Artificial nutrition and hydration practices and the American nursing home: Currents of social change and adaptation by an industry in transition

It was hypothesized that the nursing home industry would reflect practices concerning the withdrawal of artificial nutrition and hydration in ways responsive to public policy environment and organizational structure, primarily ownership. Other hypotheses were suggested predicting relationships between particular forms of ownership and practices relating to the withdrawal of artificial nutrition and hydration. The hypotheses were tested utilizing data from interviews with directors of nursing service and Health Care Financing Administration certification files. A random sample of nursing homes (N = 140) stratified by form of ownership (proprietary independent, proprietary chain, government, voluntary independent, and voluntary chain) and state location (Indiana, Minnesota, and Wisconsin) was obtained to compare the relative effects of ownership and public policy in the form of living will legislation. Other predictor variables concerning organizational structure and characteristics were also considered; including size, financial casemix, acuity casemix, and rural/urban location. The data were fitted with least squares multiple regression, with the degree to which a nursing home was measured as facilitative of the withdrawal of artificial nutrition and hydration as the dependent variable.;The hypothesis concerning public policy and organizational structure received only mixed support. It was discovered that form of ownership rather than public policy (living will legislation) tended to explain variations in the degree to which nursing homes were found to be facilitative of the withdrawal of artificial nutrition and hydration. In particular, large nursing home chain forms of ownership appeared to reduce the degree to which nursing homes were found to be facilitative of the withdrawal of artificial nutrition and hydration, both in direct and indirect ways. Directly through specific policies and practices, and indirectly through higher rates of administrative turnover. Other measures of resident autonomy were also shown to have a negative relationship with large corporate forms of nursing home ownership. It was speculated that in domains of extraordinary life support, resident autonomy conflicts with profit maximization.