Medical aid in dying brings a compassionate close to life

In May 2025, Delaware’s governor signed legislation to make it the 11th state to legalize medical assistance in dying (MAiD). This end-of-life option will now be available to more than 1 in 5 Americans. Since Oregon first authorized MAiD in 1997, legalization has steadily expanded—with nine states and the District of Columbia adopting similar laws since 2013 and 14 others currently considering related legislation.

The momentum reaches beyond the United States. In November 2024, British lawmakers advanced a landmark bill to legalize assisted dying in England and Wales. If passed, England and Wales will join 19 other countries and jurisdictions around the world where MAiD is legal.

As this movement gains traction, psychologists are taking on crucial roles in end-of-life care. They conduct assessments of patients’ capacity to consent to MAiD and collaborate closely with other providers. They also provide necessary emotional support to both patients and their families. By clearly understanding and communicating the patient’s wishes, psychologists create a supportive environment centered on patient well-being and autonomy.

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“Assistance in dying” and “assisted suicide” are often used interchangeably but there are critical differences. Assisted suicide—illegal in all U.S. states—is the term commonly used when a person actively aids another person in ending their life. For example, this could involve a person providing a lethal dose of medication to a patient living in a state where MAiD is not legal or to a patient living in a MAiD state who is too deteriorated to self-administer the lethal drugs.

MAiD, in contrast, involves a medical professional prescribing medication to a terminally ill patient to self-administer at a time of their choosing (that is, sooner than might occur from their disease’s natural progression). MAiD is a patient-centered process that gives terminally ill patients autonomy and control over their end-of-life health care options, avoiding excruciating or prolonged suffering.

In the United States, MAiD consists of a series of steps and safeguards to ensure a patient’s decision to end their life meets legal and ethical requirements. A terminally ill patient requesting MAiD must:

• Be at least 18 years old;
• Be a resident of the state where they wish to die (Oregon and Vermont are the only states that exempt the residency requirement);
• Have a prognosis of 6 months or less left to live (to be determined by two health care providers according to jurisdiction requirements);
• Demonstrate the capacity to consent (as determined by the prescribing physician);
• Be able to administer a lethal dose without assistance.

Hawaii is the only state that requires a mental health evaluation of all MAiD patients. Other states require it only if the prescribing physician doubts a patient’s ability to provide informed consent. In these instances, a licensed psychiatrist or psychologist would perform a capacity evaluation to ensure that the patient’s judgment is not impaired by any cognitive or psychological concerns. In addition, patients must provide a written statement (witnessed by another person) to at least two qualified clinicians confirming their understanding and decision. Once all of these requirements are met, the physician can prescribe the medication that the patient will self-administer (Treem, J., Journal of the Advanced Practitioner in Oncology, Vol. 14, No. 3, 2023opens in new window).

Psychologists play a critical role in ensuring that MAiD decisions are made in a way that meets these requirements while honoring the patient’s autonomy. “Desire for hastened death is not the same thing as suicidal ideation. That and assessment of capacity are huge areas in which psychology can be of great service, to better understand and ethically delineate those guardrails.” said Rebecca Allen, PhD, ABPP, a professor of psychology and executive director of the Alabama Research Institute on Aging.

“Suffering has different components to it. There’s the physical, which oftentimes people think about when they think about medical assistance in dying,” said Melissa Henry, PhD, a psychologist and associate professor at McGill University’s Gerald Bronfman Department of Oncology. “But there’s also the psychological, social, and existential aspects. There are a lot of fears that people experience when they’re thinking about the end of their life.”

A thorough evaluation of a patient’s suffering is crucial in MAiD, yet there is a dearth of standardized clinical practice guidelines. To address this gap, Henry coauthored a comprehensive scoping review of 537 clinical practice documents related to assisted dying (Psycho-Oncology, Vol. 32, No. 9, 2023opens in new window). The review revealed that while many interventions focused on active listening and managing physical symptoms, there was a notable absence of guidance on other aspects of suffering.

Recognizing this shortfall, Henry led a diverse group of researchers, clinicians, policymakers, patient representatives, and family caregivers at a 2-day Canadian Institutes of Health Research (CIHR)-funded research planning and dissemination conference followed by the Delphi Study (PDF, 2.61MB)opens in new window. This collaborative effort resulted in a report featuring 15 sets of recommendations aimed at alleviating all facets of suffering for MAiD recipients. Key recommendations included integrating social determinants of health into MAiD evaluations and introducing psychosocial care services early in the disease trajectory.

“I have tremendous humility and respect for the difficulty, vulnerability, and fear [patients experience],” said Steven Tovian, PhD, ABPP, a clinical health psychologist and professor of psychiatry and behavioral sciences at Northwestern University’s Feinberg School of Medicine. Tovian has more than 45 years of clinical experience working with cancer patients in terminal stages of their illness. “Being available to a patient at the end of their lives is truly a gift. It’s a humbling experience for me, and I treat it as such. I have no preconceived agenda items that I impose upon families or patients. I watch, I listen, and I let the patient lead.”

For a terminally ill patient, deciding how to end their final days is often the most challenging choice they will ever face. In addition, family and caregiver relationships add another layer of complexity, Tovian said, as each member may have strong opinions and feelings about end-of-life decisions and assisted dying, in particular. Many family members are struggling with anticipatory grief. Patients themselves may feel guilty about the strain their illness places on loved ones. “Many cancer patients at end of life feel that they’ve been a financial and emotional burden on their loved ones, and that is not sufficient reason,” said Tovian. “The burden needs to be looked at and evaluated and considered. Not that it should be ignored, but it’s not the reason why we help an individual to die.”

Researchers have found that the grief and bereavement experiences of families are affected by their closeness to the patient and interactions with their health care providers. Involving loved ones in the planning process for MAiD and allowing the death to serve as a meaningful ritual or ceremony for family and friends to say goodbye can be helpful (Yan, H., et al., BMJ Supportive & Palliative Care, Vol. 13, No. 4, 2023opens in new window).

“The emotional, psychological, and spiritual outcomes are largely dependent on the level of communication that has occurred, initially between the patient, their providers, the family, etc.,” said Allen. “The more a family can engage in advance planning and some of the meaning-making and relationship repairing or relationship building, the better.”

Tracy Franklin, PhD, ABPP, a geropsychologist who previously interfaced with End of Life Choices in Portland, Oregon, played a crucial role in supporting terminally ill patients and their families. Franklin advocates for compassionate discussions with family to find a path forward that everyone can accept even if full agreement isn’t possible. “We can’t make everybody in every situation feel good about it. But if we can make the patient feel good and everybody else feel okay, and that they will respect the patient’s wishes without cutting them off, then that’s a win,” she said.

Although MAiD accounts for less than 1% of deaths in the U.S. jurisdictions where it’s legal, public support is notably strong. An August 2024 Gallup pollopens in new window revealed 2 in 3 Americans believe doctors should be permitted to assist terminally ill patients to end their lives upon request. While there appears to be a broad public desire for MAiD, data show a lack of awareness that this is a legal end-of-life option.

Elissa Kozlov, PhD, a clinical psychologist and assistant professor at Rutgers School of Public Health, surveyed more than 3,200 people nationwide to gauge their awareness and attitudes toward MAiD (JAMA Network Open, Vol. 8, No. 2, 2025opens in new window). She oversampled individuals from underrepresented groups to better facilitate subgroup analyses. The results revealed a striking lack of awareness about MAiD’s legality.

More than half of 3,227 respondents (51.3%) were unsure if MAiD was legal in the United States, and 50.8% didn’t know if it was legal in their state. Those in states where MAiD is legal were more aware of its legality in the United States than those from states where it was not. Forty-four percent of overall respondents reported that they would consider MAiD if diagnosed with a terminal illness. This included 43.2% of Asian, 34.0% of Black, and 41.9% of Hispanic respondents.

According to Kozlov, these findings reveal a stark disconnect between those who desire MAiD as an end-of-life option and those who would use it if they knew about it. Better public education and awareness about MAiD’s availability may be required especially among diverse communities. “About 20% of all Americans live in a state where there’s legal health care available to them that they do not know about,” she said. “To me, that suggests that perhaps this legal health care option is not being implemented in an equitable way.”

Kozlov emphasized the need to prioritize the wishes of terminally ill patients at end of life. “We need to understand how MAiD fits into the end-of-life health care landscape, especially when thinking about patient-centered care,” said Kozlov. “People are dying in the hospital and are receiving aggressive discretionary treatments up until the day they die despite many people saying that this is not what they would want at end of life. More research is needed to better understand how MAiD fits into end-of-life care.”

Psychologists play a crucial role in providing compassionate care while also making sure that patients are competent to choose MAiD. Although capacity assessments are typically performed only when a physician doubts a patient’s ability to consent, psychologists are specifically trained to ensure that the patient’s decision is informed, voluntary, and unhindered by cognitive or mental health concerns.

To help ensure the integrity of the process, psychologists have developed multiple tools for evaluating patients’ capacity to consent to MAiD, such as a guide for creating optimal conditions—accounting for the patient’s limited energy, necessary accommodations such as glasses or hearing aids, and preferred style of communication (written, verbal, or both) (Carpenter, B., & Merz, C., in Moye, J. [Ed.], Assessing Capacities of Older Adults: A Casebook to Guide Difficult Decisions, APA, 2020opens in new window).

Evaluators must screen patients for four skills that demonstrate their decision-making capacity: the ability to understand relevant information, the ability to appreciate their disorder and its medical consequences, the ability to reason about their treatment options, and the ability to communicate a choice (Grisso, T., & Appelbaum, P. S., Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals, Oxford University Press, 1998).

Brian Goodyear, PhD, a clinical psychologist based in Honolulu, Hawaii, has been at the forefront of conducting capacity assessments since Hawaii legalized MAiD in 2018. Goodyear typically begins his evaluations by establishing a rapport with the patient. He then proceeds to conduct his assessment in three parts. First, he performs a brief mental status exam to rule out significant cognitive impairment. Next, he interviews patients about their illness, prognosis, and reasons for requesting MAiD and assesses their understanding of other palliative care options. He concludes with an exploration of the patient’s psychosocial history.

“I will always ask, ‘Is this entirely your decision?’ and ‘Have you been pressured in any way to make this decision?’” Goodyear said. This step ensures that patients, some of whom may be vulnerable because of illness, are not being coerced or manipulated.

Elissa Kolva, PhD, a clinical psychologist and associate professor of medicine at the University of Colorado Anschutz Medical Campus, has conducted significant research on decision-making capacity and psychological aspects of MAiD. Her work includes developing methods to assess decisional capacity in terminally ill patients who have requested assisted dying, particularly for those with complex psychological or cognitive issues (Journal of Aid-in-Dying Medicine, 2023 [PDF, 1.7MB]opens in new window).

The semistructured capacity assessment tool she and her coauthors developed provides a list of prompts to ascertain the patients’ understanding of their medical diagnosis, disease prognosis, what MAiD entails, including its benefits and risks, and other potential options.

Kolva has also contributed to efforts aimed at reducing patient burden in responding to capacity assessment questions, such as developing a shortened version of the Schedule of Attitudes Toward Hastened Death scale (Psychological Assessment, Vol. 29, No. 3, 2017opens in new window). Her research emphasizes the importance of efficiently assessing the desire for hastened death while also making sure the process is thorough and doesn’t cause patients unnecessary discomfort (The American Journal of Geriatric Psychiatry, Vol. 26, No. 5, 2018opens in new window).

Research indicates terminally ill patients who choose to use MAiD rarely lack the decision-making capacity to consent. Following California’s legalization of MAiD in 2015, the University of California, San Francisco’s UCSF Health required all MAiD requesters to undergo mandatory mental health assessments. A review of those patients’ records revealed none lacked decision-making capacity as a result of psychiatric conditions. The study’s authors concluded that mandatory mental health evaluations did not identify patients who were unable to make decisions about MAiD and may have created barriers for seriously ill patients. As a result, UCSF Health revised its policy to require mental health assessments only under specific clinical circumstances (Dinh, M. T., et al., Journal of the Academy of Consultation-Liaison Psychiatry, Vol. 66, No. 2, 2025opens in new window).

In Hawaii, mental health evaluations for all MAiD cases are mandatory. However, in a study published last year, Goodyear analyzed 161 cases for which he had conducted mental health evaluations. A tiny proportion of the patients (2.48%) were found to lack the necessary decisional capacity to consent because of rapid deterioration in their cognitive functioning after initial consultation with the attending provider (Journal of Forensic Psychology, Vol. 9, No. 1, 2024opens in new window). “I’ve come to the conclusion that mandatory mental capacity evaluations are not really necessary. Most of the patients, very clearly, do have the capacity,” Goodyear said. He added that in all his evaluations, he has never seen any patients who were so severely depressed that he had to disqualify them.

Kolva coauthored another study with 108 adults to better understand how brain functions affect decision-making in terminally ill cancer patients. More than half of them (58%) had advanced cancer and were receiving palliative care. While the terminally ill patients did have some impairments to brain function, these impairments were not related to their decision-making abilities (Archives of Clinical Neuropsychology, Vol. 35, No. 1, 2019opens in new window). These findings suggest that the necessity of blanket mental health assessments in MAiD cases may be minimal.

“The majority of folks facing serious illness and death are our older folks. People are very quick in our society to decide that older folks can’t make decisions for themselves, or don’t know what they’re doing. That only makes their experience psychologically, sometimes also physically, worse,” Franklin said. “Honoring people’s autonomy and their ability to make these decisions and to have relief from suffering, to me, is part of my duty as a psychologist in geriatrics and palliative care.”