Traveling To Die: The Latest Form of Medical Tourism
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In the 18 months after Francine Milano was diagnosed with a recurrence of the ovarian cancer she thought she’d beaten 20 years ago, she traveled twice from her home in Pennsylvania to Vermont. She went not to ski, hike, or leaf-peep, but to arrange to die.
“I really wanted to take control over how I left this world,” said the 61-year-old who lives in Lancaster. “I decided that this was an option for me.”
Dying with medical assistance wasn’t an option when Milano learned in early 2023 that her disease was incurable. At that point, she would have had to travel to Switzerland — or live in the District of Columbia or one of the 10 states where medical aid in dying was legal.
But Vermont lifted its residency requirement in May 2023, followed by Oregon two months later. (Montana effectively allows aid in dying through a 2009 court decision, but that ruling doesn’t spell out rules around residency. And though New York and California recently considered legislation that would allow out-of-staters to secure aid in dying, neither provision passed.)
Despite the limited options and the challenges — such as finding doctors in a new state, figuring out where to die, and traveling when too sick to walk to the next room, let alone climb into a car — dozens have made the trek to the two states that have opened their doors to terminally ill nonresidents seeking aid in dying.
At least 26 people have traveled to Vermont to die, representing nearly 25% of the reported assisted deaths in the state from May 2023 through this June, according to the Vermont Department of Health. In Oregon, 23 out-of-state residents died using medical assistance in 2023, just over 6% of the state total, according to the Oregon Health Authority.
Oncologist Charles Blanke, whose clinic in Portland is devoted to end-of-life care, said he thinks that Oregon’s total is likely an undercount and he expects the numbers to grow. Over the past year, he said, he’s seen two to four out-of-state patients a week — about one-quarter of his practice — and fielded calls from across the U.S., including New York, the Carolinas, Florida, and “tons from Texas.” But just because patients are willing to travel doesn’t mean it’s easy or that they get their desired outcome.
“The law is pretty strict about what has to be done,” Blanke said.
As in other states that allow what some call physician-assisted death or assisted suicide, Oregon and Vermont require patients to be assessed by two doctors. Patients must have less than six months to live, be mentally and cognitively sound, and be physically able to ingest the drugs to end their lives. Charts and records must be reviewed in the state; neglecting to do so constitutes practicing medicine out of state, which violates medical licensing requirements. For the same reason, the patients must be in the state for the initial exam, when they request the drugs, and when they ingest them.
State legislatures impose those restrictions as safeguards — to balance the rights of patients seeking aid in dying with a legislative imperative not to pass laws that are harmful to anyone, said Peg Sandeen, CEO of the group Death With Dignity. Like many aid-in-dying advocates, however, she said such rules create undue burdens for people who are already suffering.
Diana Barnard, a Vermont palliative care physician, said some patients cannot even come for their appointments. “They end up being sick or not feeling like traveling, so there’s rescheduling involved,” she said. “It’s asking people to use a significant part of their energy to come here when they really deserve to have the option closer to home.”
Those opposed to aid in dying include religious groups that say taking a life is immoral, and medical practitioners who argue their job is to make people more comfortable at the end of life, not to end the life itself.
Anthropologist Anita Hannig, who interviewed dozens of terminally ill patients while researching her 2022 book, “The Day I Die: The Untold Story of Assisted Dying in America,” said she doesn’t expect federal legislation to settle the issue anytime soon. As the Supreme Court did with abortion in 2022, it ruled assisted dying to be a states’ rights issue in 1997.
During the 2023-24 legislative sessions, 19 states (including Milano’s home state of Pennsylvania) considered aid-in-dying legislation, according to the advocacy group Compassion & Choices. Delaware was the sole state to pass it, but the governor has yet to act on it.
Sandeen said that many states initially pass restrictive laws — requiring 21-day wait times and psychiatric evaluations, for instance — only to eventually repeal provisions that prove unduly onerous. That makes her optimistic that more states will eventually follow Vermont and Oregon, she said.
Milano would have preferred to travel to neighboring New Jersey, where aid in dying has been legal since 2019, but its residency requirement made that a nonstarter. And though Oregon has more providers than the largely rural state of Vermont, Milano opted for the nine-hour car ride to Burlington because it was less physically and financially draining than a cross-country trip.
The logistics were key because Milano knew she’d have to return. When she traveled to Vermont in May 2023 with her husband and her brother, she wasn’t near death. She figured that the next time she was in Vermont, it would be to request the medication. Then she’d have to wait 15 days to receive it.
The waiting period is standard to ensure that a person has what Barnard calls “thoughtful time to contemplate the decision,” although she said most have done that long before. Some states have shortened the period or, like Oregon, have a waiver option.
That waiting period can be hard on patients, on top of being away from their health care team, home, and family. Blanke said he has seen as many as 25 relatives attend the death of an Oregon resident, but out-of-staters usually bring only one person. And while finding a place to die can be a problem for Oregonians who are in care homes or hospitals that prohibit aid in dying, it’s especially challenging for nonresidents.
When Oregon lifted its residency requirement, Blanke advertised on Craigslist and used the results to compile a list of short-term accommodations, including Airbnbs, willing to allow patients to die there. Nonprofits in states with aid-in-dying laws also maintain such lists, Sandeen said.
Milano hasn’t gotten to the point where she needs to find a place to take the meds and end her life. In fact, because she had a relatively healthy year after her first trip to Vermont, she let her six-month approval period lapse.
In June, though, she headed back to open another six-month window. This time, she went with a girlfriend who has a camper van. They drove six hours to cross the state border, stopping at a playground and gift shop before sitting in a parking lot where Milano had a Zoom appointment with her doctors rather than driving three more hours to Burlington to meet in person.
“I don’t know if they do GPS tracking or IP address kind of stuff, but I would have been afraid not to be honest,” she said.
That’s not all that scares her. She worries she’ll be too sick to return to Vermont when she is ready to die. And, even if she can get there, she wonders whether she’ll have the courage to take the medication. About one-third of people approved for assisted death don’t follow through, Blanke said. For them, it’s often enough to know they have the meds — the control — to end their lives when they want.
Milano said she is grateful she has that power now while she’s still healthy enough to travel and enjoy life. “I just wish more people had the option,” she said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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21 Most Beneficial Polyphenols & What Foods Have Them
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We often write about polyphenols here at 10almonds; sometimes mentioning that a certain food is good because it has them, or else occasionally an entire article about a particular polyphenol. But what about a birds-eye view of polyphenols as a whole?
Well, there are many, but we’ve picked 21 particularly beneficial for human health, and what foods contain them.
We’ll be working from this fantastic database, by the way:
❝Phenol-Explorer is the first comprehensive database on polyphenol content in foods. The database contains more than 35,000 content values for 500 different polyphenols in over 400 foods. These data are derived from the systematic collection of more than 60,000 original content values found in more than 1,300 scientific publications. Each of these publications has been critically evaluated before inclusion in the database. The whole data on the polyphenol composition of foods is available for download.❞
Source: Phenol-Explorer.EU | Database on polyphenol content in foods
We use this database at least several times per week while writing 10almonds; it’s a truly invaluable resource!
However, 500 is a lot, so here’s a rundown of 21 especially impactful ones; we’ve sorted them per the categories used in the explorer, and in some cases we’ve aggregated several very similar polyphenols typically found together in the same foods, into one item (so for example we just list “quercetin” instead of quercetin 3-O-rutinoside + quercetin 4′-O-glucoside + quercetin 3,4′-O-diglucoside, etc etc). We’ve also broadly grouped some particularly populous ones such as “anthocyanins”, “catechins”, and so forth.
Without further ado, here’s what you ideally want to be getting plenty of in your diet:
Flavonoids
- Quercetin
- Foods: onions, apples, berries, kale, broccoli, capers.
- Benefits: anti-inflammatory, reduces allergy symptoms, supports heart and brain health, and may lower blood pressure.
- See also: Fight Inflammation & Protect Your Brain, With Quercetin
- Kaempferol
- Foods: spinach, kale, tea (green and black), capers, brussels sprouts.
- Benefits: antioxidant, may reduce the risk of cancer, supports cardiovascular health, and has anti-inflammatory properties.
- Epigallocatechin gallate (EGCG)
- Foods: green tea, matcha.
- Benefits: potent antioxidant, promotes weight loss, supports brain health, and may reduce the risk of heart disease.
- Anthocyanins
- Foods: blueberries, blackberries, raspberries, red cabbage, cherries.
- Benefits: improve brain health, support eye health, and reduce the risk of cardiovascular diseases.
- Apigenin
- Foods: parsley, celery, chamomile tea.
- Benefits: anti-inflammatory, reduces anxiety, and supports brain and immune system health.
- Luteolin
- Foods: peppers, thyme, celery, carrots.
- Benefits: anti-inflammatory, supports brain health, and may help reduce the growth of cancer cells.
- Catechins (aside from EGCG)
- Foods: green tea, dark chocolate, apples
- Benefits: boosts metabolism, supports cardiovascular health, and reduces oxidative stress.
- Hesperidin
- Foods: oranges, lemons, limes, grapefruits.
- Benefits: supports vascular health, reduces inflammation, and may help manage diabetes.
- Naringenin
- Foods: oranges, grapefruits, tomatoes.
- Benefits: antioxidant, supports liver health, and may improve cholesterol levels.
For more on epigallocatechin gallate and other catechins, see: Which Tea Is Best, By Science?
Phenolic Acids
- Chlorogenic acid
- Foods: coffee, artichokes, apples, pears.
- Benefits: supports weight management, improves blood sugar regulation, and reduces inflammation.
- See also: Green Coffee Bean Extract: Coffee Benefits Without The Coffee?
- Caffeic acid
- Foods: coffee, thyme, sage, basil.
- Benefits: antioxidant, anti-inflammatory, and supports skin health.
- See also: The Bitter Truth About Coffee (or is it?)
- Ferulic acid
- Foods: whole grains, rice bran, oats, flaxseeds, spinach.
- Benefits: protects skin from UV damage, reduces inflammation, and supports cardiovascular health.
- Gallic acid
- Foods: green tea, berries, walnuts.
- Benefits: antioxidant, may reduce the risk of cancer, and supports brain health.
Stilbenes
- Resveratrol
- Foods: red currants, blueberries, peanuts.
- Benefits: anti-aging properties, supports heart health, and reduces inflammation.
- See also: Resveratrol & Healthy Aging ← and no, you can’t usefully get it from red wine; here’s why!
Lignans
- Secoisolariciresinol
- Foods: flaxseeds, sesame seeds, whole grains.
- Benefits: supports hormone balance, reduces the risk of hormone-related cancers, and promotes gut health.
- Matairesinol
- Foods: rye, oats, barley, sesame seeds.
- Benefits: hormonal support, antioxidant, and may reduce the risk of cardiovascular diseases.
See also: Sprout Your Seeds, Grains, Beans, Etc ← for maximum nutritional availability!
Tannins
- Ellagic acid
- Foods: pomegranates, raspberries, walnuts.
- Benefits: anti-cancer properties, supports skin health, and reduces inflammation.
- Proanthocyanidins
- Foods: cranberries, apples, grapes, dark chocolate.
- Benefits: supports urinary tract health, reduces inflammation, and improves blood vessel health.
See also: Enjoy Bitter Foods For Your Heart & Brain
Curcuminoids
- Curcumin
- Foods: turmeric.
- Benefits: potent anti-inflammatory, supports joint health, and may reduce the risk of chronic diseases.
- See also: Why Curcumin (Turmeric) Is Worth Its Weight In Gold
Isoflavones
- Genistein
- Foods: soybeans, chickpeas.
- Benefits: supports bone health, reduces the risk of hormone-related cancers, and promotes heart health.
- Daidzein
- Foods: soybeans, legumes.
- Benefits: hormonal balance, supports bone health, and may help alleviate menopausal symptoms.
See also: What Does “Balance Your Hormones” Even Mean?
Well, that’s a lot of things to remember!
If you want to make it easier for yourself, you can simply make sure to get at least 30 different kinds of plant into your diet per week, and by doing so, statistically, you should cover most of these!
Read more: What’s Your Plant Diversity Score?
Alternatively, for a middle-ground approach of targetting 16 most polyphenol delivering foods, check out this super-dense arrangement:
Mediterranean Diet… In A Pill? ← it’s about plant extracts from 16 specific foods, and the polyphenols they deliver
Enjoy!
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Dopamine Nation – by Dr. Anna Lembke
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We live in an age of abundance, though it often doesn’t feel like it. Some of that is due to artificial scarcity, but a lot of it is due to effectively whiting out our dopamine circuitry through chronic overuse.
Psychiatrist Dr. Anna Lembke explores the neurophysiology of pleasure and pain, and how each can (and does) lead to the other. Is the answer to lead a life of extreme neutrality? Not quite.
Rather, simply by being more mindful of how we seek each (yes, both pleasure and pain), we can leverage our neurophysiology to live a better, healthier life—and break/avoid compulsive habits, while we’re at it.
That said, the book itself is quite compelling reading, but as Dr. Lembke shows us, that certainly doesn’t have to be a bad thing.
Bottom line: if you sometimes find yourself restlessly cycling through the same few apps (or TV channels) looking for dopamine that you’re not going to find there, this is the book for you.
Click here to check out Dopamine Nation, and get a handle on yours!
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Gravitas – by Caroline Goyder
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A no-nonsense guide to (more than!) public speaking that isn’t just “tell jokes in your speech and imagine the audience naked”.
Because this isn’t just about speech-writing or speech delivery, so much as giving you important life skills. The kind that weren’t taught in school, but that nevertheless make a huge impact on success… whether you’re giving a presentation or hosting a party or negotiating a deal or just attending a social event. Or making a phonecall, even.
Whereas a lot of books of this kind treat “the audience” as a nebulous and purely responsive passive crowd of extras, Goyder does better. People are individuals, even if they’re all facing the same way for a moment. She works with that! She also teaches how to deal with not just hecklers, but also simply those people who sap your confidence and find fault with you and anything you do or say.b
Bottom line is: if you for whatever reason communicate with people, and would like them to think better of you, this is the book for you.
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Apricot vs Banana – Which is Healthier?
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Our Verdict
When comparing apricot to banana, we picked the banana.
Why?
Both are great, and it was close!
In terms of macros, apricot has more protein, while banana has more carbs and fiber; both are low glycemic index foods, and we’ll call this category a tie.
In the category of vitamins, apricot has more of vitamins A, C, E, and K, while banana has more of vitamins B1, B2, B3, B5, B6, B7, B9, and choline, giving banana the win by strength of numbers. It’s worth noting though that apricots are one of the best fruits for vitamin A in particular.
When it comes to minerals, apricot has slightly more calcium, iron, and zinc, while banana has a lot more magnesium, manganese, potassium, and selenium, meaning a moderate win for banana here.
Adding up the sections makes for an overall win for banana—but of course, by all means enjoy either or both!
Want to learn more?
You might like to read:
Top 8 Fruits That Prevent & Kill Cancer ← we argue for apricots as bonus number 9 on the list
Take care!
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Applesauce vs Cranberry Sauce – Which is Healthier?
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Our Verdict
When comparing applesauce to cranberry sauce, we picked the applesauce.
Why?
It mostly comes down to the fact that apples are sweeter than cranberries:
In terms of macros, they are both equal on fiber (both languishing at a paltry 1.1g/100g), and/but cranberry sauce has 4x the carbs, of which, more than 3x the sugar. Simply, cranberry sauce recipes invariably have a lot of added sugar, while applesauce recipes don’t need that. So this is a huge relative win for applesauce (we say “relative” because it’s still not great, but cranberry sauce is far worse).
In the category of vitamins, applesauce has more of vitamins B1, B2, B5, B6, B9, and C, while cranberry sauce has more of vitamins E, K, and choline. A more moderate win for applesauce this time.
When it comes to minerals, applesauce has more calcium, copper, magnesium, phosphorus, and potassium, while cranberry sauce has more iron, manganese, and selenium. Another moderate win for applesauce.
Since we’ve discussed relative amounts rather than actual quantities, it’s worth noting that neither sauce is a good source of vitamins or minerals, and neither are close to just eating the actual fruits. Just, cranberry sauce is the relatively more barren of the two.
While cranberries famously have some UTI-fighting properties, you cannot usefully gain this benefit from a sauce that (with its very high sugar content and minimal fiber) actively feeds the very C. albicans you are likely trying to kill.
All in all, a pitiful show of nutritional inadequacy from these two products today, but one is relatively less bad than the other, and that’s the applesauce.
Want to learn more?
You might like to read:
From Apples to Bees, and High-Fructose Cs: Which Sugars Are Healthier, And Which Are Just The Same?
Enjoy!
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The Autoimmune Cure – by Dr. Sara Gottfried
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We’ve featured Dr. Gottfried before, as well as another of her books (“Younger”), and this one’s a little different, and on the one hand very specific, while on the other hand affecting a lot of people.
You may be thinking, upon reading the subtitle, “this sounds like Dr. Gabor Maté’s ideas” (per: “When The Body Says No”), and 1) you’d be right, and 2) Dr. Gottfried does credit him in the introduction and refers back to his work periodically later.
What she adds to this, and what makes this book a worthwhile read in addition to Dr. Maté’s, is looking clinically at the interactions of the immune system and nervous system, but also the endocrine system (Dr. Gottfried’s specialty) and the gut.
Another thing she adds is more of a focus on what she writes about as “little-t trauma”, which is the kind of smaller, yet often cumulative, traumas that often eventually add up over time to present as C-PTSD.
While “stress increases inflammation” is not a novel idea, Dr. Gottfried takes it further, and looks at a wealth of clinical evidence to demonstrate the series of events that, if oversimplified, seem unbelievable, such as “you had a bad relationship and now you have lupus”—showing evidence for each step in the snowballing process.
The style is a bit more clinical than most pop-science, but still written to be accessible to laypersons. This means that for most of us, it might not be the quickest read, but it will be an informative and enlightening one.
In terms of practical use (and living up to its subtitle promise of “cure”), this book does also cover all sorts of potential remedial approaches, from the obvious (diet, sleep, supplements, meditation, etc) to the less obvious (ketamine, psilocybin, MDMA, etc), covering the evidence so far as well as the pros and cons.
Bottom line: if you have or suspect you may have an autoimmune problem, and/or would just like to nip the risk of such in the bud (especially bearing in mind that the same things cause neuroinflammation and thus, putatively, depression and dementia too), then this is one for you.
Click here to check out the Autoimmune Cure, and take care of your body and mind!
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