A Walker and Avant concept analysis of slow code practice in end-of-life resuscitation

Abstract

Background

The slow code is a complex and ethically sensitive phenomenon in cardiopulmonary resuscitation (CPR), referring to a deliberately partial or delayed resuscitation attempt in patients with poor prognosis or terminal conditions. Although it is recognized in clinical practice, the concept remains ambiguous and ethically controversial. Clarifying its defining attributes, antecedents, and consequences is essential for ensuring ethical and responsible end-of-life decision-making in healthcare.

Methods

This study applied Walker and Avant’s (2019) concept analysis method to clarify the concept of slow code in CPR. A comprehensive literature review was performed using PubMed, Scopus, Web of Science, CINAHL, ProQuest, and SID databases. The search covered studies published up to 2025 in both English and Persian. The following keywords and their combinations were used with Boolean operators AND and OR: slow code, symbolic resuscitation, code status, do not resuscitate, end-of-life decision-making, nursing ethics, and CPR ethics. Relevant literature was screened and analyzed to identify defining attributes, antecedents, and consequences of the concept.

Results

The analysis revealed that the slow code represents a symbolic and ethically complex clinical act, performed when resuscitation is deemed clinically futile but ethical, cultural, or familial expectations pressure healthcare teams to act. Defining attributes include partial or intentionally delayed resuscitation, symbolic compliance with clinical or institutional norms, and an underlying intent to reconcile professional ethics with contextual constraints. Antecedents include patient-related factors (terminal illness, poor prognosis, low probability of return of spontaneous circulation), team-related factors (moral distress, perception of futility, prior ethical conflict), and organizational factors (absence of DNR policies, ambiguous end-of-life care guidelines, hierarchical team culture, and time pressure). Consequences include prolonged patient suffering, family misunderstanding or loss of trust, moral distress and emotional burden among healthcare providers, and organizational ethical dilemmas. However, transparent management guided by ethical frameworks can facilitate constructive discussions about end-of-life care, improve communication with families, and inform institutional policy development.

Conclusions

This concept analysis clarifies slow code as a distinct yet ethically controversial phenomenon characterized by intentionally limited or symbolic resuscitation despite perceived medical futility. Clarifying this concept does not endorse its clinical use; rather, it provides a clearer conceptual framework for distinguishing slow code from related end-of-life practices, supporting ethical education, informing institutional policies, and guiding future empirical research. The findings further highlight the importance of advance care planning, transparent communication, and documented do-not-resuscitate (DNR) decisions as ethically appropriate alternatives to slow code in end-of-life care.

Background

Cardiac arrest is among the most frequent causes of sudden death worldwide [1, 2]. Advanced cardiac life support (ACLS) is an urgent, algorithmic treatment for cardiac arrest designed to restore spontaneous circulation and restore as high a level of functioning as possible [3, 4]. By contrast, a “slow code” denotes a clinical scenario in which providers appear to initiate ACLS while deliberately withholding full resuscitative effort, typically on the grounds that aggressive intervention is considered futile for the patient [5, 6]. Common manifestations include curtailing the duration of CPR, performing chest compressions or ventilation at a deliberately unhurried pace, or omitting certain pharmacological or mechanical interventions [7]. While multiple definitions appear in the literature, significant interpretive ambiguity persists across clinical and ethical contexts [8].

Slow code practices are deeply embedded in broader ethical and philosophical debates about medical futility, respect for patient autonomy, and the professional obligations of clinicians at the end of life [9]. Research over recent decades consistently shows that resuscitation decisions frequently unfold amid profound ethical and emotional uncertainty contexts where death appears inevitable yet clinicians experience strong professional and moral pressure to act [9, 10]. Under such circumstances, the slow code may function as an unstated strategy for navigating the tension between the clinical team’s ethical convictions and the expectations of the patient or family [11].

Despite decades of engagement in the bioethics and palliative care literature, the slow code remains without a consensus definition. The boundaries separating it from related constructs including therapeutic futility and the partial code have not been clearly delineated, and agreement is lacking on the conditions under which it might be ethically or professionally defensible. This definitional uncertainty hinders both rigorous ethical analysis and sound clinical governance, and impedes the development of coherent institutional policies on resuscitation practice [12].

Therefore, a systematic concept analysis of the “slow code” is essential to accurately identify its defining attributes, antecedents, and consequences. This study employs the Walker and Avant (2019) approach to provide a clear and comprehensive definition of this phenomenon within the context of cardiopulmonary resuscitation and to enhance the ethical and professional understanding of nurses regarding this complex and controversial practice [13].

Methods

Design

This study was conducted based on the concept analysis model developed by Walker and Avant (2019) [13]. This structured approach consists of the following steps: (1) selecting the concept, (2) determining the aims of the analysis, (3) identifying all possible uses of the concept, (4) determining the defining attributes of the concept, (5) identifying a model case, (6) identifying borderline, related, and contrary cases, (7) identifying antecedents and consequences, and (8) identifying empirical referents of the concept.

Data sources

A literature search was performed to identify relevant studies on the concept of slow code in CPR. The search was conducted across major academic databases including PubMed, Scopus, CINAHL, Web of Science, and Google Scholar, covering all publications up to September 30, 2025. The search strategy incorporated both MeSH terms and Boolean operators, combining keywords such as slow code, partial code, symbolic resuscitation, Show Code, futile resuscitation, and limited code, along with terms such as cardiopulmonary resuscitation, nursing ethics, clinical practice, and end-of-life care.

The inclusion criteria were as follows: (1) articles published in English or other relevant languages; (2) original research studies, systematic reviews, concept analyses, theoretical papers, or qualitative studies that directly addressed the phenomenon of slow code or related practices in resuscitation; and (3) No restrictions were imposed regarding study design, publication year, or geographical location to ensure a comprehensive understanding of the concept. Additionally, the reference lists of included articles were manually reviewed to identify any additional relevant sources.

The initial search yielded 352 records. After removing duplicates, 325 studies remained for preliminary screening. Titles and abstracts were independently reviewed by two researchers according to the predefined inclusion and exclusion criteria. Subsequently, 48 full-text articles were assessed for eligibility. After applying detailed criteria such as conceptual relevance, methodological rigor, and focus on the phenomenon of slow code 33 articles were excluded.

Finally, 15 articles were included in the final analysis. All records were manually screened and reviewed without the use of automation tools. The included studies were analyzed using Walker and Avant’s (2019) concept analysis approach, focusing on the identification of the defining attributes, antecedents, and consequences of the slow code concept. To systematically extract and categorize data, a conventional content analysis method was employed (Fig. 1). This approach ensured that all dimensions clinical, ethical, and professional of the slow code were comprehensively identified, clarified, and contextualized within contemporary nursing and resuscitation practice.

Fig. 1.

PRISMA flow diagram illustrating the article selection process

Result

Step 1: selecting a concept

The concept of slow code in CPR has been selected due to its ethically complex and clinically significant role in resuscitation practice, yet one that remains ambiguously defined and often misunderstood in healthcare. Slow code refers to resuscitative efforts that are intentionally incomplete, delayed, or performed without full intensity, typically in situations where clinicians perceive CPR to be medically futile or misaligned with patient best interests. The growing importance of this concept stems from the need to clarify the ethical, professional, and clinical dimensions of resuscitation practices, particularly at the end of life. As healthcare increasingly emphasizes patient-centered and ethically sound approaches, understanding the slow code is essential for guiding clinical decision-making, supporting ethical deliberation, and informing policies and educational programs aimed at reducing moral distress, enhancing professional accountability, and improving patient care outcomes during critical events.

Furthermore, as McLennan et al. (2025) describe, significant shifts in resuscitation practices including increased awareness of clinical futility and the growing emphasis on patient-centered care have brought the phenomenon of slow code into sharper focus, underscoring its continuing relevance to contemporary ethical deliberations in healthcare [12].

Step 2: determining the aims of the analysis

Despite its frequent reference in clinical discussions, the term slow code remains conceptually vague and ethically controversial. The main aim of this analysis is to refine the meaning of slow code in CPR by identifying its essential characteristics, antecedents, and outcomes, thereby distinguishing it from related concepts such as “partial code,” “symbolic resuscitation,” and “futile resuscitation.” The results of this analysis will help establish conceptual clarity, guiding ethical decision-making and professional education in nursing and resuscitation teams.

Step 3: identifying the use of the concept

To explore the meaning of slow code in CPR, it is necessary to first examine the individual terms slow and code using linguistic and disciplinary sources, including dictionaries and professional literature in medicine and nursing.

Slow

According to the Merriam-Webster Dictionary, “ slow” refers to something characterized by reduced speed, delay, or intentional restraint in action or process [14]. In the healthcare context, the term “ slow” implies a deliberate decrease in the urgency or intensity of medical intervention, often reflecting an ethical or compassionate consideration rather than purely technical delay [12, 15].

Code

In the clinical setting, “ code” is an abbreviation of “code blue,” a term used to denote a cardiac or respiratory arrest that requires immediate resuscitation efforts [16]. Therefore, “ code” represents the institutionalized and procedural dimension of resuscitation, encompassing all interventions aimed at restoring cardiac and respiratory function [17].

Slow code in nursing and medical literature

The combination of these two terms slow and code gives rise to the concept of slow code, which has been described in medical ethics literature as a deliberately delayed, partial, or symbolic attempt at resuscitation, usually performed when healthcare providers believe that full resuscitation is medically futile or ethically inappropriate [12, 18]. In other words, a slow code occurs when resuscitation is initiated without full intensity or is intentionally prolonged in a token manner to appease family expectations or institutional norms, rather than to achieve clinical recovery [9, 19].

In nursing literature, slow code reflects the moral and emotional conflict faced by nurses who must balance professional duties, ethical reasoning, and compassion for terminally ill patients. It highlights the tension between ethical principles (autonomy, beneficence, non-maleficence, and justice) and the realities of clinical practice, where institutional pressures or lack of advance directives often leave nurses uncertain about the most appropriate action [20, 21].

Slow code can be viewed as a manifestation of moral distress in nursing practice a situation in which nurses recognize the ethically appropriate action (not to perform futile CPR) but are constrained from acting accordingly due to external expectations or hierarchical decisions [18]. The practice may also reflect deficiencies in communication among healthcare teams, unclear resuscitation orders, or cultural norms that discourage open discussions about death and dying [6].

Compared to other approaches to cardiopulmonary resuscitation (CPR), the concept of the slow code holds an ambiguous and distinctive position. In a full code, all resuscitation procedures are performed according to standardized protocols, with the maximal effort aimed at restoring the patient’s life [22]. In contrast, a Do Not Resuscitate (DNR) order represents a formal and explicit medical directive, based on the patient’s wishes or the clinical judgment of the healthcare team, to withhold any resuscitative interventions in the event of cardiac arrest [23, 24]. The partial code occupies an intermediate position, in which specific components of resuscitation such as medication administration without intubation or defibrillation are pre-determined to be performed [25]. However, the slow code is conceptually distinct from all of these approaches [9].

A slow code typically occurs when the healthcare team, despite recognizing the clinical futility of resuscitation, feels compelled to take some form of action to appear responsive both ethically and in view of family expectations. In such situations, resuscitation is carried out superficially, slowly, or incompletely, lacking the urgency and vigor characteristic of a genuine full code. Unlike a full code or DNR, the slow code lacks formal documentation or institutional guidelines that legitimize the actions taken. Consequently, it occupies a gray area between active intervention and non-intervention [18, 19, 24].

From an ethical perspective, the slow code reflects deep professional and moral conflicts among healthcare providers. Nurses and resuscitation team members often find themselves torn between the principles of beneficence, non-maleficence, and respect for patient autonomy on one hand, and institutional, cultural, or familial pressures on the other [26]. In nursing practice, participation in a slow code may give rise to moral distress, as nurses recognize that refraining from futile resuscitation would be the ethically appropriate course, yet are compelled to participate due to environmental or organizational constraints [18, 26]. This experience threatens professional integrity, undermines trust between the care team and the patient’s family, and may compromise the quality of end-of-life care [12, 20].

Overall, the slow code represents a phenomenon that is neither formally endorsed nor explicitly prohibited, but one that, in practice, serves as an implicit strategy to manage moral tensions surrounding end-of-life decisions. Its significance to nursing is particularly profound, as nurses are often the first to confront these ethically charged situations during resuscitation, bearing a substantial moral and emotional burden in balancing professional duty, compassion, and ethical integrity [12, 19, 26].

Step 4: attributes of a slow code

Symbolic—Performative action

Slow code refers to a practice in hospitals or other healthcare settings that can be described as a “performed” or “staged” CPR: members of the medical team go through the visible motions of resuscitation such as placing monitors, giving verbal commands, or making symbolic medication injections yet the genuine intent and full effort [6, 21]. required to truly save the patient’s life are absent. This behavior has been identified in the medical ethics literature as a central moral concern, as it consistently raises critical questions regarding professional honesty, potential deception of the patient’s family, and the preservation of trust. Descriptive studies have shown that medical teams sometimes adopt this approach to demonstrate effort to the family or to maintain organizational cohesion, even when a full resuscitative attempt is considered clinically futile [19, 26].

Reduced Intensity

One of the defining attributes of a slow code is the delivery of medical interventions with reduced intensity compared to standard practice. For example, this may include performing chest compressions with insufficient depth or rate, delaying or lowering the dosage of resuscitation drugs, or shortening the overall duration of the resuscitation effort. Such reduction in intensity may be motivated by a desire to minimize the patient’s suffering or to avoid “therapeutic violence” at the end of life [27]. However, it simultaneously carries implications of inadequate clinical performance and raises potential legal and ethical concerns. Studies have shown that such behavioral deviations from standard ACLS protocols can result in psychological consequences for healthcare professionals particularly moral distress and may also affect communication and trust with the patient’s family [9, 26].

Delayed Response

A slow code frequently involves the deliberate omission or incomplete execution of certain invasive interventions. Examples include withholding endotracheal intubation, refraining from defibrillation when indicated, or performing advanced ACLS maneuvers only partially [18, 26, 27]. These limitations may be predetermined by the clinical team or decided spontaneously at the scene. A key distinction between a slow code and a “partial code” lies in the basis of these limitations: in a partial code, restrictions are typically derived from explicit patient or family directives and are formally documented, whereas in a slow code, they are often informal, undocumented, and based on clinical judgment or external pressures [9]. This lack of documentation raises important concerns regarding clinical transparency and professional accountability [8].

Medical futility as motivation

When the resuscitation team concludes that a full resuscitation effort is clinically futile meaning.

the likelihood of return of spontaneous circulation is extremely low or nonexistent some members may choose to perform a symbolic intervention rather than a full, aggressive resuscitation [12, 18]. This approach is often intended to minimize the physical trauma and perceived “therapeutic violence” associated with invasive procedures, while also managing the emotional and communicative challenges of dealing with family expectations or pressure. However, the very notion and application of “futility” remain subjects of ethical debate. Bioethical literature emphasizes that decisions should be grounded in evidence-based assessments, transparent communication, and clear institutional policies to prevent symbolic or deceptive practices that undermine trust and professional integrity [6, 26].

Step 5: model case

Mrs. Ahmadi, an 83-year-old woman with a history of multi-organ failure, uncontrolled diabetes, and metastatic cancer, is hospitalized in an internal medicine ward. In recent days, her level of consciousness has declined, accompanied by progressive respiratory and cardiac failure. The treatment team considers her prognosis extremely poor; however, due to the family’s opposition, no formal DNR order has been documented in her medical record. Late at night, the patient experiences a cardiac arrest, and the nurse announces a “Code Blue.” The resuscitation team immediately arrives, but the team leader, the on-call physician, after a rapid assessment of the patient and a review of her records, concludes that the likelihood of return of spontaneous circulation (ROSC) is almost zero. The physician determines that a full resuscitation attempt would merely prolong the dying process and cause additional physical and psychological suffering.

Under these circumstances, the team decides to perform a symbolic and low-intensity resuscitation. The members enter the room following the usual resuscitation protocol, connect the cardiac monitor, and loudly announce commands to preserve the outward appearance of a genuine resuscitation effort. However, chest compressions are performed with less depth and force than the recommended standard, resuscitation drugs such as epinephrine are administered at longer intervals and in reduced doses, and invasive procedures such as intubation or defibrillation are deliberately avoided. The team’s response to the code call is also slightly delayed, giving the entire process a softer and less invasive tone.

All of these actions occur with the team fully aware that a complete resuscitation would be medically futile and would only increase the patient’s suffering. Thus, their primary motivation is to avoid therapeutic violence and unnecessary distress at the end of life, while still maintaining the appearance of professional action and institutional responsiveness to a Code Blue. This behavior, which outwardly mimics a genuine resuscitation but lacks the true intent and vigor to save the patient’s life, represents a clear example of performative or symbolic action. After several minutes, with no return of vital signs, death is declared. The patient’s family, waiting outside the ward, appears calm, reassured that the team did everything possible.

Step 6: borderline case, contrary case, and related case

Mr. Rezaei, a 76-year-old man with advanced chronic obstructive pulmonary disease (COPD) and end-stage heart failure, is admitted to the intensive care unit following repeated episodes of respiratory distress. Despite the poor prognosis, no DNR order has been officially recorded, as his family insists that “everything possible” be done. One morning, he experiences cardiac arrest. The resuscitation team promptly arrives and initiates CPR according to standard protocol. However, due to the patient’s extreme frailty and prior discussions among the team about the futility of full intervention, the compressions are performed somewhat gently, and intubation is attempted but not pursued aggressively after initial difficulty. Although drugs are administered according to the algorithm, intervals are slightly longer, and efforts appear less energetic than usual. After 10 min, without any sign of recovery, the physician in charge terminates the resuscitation.

Contrary case

Ms. Karimi, a 54-year-old woman with no significant medical history, suddenly collapses in the hospital corridor due to an acute myocardial infarction. The code blue team arrives within seconds and performs a full, vigorous resuscitation: chest compressions are strong and rhythmic, defibrillation is applied promptly, and medications are administered exactly according to advanced life support guidelines. The team works continuously and with full commitment until spontaneous circulation returns. The patient later regains consciousness and is transferred to the cardiac care unit for further management.

Related case

In the oncology ward, Mr. Hosseini, a 79-year-old man with terminal pancreatic cancer, is in the final stages of life. The healthcare team has previously held multiple family conferences to discuss his prognosis and quality of life. Although the family initially requested full intervention, they eventually agree to a DNR order after comprehensive counseling. When the patient later experiences cardiac arrest, no resuscitation is initiated. Instead, the team provides comfort care oxygen administration, hand-holding, and presence allowing a dignified and peaceful death.

Step 7: identification of antecedents and consequences

Walker and Avant define antecedents as events or conditions that must exist prior to the occurrence of a concept, while consequences are the outcomes that result from its manifestation. In this analysis, the antecedents and consequences of the slow code in CPR are identified to clarify the contextual factors leading to its emergence and the outcomes following its implementation (Fig. 2).

Fig. 2.

Conceptual framework of slow code in cardiopulmonary resuscitation

antecedent

Slow code in cardiopulmonary resuscitation is a complex and multifaceted concept shaped by patient-related, healthcare team-related, family-related, and organizational factors. Patient-related antecedents include critical illnesses with poor prognoses, advanced or terminal stages of disease, and a low likelihood of return of spontaneous circulation (ROSC) despite full implementation of resuscitation efforts [6, 9].

Healthcare team-related antecedents include clinicians' perceptions of medical futility, experiences of moral distress, uncertainty in end-of-life decision-making, and previous exposure to ethical conflicts during resuscitation [20, 21].

Family-related antecedents include insistence on pursuing all possible life-sustaining interventions, unrealistic expectations regarding resuscitation outcomes, and the absence of documented advance directives or previously expressed patient wishes [9].

Organizational antecedents include the absence of clear do-not-resuscitate (DNR) policies, ambiguous institutional guidance regarding end-of-life care, hierarchical team culture, time constraints, limited ethics support, and the high acuity of patients in intensive care settings [19]. Collectively, these antecedents create a context in which slow code may emerge as a response to unresolved ethical tensions in end-of-life decision-making [21].

Consequences

The consequences of slow code extend to patients, families, healthcare professionals, and healthcare organizations. For patients, slow code may prolong the dying process without providing meaningful clinical benefit and may increase unnecessary physical or psychological suffering [6]. Some families may initially perceive reassurance in believing that every possible effort was made. However, if the symbolic or intentionally limited nature of the intervention becomes apparent, feelings of deception, loss of trust, and dissatisfaction with care may arise [8].

For healthcare professionals, slow code may contribute to moral distress, ethical conflict, emotional burden, and professional dissatisfaction as clinicians attempt to reconcile perceived medical futility with family expectations or institutional pressures. These experiences may ultimately increase the risk of burnout and compromise professional integrity [18, 26].

At the organizational level, slow code may undermine trust in healthcare services, create ethical and legal challenges, and expose institutions to reputational risks. At the same time, recognition of these ethically challenging situations may encourage healthcare organizations to strengthen advance care planning, establish clear DNR policies, improve ethics consultation services, and enhance communication regarding end-of-life decision-making [12, 21].

Overall, these findings demonstrate that slow code has substantial ethical, psychological, organizational, and clinical implications, reinforcing the need for transparent institutional policies, comprehensive ethics education, effective communication, and patient-centred end-of-life decision-making [9].

Step 8: empirical referents

According to Walker and Avant, the final step in concept analysis involves identifying empirical referents, which illustrate how defining attributes of a concept can be observed, measured, or otherwise recognized in real-world practice. These indicators do not serve as direct instruments for the concept itself but help validate its significance and operationalize its attributes. For the concept of slow code in cardiopulmonary resuscitation, empirical referents focus on observable behaviors, procedural deviations, and ethical or psychological outcomes that signify the occurrence of a slow code.

Several instruments and observational tools have been used to assess the defining characteristics of slow codes. The Slow Code Survey, developed by Piscitello et al., is a validated questionnaire that evaluates healthcare providers’ perceptions, practices, and ethical considerations surrounding slow code events in hospital settings. It captures data on behaviors such as reduced intensity of chest compressions, delayed response to code announcements, symbolic performance of resuscitation steps, and decision-making influenced by perceptions of medical futility [6].

Discussion

Slow code has been described in the literature as a moral and clinical response to ethically challenging end-of-life situations, particularly when full resuscitation is perceived to be medically futile or inconsistent with patient-centered goals of care. The findings of this concept analysis suggest that slow code is generally understood as an attempt by healthcare professionals to reconcile competing ethical obligations rather than as a passive or negligent act. Importantly, this interpretation should not be viewed as an endorsement of the practice, which remains ethically controversial and is not recommended by current resuscitation guidelines [6, 9].

It is worth emphasizing that, although slow codes are not formally recommended in clinical guidelines and lack explicit regulatory recognition, they are likely performed with considerable frequency in clinical practice. The limited empirical data on prevalence reflects partly the covert and undocumented nature of the practice rather than its rarity. This observation underscores the critical importance of the conceptual clarity provided by this analysis: without a clear and agreed-upon definition, developing the empirical tools and quantitative studies necessary to document prevalence and evaluate preventive strategies remains impossible. Future research should therefore prioritize prevalence studies and investigate how the perceived necessity of slow codes among healthcare providers can be addressed through improved ethics education, communication training, and advance care planning [9, 20].

This concept is shaped by multiple antecedents including team-related factors (such as awareness of the futility of treatment and moral distress), organizational antecedents (including the absence of clear DNR policies and ambiguous end-of-life care guidelines), and contextual pressures such as hierarchical culture and high patient acuity in critical care units [26]. These antecedents collectively create a moral climate in which the slow code becomes a compromise between ethical responsibility and institutional constraints. The consequences of slow code remain highly debated in the literature. Some healthcare professionals perceive that slow code may temporarily reduce confrontation with families, limit aggressive interventions in patients with irreversible conditions, and alleviate moral distress in situations of perceived medical futility. However, these perceived benefits are largely based on clinicians' experiences and ethical arguments rather than robust empirical evidence. Conversely, critics argue that slow code may compromise transparency, undermine trust, prolong non-beneficial interventions, and conflict with patient autonomy when undertaken without explicit patient preferences or documented advance directives. This concept analysis therefore highlights the need to understand both the perceived rationale for slow code and its substantial ethical challenges rather than interpreting it as an endorsed clinical practice [8, 12].

However, it is important to acknowledge that these same factors may equally serve as arguments against slow codes [10]. Performing a slow code rather than entirely withholding CPR may in fact increase the number of interventions relative to a clear DNR decision, potentially exacerbating rather than alleviating moral distress when providers sense deception is involved. Similarly, the practice may contradict patient-centered care principles if it is not aligned with the patient’s previously expressed wishes or advance directives. A more balanced appraisal thus acknowledges both the potential benefits and the substantial ethical risks inherent in slow code practices, reinforcing the need for transparent, documented, and institutionally supported decision-making frameworks [28, 29].

However, despite its potential benefits, the slow code remains ethically controversial. Critics argue that it risks undermining transparency and trust in healthcare relationships. Therefore, the development of clear institutional policies and ethical frameworks is essential to guide healthcare professionals in navigating these complex decisions [18, 20]. In essence, this concept analysis highlights that the slow code is a nuanced ethical practice reflecting both the limitations of medical interventions and the enduring human values at the end of life. Nursing managers and policymakers are encouraged to foster open dialogue, implement explicit DNR protocols, and strengthen ethical training to ensure decisions are both compassionate and ethically justified.

Limitations

This concept analysis has several limitations. First, the analysis relied primarily on published literature, and the number of studies specifically addressing slow code remains limited. Second, because slow code is an ethically controversial practice, many reported descriptions are based on perceptions or ethical discussions rather than direct observational evidence. Third, cultural and legal differences across healthcare systems may influence how slow code is understood and practiced, limiting the transferability of the findings. Finally, the absence of standardized empirical measures makes it difficult to estimate the prevalence of slow code in clinical practice. Future research should focus on developing validated instruments, exploring clinicians' experiences across different healthcare settings, and evaluating interventions that promote transparent end-of-life decision-making.

Conclusion

This concept analysis clarifies slow code as an ethically controversial and conceptually distinct phenomenon that occurs when clinicians perceive resuscitation to be medically futile but nevertheless perform symbolic or intentionally limited resuscitative efforts. Clarifying this concept does not imply endorsement of the practice; rather, it provides a framework for distinguishing slow code from related end-of-life decisions, supporting ethical education, and informing institutional policy. Future research should investigate the prevalence of slow code, examine the factors contributing to its occurrence, and evaluate strategies that strengthen advance care planning, transparent communication, and ethically appropriate resuscitation decision-making. Future research should focus on developing standardized instruments to identify slow code practices, determining their prevalence across different healthcare settings, and evaluating interventions that reduce the perceived need for slow code through improved advance care planning, transparent communication, ethics education, and institutional support for end-of-life decision-making.

Abbreviations

CPR

Cardiopulmonary resuscitation

ACLS

Advanced cardiac life support

DNR

Do Not Resuscitate

ROSC

Returns of spontaneous circulation

COPD

Chronic obstructive pulmonary disease

Authors’ contributions

HG: Conceptualization, methodology, investigation, interpretation of data, writing‐original draft, validation, review & editing. HH: Methodology, investigation, validation, review & editing. HH: Methodology, investigation, validation, review & editing. EA: Methodology, investigation, validation, review & editing. All the authors reviewed the manuscript and agreed on the final version.

Funding

The present study was financially supported by Tabriz University of Medical Sciences, Tabriz, Iran.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was part of a PhD dissertation approved by the ethics committee of Tabriz University of Medical Sciences (code of ethics: IR.TBZMED.REC.1404.206). All methods were carried out under relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.