Balancing Life and Death: Hospice Responses to MAID and the Dialectics of Transparency

Background and Purpose: Although Medical Aid in Dying (MAID) is legal in Washington State, hospice organizations vary in whether—and how—they disclose their policies. State law requires hospices to establish internal MAID protocols but does not mandate public disclosure, resulting in inconsistent access for patients and families. While MAID’s role in end-of-life care continues to grow, no prior research has systematically examined how hospices disclose or frame these policies to the public. This study examines how institutional features influence MAID policy transparency and how hospices frame their policies. Guided by Van de Ven and Poole’s Dialectical Model of Organizational Change—which conceptualizes organizational adaptation as a synthesis of opposing forces (e.g., traditional hospice philosophy vs. patient autonomy)—this study asks: (1) Do institutional characteristics predict whether hospices disclose MAID policies? (2) Among disclosing hospices, how are those policies framed?

Methods: This mixed-methods study used an explanatory sequential design, where quantitative analysis informed qualitative exploration. The sample included 27 Medicare-certified hospices in Washington State. Data sources included Medicare Care Compare, the Washington State Department of Health, and hospice websites. Quantitative analysis used descriptive statistics and binary logistic regression to assess associations between MAID policy disclosure (yes/no) and hospice characteristics: profit status, NHPCO membership, organizational age, and service scope. The qualitative phase employed structured document analysis using the READ (Ready, Extract, Analyze, Distill) method. Public-facing materials were thematically coded and classified into four categories based on the language and institutional positioning used to frame (or omit) MAID policy information.

Results: Quantitative analysis revealed variability in disclosure. Fewer than two-thirds referenced MAID, and only 55.6% provided a complete policy document online. For-profit hospices had lower odds of disclosure—a relationship that approached statistical significance (OR = 0.15, p = .06). NHPCO membership and organizational age were associated with a higher likelihood of disclosure, though nonsignificantly. Findings from the qualitative study further revealed four distinct strategies. Proactive Adaptation (11.1%) hospices used affirming, values-based language and provided detailed, compassionate support for patients and staff. Strategic Adaptation (33.3%) hospices disclosed policies in neutral, compliance-focused terms emphasizing regulatory adherence without moral positioning. Dialectical Conflict (18.5%) hospices framed MAID as ethically incompatible with hospice, employing oppositional language (e.g., “suicide”) and imposing restrictions. In contrast, Dialectical Avoidance (37.1%) hospices omitted MAID entirely from public-facing materials despite filing policies with the state. This novel typology illustrates how hospices actively negotiate competing ethical, regulatory, and identity-based pressures through public communication, offering a new framework for understanding institutional responses to ethically contested care.

Conclusions and Implications: This study offers a conceptual framework for understanding how hospices publicly navigate ethically complex, policy-driven tensions around MAID. Disclosure practices are not merely procedural choices, but reflections of deeper institutional negotiations. Findings reveal how these practices may shape patient autonomy and care navigation at the end of life. The typology developed here offers a new lens for understanding institutional communication around morally contested care and may inform transparency initiatives and policy reforms across scenarios where organizational values and patient rights collide.