As of this writing, medical aid in dying (MAID) is available in 11 U.S. states and the District of Columbia, with further expansion projected. Legal protections for conscientious objection foreground clinician attitudes as substantial barriers or facilitators to MAID access for interested patients. Although upward of roughly three quarters of patients who use MAID are enrolled in hospice care, little is known about hospice clinicians’ attitudes toward MAID. The purpose of this three-paper dissertation was to examine attitudes toward MAID in a national sample of hospice clinicians. Participants were recruited from national hospice and palliative care membership associations representing the four core disciplines of the hospice interdisciplinary group (i.e., medicine, nursing, social work, chaplaincy) to complete a one-time, self-administered survey. Paper 1 examined the preliminary psychometric properties of a modified version of the only empirically evaluated scale on attitudes toward MAID. Confirmatory factor analysis results indicated that the Attitudes Toward Medical Aid in Dying Scale demonstrated factorial validity. Construct validity was established through correlation analyses targeting convergent validity (vis-à-vis a researcher-constructed measure of attitudes toward MAID) and discriminant validity (vis-à-vis a researcher-constructed measure of attitudes toward euthanasia and a scale assessing religiosity). High congeneric reliability estimates supported internal consistency reliability. Despite the favorability of these statistical results, conceptual mismatches between scale items and the U.S. practice context as defined by state laws caution against wider scale use. Further psychometric development is warranted.

Paper 2 explored institutional factors tied to the hospice context of care as correlates of MAID attitudes. Using a 3-point version of Paper 1’s ordinal convergent validity item, results of a partial proportional odds model indicated that professional experience working in a state where MAID was legal and increased orientation toward patient-centeredness were both significantly associated with higher odds of more supportive MAID attitudes across each threshold of the dependent variable. Increased commitment to the hospice philosophy of care also was significantly associated with higher odds of more supportive MAID attitudes. Accounting for differing slopes across dependent variable thresholds, however, this association reached statistical significance only when estimating the odds of being in a category above the midpoint response option (neither support nor oppose). Findings support the assessment of ecological factors that drive hospice ethos and functioning when exploring attitudes toward MAID.

Paper 3 explored attitudes toward being physically present throughout MAID in a hypothetical patient scenario governed by certain safeguards. The 74% of participants who indicated willingness to be present did so based on feelings of personally derived support for MAID, definitions of quality clinical care, and values from their professional training. This broad support, however, was conditioned by boundary setting though which participants described specific conditions required for their participation. In contrast, 15% of participants were unwilling to be present. These attitudes were attributed to objections to the concept of MAID, objections to participation in MAID, and perceptions that MAID is misaligned with health care. Merely 11% of participants were unsure, relating their hesitation to feelings of ambivalence and a lack of experience with MAID. The tensions that participants across samples reported experiencing with themselves, their profession, and broader society reflect a need for greater professional guidance on the safe and effective provision of MAID.