A “slow code” refers to intentionally limited CPR efforts in hospital settings, often used when clinicians believe the intervention would offer no benefit and no formal Do-Not-Resuscitate (DNR) order exists. The practice raises ethical concerns about transparency, communication, and patient autonomy.
When a patient’s heart stops in a hospital, the expected response is to begin cardiopulmonary resuscitation (CPR) immediately. But in certain cases, healthcare teams may perform what is known as a “slow code.” This is when CPR is carried out in a way that is not intended to restart the heart or restore breathing. The situation usually arises when doctors believe that CPR would not help the patient, but no formal instructions exist to withhold resuscitation.
Such situations typically arise when clinicians believe CPR would offer no benefit, but no formal Do-Not-Resuscitate (DNR) order exists.
A slow code refers to a situation where medical staff appear to provide CPR, but the efforts are minimal or delayed. The patient or their family is not explicitly informed that the procedure is symbolic. The idea behind this approach is to avoid aggressive measures that are unlikely to benefit the patient.
Slow codes are most often encountered in hospital wards and intensive care settings during end-of-life situations, where CPR is unlikely to change the outcome. These situations may involve:
Terminal illness
Multiple organ failure
Severe neurological injury
Advanced age with frailty
In such cases, CPR may only prolong the dying process rather than contribute to recovery.
Studies highlight several contributing factors:
Lack of documented patient preferences
Without a Do-Not-Resuscitate (DNR) order, clinicians may feel compelled to start CPR.
Concern about conflict
Families may request “everything possible,” even when outcomes are unlikely.
Hospital policy pressures
Many institutions default to attempting CPR unless clearly contraindicated.
These situations reflect broader CPR policies in many hospitals, where resuscitation is often expected unless clearly documented otherwise, which can create ethical and legal challenges when the clinical benefit is uncertain.[1]
The ethical debate focuses on communication and transparency.
Is it a form of deception?
Some argue that families may believe full efforts were made when they were not.
Is it a form of professional resistance?
Slow code CPR has also been discussed as a form of ethical resistance, where clinicians refrain from providing interventions they believe will not offer meaningful benefit or may prolong suffering.[2]
Is it different from other medical judgments?
It has also been noted that clinicians often decide not to pursue treatments that are unlikely to work. Slow codes become controversial because CPR is typically seen as the default emergency action.[3]
Improving communication can reduce the need for slow codes:
Advance care discussions before emergencies
Shared decision-making with patients and families
Clear institutional guidelines on CPR when benefit is unlikely
Training healthcare staff to discuss end-of-life choices respectfully
These steps help ensure that treatment aligns with a patient’s values and goals.
Slow code is not simply a procedural choice. It reflects larger challenges in how CPR decisions are made, documented, and communicated. Understanding this practice highlights the importance of timely conversations about end-of-life care, so medical teams can provide treatment that respects both the patient’s condition and their wishes.
Is a slow code legal?
The legality depends on local policy and legislation. Many institutions view overtly symbolic resuscitation as ethically problematic, even if not explicitly illegal.
How does a slow code differ from a “Do-Not-Resuscitate” (DNR) order?
A DNR is a formal order to withhold CPR; a slow code is a non-transparent attempt to perform CPR with no realistic expectation of success, in the absence of a DNR.
Can families request a full code even if clinicians believe it is futile?
Yes. Family requests for “everything possible” often drive the default of attempting CPR, even when medical benefit is minimal.
What should clinicians do instead of resorting to a slow code?
Engage in early goals-of-care conversations, document patient preferences, and establish clear policies for when full CPR is unlikely to benefit the patient.
Does performing a slow code respect patient autonomy?
Not fully. Because the patient or family may not be aware the CPR is symbolic, transparency and informed decision-making are compromised.
1. McLennan S, Bak M, Knochel K. Slow Codes are symptomatic of ethically and legally inappropriate CPR policies. Bioethics. 2025 May;39(4):327-336. doi: 10.1111/bioe.13396. Epub 2025 Jan 31. PMID: 39887721; PMCID: PMC12015803.
2. Wasserman JA. Slow codes as ethical disobedience. Bioethics. 2025 May;39(4):368-374. doi: 10.1111/bioe.13409. Epub 2025 Mar 20. PMID: 40112334.
3. Grosso MB, Nicolas P. Are slow codes uniquely deceptive? Bioethics. 2025 May;39(4):350-358. doi: 10.1111/bioe.13415. Epub 2025 Apr 2. PMID: 40171898.
Edited by M Subha Maheswari