Ethical Implications of the Slow Code: A Systematic Review of Ethics of Slow Codes in U.S. Hospitals.

Abstract

Policies that make cardiopulmonary resuscitation (CPR) the default or require it at patient or family request, combined with physician reluctance to decline nonbeneficial resuscitation, may contribute to the practice of a "slow code," in which clinicians appear to perform advanced cardiac life support without fully committing to resuscitative efforts. The space between "full code" and "comfort measures" in medically futile situations presents significant ethical challenges. This systematic review examines the ethical implications of slow codes and factors influencing their use. We conducted a qualitative systematic review of slow codes in U.S. hospitals. A librarian searched MEDLINE, Embase, CINAHL, and Web of Science using terms related to CPR, futility, and ethics. The initial search was performed on May 16, 2024, with an updated search on August 7, 2025, including "slow code" and "partial code." After duplicate removal, 12,863 articles underwent dual, independent screening. Thirty-four studies met inclusion criteria. Included articles were ethics literature (academic articles, commentaries, and opinion pieces) and excluded empirical studies. Of 34 articles analyzed, 61.8% (n = 21) argued physicians ought to be allowed to refuse CPR in futile cases, whereas 23.5% (n = 8) supported slow/partial codes when patients or families request full resuscitation. A further 26.5% (n = 9) described nuanced approaches. Ethical concerns included deception, patient harm, violation of autonomy, paternalism, moral distress, legal considerations, and communication breakdown. Most ethics literature deems slow codes impermissible. Their use often reflects concerns that surrogate decision-makers may not fully understand the implications or mechanics of CPR. In medically futile situations, choosing between "do nothing" and "do everything" can be distressing for families, whereas performing resuscitation can be distressing for clinicians. Physicians remain divided in practice, highlighting the need for clear communication and ethical guidance to support transparent, patient-centered end-of-life care.