Abstract Rationale While life-sustaining treatment (LST) decisions are frequently made in hospital settings for patients lacking decision-making capacity, there is limited understanding about state-level regulations which govern these decisions. We aimed to investigate 1) the presence of any guidance for how to make medical decisions about life-sustaining treatment for patients lacking decision-making capacity at the state level, and 2) decision priority granted to previously stated patient instructions and surrogate decision-makers for medical care in these situations. Methods Between March and May 2025, we used Justia and official US state government websites to identify the most current statutes for all US states and Washington D.C. that addressed decisions to maintain or withdraw LST (e.g. cardiopulmonary resuscitation, artificial nutrition and hydration) from incapacitated patients. Two reviewers independently identified regulations surrounding incapacitated patients within each statute and themes involving authority of previously stated patient instructions and authority of surrogate decision-makers regarding LST decisions. Disagreements were resolved with consensus adjudication. Results We found a mention of incapacitated patients at least once in each state’s statutes. We subsequently organized themes into two groups: guidance requiring adherence to patient instructions (written and verbal) for LST decisions and guidance granting greater authority to surrogate judgement over patient instructions regarding LST decisions. Each state was then placed on a continuum based on the number of themes identified within each group (Figure 1). Within the 24 (47%) states with statutes regulating surrogate decision-making for incapacitated patients, 15 (29%) explicitly allow surrogates to execute a Do Not Resuscitate (DNR) order for an incapacitated patient, while 11 (22%) allow surrogates to revoke a DNR order, and 12 (24%) specify that patients’ advance directives or previously stated wishes must be followed. Twenty-two (43%) states govern nutrition and hydration separately from other types of LST, with 15 (29.4%) placing restrictions on surrogates instructing the withdrawal of nutrition/hydration and 7 (13.7%) instructing that known patient wishes regarding nutrition/hydration must be followed. Sixteen (31%) states provide avenues to others known to the patient to contest surrogate decisions or authority in court. Few states (4, 7.8%) differentiate between the authority of surrogates designated by the patient or not. Conclusions While all states have codified at least one statute regarding LST decision-making for incapacitated patients, the presence and content of these regulations vary. State-level differences in how much authority is granted surrogates to follow or overrule patient wishes are substantial and likely have important consequences for patient care. This abstract is funded by: None
Park-Egan et al. (Fri,) studied this question.