2025 Report: An Investigative Analysis of Implementation Barriers Across U.S. Jurisdictions Where Medical Aid in Dying is Legal

Last year, the Completed Life Initiative commissioned Sarah J. Kiskadden-Bechtel, MBe to conduct a landscape analysis of common barriers and best practices of medical aid in dying (MAID) in the United States. As a bioethicist with over a decade of experience in end-of-life policy and care, Kiskadden-Bechtel holds a Master of Science in Bioethics from Columbia University and now serves as Executive Director of the Academy of Aid-in-Dying Medicine.

This landscape analysis examines MAID across the 10 states where the practice was legal as of December 2025, plus the District of Columbia. Interviews were conducted with 25 MAID experts with a diverse array of professional backgrounds over a four month period.

Evaluating 28 years of MAID history, which began with Oregon’s 1997 law, the analysis reveals through interviews, utilization data, and policy documents that legalization alone does not ensure equitable access to MAID. Despite diverse legal approaches and geographies across jurisdictions, consistent barriers emerge across all settings, preventing eligible patients from accessing this end-of-life option.

Main Barriers to Accessing MAID

• Most providers operate under a “don’t ask, don’t tell” MAID culture, even though there is no law requiring silence.
• MAID is not typically included in medical school curricula, forcing clinicians to re-invent processes independently which results in inconsistent quality standards.
• Many hospices and hospital systems do not support MAID and force terminally ill patients interested in MAID to switch providers at a critical time in their care.
• There is a federal prohibition on Medicare/Medicaid being used for MAID services, and most commercial insurance companies do not cover MAID services.
• Training gaps, institutional prohibitions, the emotional toll, and the time-intensive nature of MAID services contribute to provider shortages and burnout.
• MAID implementation often has better results when there is a waiting period between when the law is passed and when the law goes into effect because jurisdictions have time to organize providers, recruit pharmacies, and clarify law details.

In order to make MAID realistically accessible, our recommendations include increasing clinical education on MAID, standardizing goals-of-care conversations with patients to include MAID as one of many end-of-life options, expanding professional infrastructure for MAID practitioners to decrease burnout, recruiting more pharmacies to provide MAID medications, developing hospice partnerships, and creating public awareness campaigns. 

As MAID becomes available in additional jurisdictions—which is happening in Delaware, New York, and Illinois in 2026—implementation experiences from existing states offer valuable insights. Right now, MAID implementation is largely dependent on individual commitment instead of systematic, replicable infrastructure. How jurisdictions address the implementation challenges documented in the report will shape how legal authorization translates to meaningful access for all eligible patients who choose MAID as an end-of-life option.