Twenty-eight years after Oregon’s Death with Dignity Act, the implementation of MAID across fourteen U.S. jurisdictions demonstrates a notable pattern: legal authorization, while essential, does not automatically translate to accessible services. The barriers documented in this landscape analysis— information gaps, provider shortages, limited pharmacy capacity, insurance coverage exclusions, institutional restrictions, and geographic constraints—are not inherent to MAID but reflect implementation choices that vary across jurisdictions.
The current implementation of MAID depends heavily on dedicated individual practitioners: providers traveling thousands of miles monthly, pharmacists personally delivering medications statewide, volunteers attending deaths, and coordinators building relationships through sustained personal outreach. These individuals demonstrate extraordinary commitment and have enabled services to develop despite limited infrastructure. However, individual dedication cannot substitute for systematic implementation—adequate provider training pipelines, reliable pharmacy networks, sustainable organizational funding, and insurance coverage that enable equitable access.
Current models raise sustainability questions. Providers report cutting practices to accommodate time-intensive MAID work, absorbing financial costs through sliding scales or pro-bono care, processing emotional demands without institutional support, and working extended hours including nights and weekends. Patient navigation networks have transitioned from volunteer to fee-based models as demand has exceeded volunteer capacity. These patterns suggest that sustainable implementation requires systematic infrastructure: training integrated into medical education, insurance coverage enabling provider compensation, organizational capacity supporting professional staffing, and institutional recognition of the time and expertise required. Implementation Insights This analysis identified several factors associated with more effective implementation methods: • Pre-Implementation Planning States that engage pharmacies, hospices, and providers before authorization can offer services from day one—rather than scrambling to build infrastructure after the fact
• Organizational Infrastructure Dedicated staffing and sustainable funding support consistent provider recruitment, patient navigation, and stakeholder engagement
• Training Integration Incorporating MAID into existing medical education structures normalizes practice and builds provider pipelines
• Stakeholder Collaboration Sustained relationship-building with hospices, pharmacies, and healthcare systems facilitates integration • Data Collection Systematic outcome monitoring enables evidence-based program refinement
• Policy Refinement States with implementation experience have made targeted policy adjustments based on identified challenges
Looking Forward As MAID becomes available in additional jurisdictions, implementation experiences from existing states offer valuable insights. The transition from pioneering implementation that remains dependent on individual commitment enables sustainable, equitable access and represents an ongoing evolution. How jurisdictions address the implementation challenges documented here—through pre-implementation planning, organizational development, training integration, insurance coverage, data collection, stakeholder engagement, and policy refinement—will shape how legal authorization translates to meaningful access for all eligible patients who choose MAID as an end-of-life option.
With gratitude to and attribution from Sarah Kiskaden-Bechtel. Please read the complete analysis at: https://completedlife.org/an-investigative-analysis-of-implementation-barriers-across-u-s-jurisdictions-where-medical-aid-in-dying-is-legal/
