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October 15, 2003

State Legislation and Use of Feeding Tubes in Cognitively Impaired Patients

Author Affiliations

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;290(15):1995-1996. doi:10.1001/jama.290.15.1995-a

To the Editor: In their nationwide US survey, Dr Mitchell and colleagues1 found that more than one third of severely cognitively impaired residents of nursing homes have feeding tubes. They also found that use of feeding tubes was influenced by several clinical, organizational, financial, and demographic characteristics.

However, the authors did not consider variation between states in whether this intervention is legally considered to be a "heroic measure." In New York State, for instance, the courts have ruled that the provision of artificial nutrition is not considered a heroic measure.2 This sets a higher legal standard to withhold feeding tubes. In this case, to withhold these basic provisions from a patient lacking capability or proxy to make health care decisions, one must rely on what the courts have termed clear and convincing evidence that the patient would refuse a feeding tube if able to express his or her views. This usually entails the next of kin certifying that they had previously had a specific conversation with the patient, who stated clearly that he or she would not want to receive tube feeding if they were incompetent and in a terminal state. When next of kin in such states are unable to meet this stringent criterion, physicians are then legally obligated to insert a feeding tube. By contrast, withholding of feeding tubes is much more feasible in states that have ruled that feeding tubes do represent a heroic measure.3,4

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