Mary Ware's death highlights an emerging debate over a key element of long-term care — whether facilities should force residents to take showers.

People with dementia often resist being bathed, and for many years it was considered standard nursing home practice to subject them to the kind of forced showering that Ware endured on her last day of life.

But in the last decade, more health care researchers have called for an end to "bathing people routinely against their wishes."

Registered nurse Joanne Rader has produced a textbook, "Bathing Without a Battle," and training videos for nursing homes that emphasize person-centered care — based on an individual's needs instead of the facility's. In a 2006 paper, she and co-authors said the physical pain that plagues most elderly residents is better addressed by a return to the age-old practice of towel baths given in bed.

"Many nursing home residents with dementia can't describe their pain verbally," they wrote, "leading to behavioral symptoms such as aggression, resisting care, and vocalizations."

"The issue isn't to get people to stop being aggressive during bathing," Rader said. "The issue is to make bathing pleasant. Yes, we have to get people clean; there's no question about that. But how and when we do it needs to be flexible — which means the CNAs are not taken to task if they don't put someone in the shower."

Rader said in some parts of the country, "it's unthinkable that there would be forced bathing anymore, but there are still pockets of settings" where directors of nursing or regulators consider it necessary.

The practice, she said, is based on "our societal belief that it takes a lot of water to get people clean. We do have that in our culture."

Rader said Ware could have been dying at the time she was sprayed in the face — but this would make a forced shower even harder to justify.

"A 96-year-old woman with terminal colon cancer: Where on the face of the earth did we get the idea this would be something good for her?" she asked.

Brian Lee, director of the advocacy group Families for Better Care, said too many Florida facilities pressure staff members to have residents fed and bathed according to rigid schedules.

"It's not dignified and it's uncaring," he said. "What happened to this woman seems to show a lack of compassion for her as a resident. It's not surprising that she died in this circumstance."

Philip D. Sloane, a professor in family medicine at UNC Chapel Hill, was among the first doctors to challenge standard bathing practices for dementia patients. But he resisted any assumption that the forced shower played a role in Ware's death.

"People are eager to attribute causation and blame when bad things happen," he said. "But the pathways leading to a bad event in a nursing home are usually complex and involve an interplay of many factors. Simple explanations are usually incorrect ones."