioethics takes a look at what. What kinds of choices we have that make the world a little less bad, like that make life a little less worse for people.

Eric 45:13

So.

Jason 45:13

And it’s okay to navigate that kind of practical situation.

Eric 45:17

Moving from the ivory tower of academics telling us what we should do to the real life of Gina is showing us is that this happens all the time.

Jason 45:25

Yeah. So I think that like, you know, for the most part, we all wish for a world in which slow codes were unnecessary. And we should all work towards that world by strengthening laws and educating judges about clinical judgment and doing better communication.

Eric 45:40

One last pushback. One last pushback on that. Jason. Imagine the judge either found out that you called the code at five seconds and he gonna get mad or you did a show code where you.

Jason 45:54

Yeah.

Eric 45:55

Which would piss him off. Work through.

Jason 45:57

Yeah, Work through. An analysis of ethical disobedience. That a framework. I think you’re very unlikely to be caught. So I think. And I think that that matters. All right, now I’m shaking your head. Please include this in the. In the production. Okay. I’m going to never recommend it.

Parker 46:13

Lightning round.

Eric 46:13

Then we’ll get to Alex’s song. You’re going to make one last argument for your case. You gotta do it real briefly. Show codes, good or bad. Gina, I’m gonna start with you. You were shaking your head.

Gina 46:23

Yes, slow codes are bad. Doctors should be honest with their patients and families.

Alex 46:29

Great.

Parker 46:29

Parker, Slow codes are okay when they minimize harms.

Eric 46:35

Wonderful.

Jason 46:35

Jason, Slow codes are a non ideal, but nonetheless practical way to respond to a world that doesn’t sufficiently respect clinical judgment.

Parker 46:45

Okay, I’ll go.

Jason 46:46

And I never recommend them in practice, by the way.

Parker 46:48

Just say that.

Alex 46:49

Here’s mine. Eric does slow codes and recommends them, though he doesn’t want to admit it.

Eric 46:56

It’s not a slow code. A slow code, you know, it’s not going to work. I just want them to make sure that like, the oxygen didn’t fall out, like there’s no irreversible issue that’s going on. And a slow code, you know, there’s no like, you know, protest. Too loud. I doth protest. Alex. Bring us home. We’ll Motown.

Alex 47:27

(singing)

Eric 48:25

Gina Parker. Jason, thanks for being on. We’re gonna have to have you on again because I know I’m gonna get a million comments from this. It was great. So thank you very much, Alex. I think we’re still on Echo. And a big thank you to everybody who is listening to this podcast. We’re gonna have a ton of the articles on the show Notes. So go to the GeriPal website and show Notes.

And big thank you to all of our GeriPal listeners for your continued support.

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