Living will legislation, nursing home care, and the rejection of artificial nutrition and hydration: an analysis of bedside decision-making in three states.

Although state living will legislation establishing the boundaries of unwanted medical intervention has become almost universal, many states define artificial nutrition and hydration as a basic comfort measure rather than extraordinary intervention. In addition, several states have legislation prohibiting its withholding or withdrawal under any circumstances. Despite the recent growth in public awareness and controversy concerning artificial nutrition and hydration, there is little known about the actual influence of prohibitive legislation on bedside decisions involving its withdrawal. An analysis is undertaken of nursing home decision-making concerning the withdrawal of artificial nutrition and hydration in three states with typical variation in living will legislation specific to its legality. Data from interviews with 140 nursing home directors of nursing service responding to hypothetical case vignettes suggest that living will laws prohibiting the withdrawal of artificial nutrition and hydration have little influence over bedside decision-making in nursing homes. Factors found to be determinate of the likelihood of the withdrawal of artificial nutrition and hydration include the competency of the nursing home resident and form of nursing home ownership. State context exerts a significant influence over the likelihood of artificial nutrition and hydration withdrawal, but not in a direction consistent with language of living will legislation.