Doctors sometimes fake CPR — and they should

There’s a bit of theater sometimes performed in hospital rooms: the play-acting of what’s known as a “slow code.”

A slow code is a half-hearted attempt at CPR. Maybe the doctors will walk, not run, to the room. Maybe they’ll push a little less hard on the person’s chest. Whatever the method, it’s pretend CPR. They are not trying to resuscitate the patient. Instead, they are trying to limit the harm and brutality that might otherwise characterize the inevitable death of the patient while also avoiding conflict with grieving families struggling to face the inevitable.

At first glance, it sounds like malpractice. And for decades, that’s exactly what bioethicists have called it. The consensus has been near-total: Slow codes are unethical and should never be performed. They were taken to task in the 1990s, as concern about amplifying patient autonomy was hitting a crescendo. Since then, suggestions about the permissibility of sham CPR have occasionally dripped into discussions about how to mitigate the damage of futile, default resuscitation. But these intimations have nearly always been roundly rejected. After all, the thinking goes, slow codes are inherently deceptive.

Yet slow codes themselves haven’t gone away. In fact, they’ve quietly persisted despite the uniformity of the academic chorus of disapproval — and for good reason. Recent data show that not only do many physicians and nurses still engage in the practice, but many believe it’s ethical in certain circumstances.

They may be right. As professional bioethicists, we believe the field retired this discussion too quickly, trading the moral complexity of the hospital wards for rhetorical clarity in the academic journals. That was a mistake. We recently revisited the debate as editors of a special issue of the journal Bioethics, inviting fresh voices into the conversation. The result? We’re convinced that slow codes are not only ethical in some circumstances— they might be essential in today’s conflict-ridden medical landscape.

Here’s why: CPR is one of the most overused and misunderstood interventions in all of medicine. Yes, it can save lives — when used appropriately. But in the hospital, especially among frail or terminally ill patients, the odds of surviving CPR are dismal. The procedure itself is brutal: broken ribs, brain damage, prolonged suffering, and a high likelihood of dying anyway — only more painfully. Yet families, judges, and state laws sometimes compel doctors to perform it in obviously futile situations, mistakenly thinking that it will help.

Physicians often lack the freedom to say “no.” Litigious families, judicial orders, and the constraints of state law sometimes put them in an impossible situation. In this no-win environment, the slow code may still be deceptive, but it also must be understood as a reasonable attempt to triage morality — an ethical compromise that aims to balance truth, compassion, and professional responsibility.

While it is certainly imperfect, the slow code may be the least-bad option when judges or legislators acting as doctors and families informed by CPR as it is portrayed in TV and movies force physicians into morally impossible terrain.

Ethical critiques of slow codes often presume an ideal world — where patients and families are fully and accurately informed, making reasonable decisions, and where hospitals and the law support a physician’s right to refrain from harming patients. But in reality, physicians practice in a world shaped by misinformation, suspicion of expertise, and increasing government overreach. When politicians and judges start practicing medicine from the bench or the statehouse, physicians are left with dwindling options to preserve humane, patient-centered care.

Empirical studies back this up. One recent article found that nearly half of surveyed physicians believed slow codes were ethical in certain scenarios. Nurses — often the most ethically attuned clinicians in the room — reported similar views. The disconnect between academic assessment and actual practice means trainees learn about slow codes and their role in critical care as a kind of hidden curriculum, handed down by example. Slow codes aren’t an anomaly; they’re a symptom of a deeper dysfunction in how we manage death and dying in America.

If you want to eliminate slow codes, you have to eliminate the conditions that make them necessary. That means empowering physicians to practice good medicine — even when that means telling families what they don’t want to hear. It means challenging the anti-science rhetoric that undermines trust in medical expertise. And it means pushing back against legislative and judicial overreach that politicize end-of-life decisions at the expense of evidence-based practice and professional integrity.

Until then, the slow code will remain a necessary fiction — a quiet act of resistance in defense of decency, compassion, and good medicine.