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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Radical CBT
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Radical Acceptance!
A common criticism of Cognitive Behavioral Therapy (CBT) is that much of it hinges on the following process:
- You are having bad feelings
- Which were caused by negative automatic thoughts
- Which can be taken apart logically
- Thus diffusing the feelings
- And then feeling better
For example:
- I feel like I’m an unwanted burden to my friend
- Because he canceled on me today
- But a reasonable explanation is that he indeed accidentally double-booked himself and the other thing wasn’t re-arrangeable
- My friend is trusting me to be an understanding friend myself, and greatly values my friendship
- I feel better and look forward to our next time together
But what if the negative automatic thoughts are, upon examination, reasonable?
Does CBT argue that we should just “keep the faith” and go on looking at a cruel indifferent world through rose-tinted spectacles?
Nope, there’s a back-up tool.
This is more talked-about in Dialectic Behavior Therapy (DBT), and is called radical acceptance:
Click Here If The Embedded Video Doesn’t Load automatically!
Radical acceptance here means accepting the root of things as true, and taking the next step from there. It follows a bad conclusion with “alright, and now what?”
“But all evidence points to the fact that my friend has been avoiding me for months; I really can’t ignore it or explain it away any longer”
“Alright. Now what?”- Maybe there’s something troubling your friend that you don’t know about (have you asked?)
- Maybe that something is nothing to do with you (or maybe it really is about you!)
- Maybe there’s a way you and he can address it together (how important is it to you?)
- Maybe it’s just time to draw a line under it and move on (with or without him)
Whatever the circumstances, there’s always a way to move forwards.
Feelings are messengers, and once you’ve received and processed the message, the only reason to keep feeling the same thing, is if you want to.
Note that this is true even when you know with 100% certainty that the Bad Thing™ is real and exactly as-imagined. It’s still possible for you to accept, for example:
“Alright, so this person really truly hates me. Damn, that sucks; I think I’ve been nothing but nice to them. Oh well. Shit happens.”
Feel all the feelings you need to about it, and then decide for yourself where you want to go from there.
Get: 25 CBT Worksheets To Help You Find Solutions To A Wide Variety of Problems
Recognizing Emotions
We talked in a previous edition of 10almonds’ Psychology Sunday about how an important part of dealing with difficult emotions is recognizing them as something that you experience, rather than something that’s intrinsically “you”.
But… How?
One trick is to just mentally (or out loud, if your current environment allows for such) greet them when you notice them:
- Hello again, Depression
- Oh, hi there Anxiety, it’s you
- Nice of you to join us, Anger
Not only does this help recognize and delineate the emotion, but also, it de-tooths it and recognizes it for what it is—something that doesn’t actually mean you any harm, but that does need handling.
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Chia Seeds vs Sunflower Seeds – Which is Healthier?
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Our Verdict
When comparing chia seeds to sunflower, we picked the chia.
Why?
It was close, and they both have their merits!
In terms of macros, chia has more carbs and a lot more fiber, while sunflower has a little more protein and a lot more fat. While the fat (in the seeds, not processed seed oils!) is mostly healthy polyunsaturated fat in both cases, chia has a lot more omega-3. All in all, we’re calling it a win for chia on macros.
In the category of vitamins, chia has more of vitmains B3 and C, while sunflower has ore of vitamins B1, B2, B9, and E. Thus, a win for sunflower seeds this time.
When it comes to minerals, chia has more calcium, iron, magnesium, manganese, phosphorus, and selenium, while sunflower has more copper, potassium, and zinc. A 6:3 win for chia here.
Adding up the sections makes for an overall win for chia, but by all means enjoy either or both; diversity is good!
Want to learn more?
You might like to read:
The Tiniest Seeds With The Most Value: If You’re Not Taking Chia, You’re Missing Out!
Take care!
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Heart Rate Zones, Oxalates, & More
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It’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝I think the heart may be an issue for lots of us. I know it is for me due to AFib. When I’m in my training zone like on a treadmill, I’m usually around 110 to 120. But there are occasionally times when I’m at 140 or 150. How dangerous is that? If I use that formula of 180 minus age, thats 103. I get nothing from that. My resting heart rate is in the 50 to 60 range.❞
First, for safety, let us draw attention to our medical disclaimer at the bottom of each email, and also specifically note that we are not cardiologists here, let alone your cardiologist. There’s a lot we can’t know or advise about. However, as general rules of thumb:
For people without serious health conditions, it is considered good and healthful for one’s heart rate to double (from its resting rate) during exercise, with even more than 2.5x resting rate being nothing more than a good cardio workout.
As for “180 minus age” (presuming you mean: to calculate the safe maximum heart rate), more common (and used by the American Heart Association) is 220 minus age. In your case, that’d give 143.
Having atrial fibrillation may change this however, and we can’t offer medical advice.
We can point to this AHA “AFib Resources For Patients and Professionals”, including this handy FAQ sheet which says:
“Am I able to exercise?” / “Yes, as long as you’re cleared by your doctor, you can perform normal activities of daily living that you can tolerate” (accompanied by a little graphic of a person using an exercise bike)
You personally probably know this already, of course, but it’s quite an extensive collection of resources, so we thought we’d include it.
It’s certainly a good idea for everyone to be aware of their healthy heart rate ranges, regardless of having a known heart condition or not, though!
American Heart Association: Target Heart Rates Chart
❝I would like to see some articles on osteoporosis❞
You might enjoy this mythbusting main feature we did a few weeks ago!
The Bare-Bones Truth About Osteoporosis
❝Interesting, but… Did you know spinach is high in oxylates? Some people are sensitive and can cause increased inflammation, joint pain or even kidney stones. Moderation is key. My sister and I like to eat healthy but found out by experience that too much spinach salad caused us joint and other aches.❞
It’s certainly good to be mindful of such things! For most people, a daily serving of spinach shouldn’t cause ill effects, and certainly there are other greens to eat.
We wondered whether there was a way to reduce the oxalate content, and we found:
How to Reduce Oxalic Acid in Spinach: Neutralizing Oxalates
…which led us this product on Amazon:
Nephure Oxalate Reducing Enzyme, Low Oxalate Diet Support
We wondered what “nephure” was, and whether it could be trusted, and came across this “Supplement Police” article about it:
Nephure Review – Oxalate Reducing Enzyme Powder Health Benefits?
…which honestly, seems to have been written as a paid advertisement. But! It did reference a study, which we were able to look up, and find:
In vitro and in vivo safety evaluation of Nephure™
…which seems to indicate that it was safe (for rats) in all the ways that they checked. They did not, however, check whether it actually reduced oxalate content in spinach or any other food.
The authors did declare a conflict of interest, in that they had a financial relationship with the sponsor of the study, Captozyme Inc.
All in all, it may be better to just have kale instead of spinach:
- 20 Foods High in Oxalates to Limit if You Have Kidney Stones
- The Kidney Dietician: The Best Low Oxalate Greens
We turn the tables and ask you a question!
We’ll then talk about this tomorrow:
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Hoisin Sauce vs Teriyaki Sauce – Which is Healthier?
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Our Verdict
When comparing hoisin sauce to teriyaki sauce, we picked the teriyaki sauce.
Why?
Neither are great! But spoonful for spoonful, the hoisin sauce has about 5x as much sugar.
Of course, exact amounts will vary by brand, but the hoisin will invariably be much more sugary than the teriyaki.
On the flipside, the teriyaki sauce may sometimes have slightly more salt, but they are usually in approximately the same ballpark of saltiness, so this is not a big deciding factor.
As a general rule of thumb, the first few ingredients will look like this for each, respectively:
Hoisin:
- Sugar
- Water
- Soybeans
Teriyaki:
- Soy sauce (water, soybeans, salt)
- Rice wine
- Sugar
In essence: hoisin is a soy-flavored syrup, while teriyaki is a sweetened soy sauce
Wondering about that rice wine? The alcohol content is negligible, sufficiently so that teriyaki sauce is not considered alcoholic. For health purposes, it is well under the 0.05% required to be considered alcohol-free.
For religious purposes, we are not your rabbi or imam, but to our best understanding, teriyaki sauce is generally considered kosher* (the rice wine being made from rice) and halal (the rice wine being de-alcoholized by the processing, making the sauce non-intoxicating).
Want to try some?
You can compare these examples side-by-side yourself:
Enjoy!
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Constipation increases your risk of a heart attack, new study finds – and not just on the toilet
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If you Google the terms “constipation” and “heart attack” it’s not long before the name Elvis Presley crops up. Elvis had a longstanding history of chronic constipation and it’s believed he was straining very hard to poo, which then led to a fatal heart attack.
We don’t know what really happened to the so-called King of Rock “n” Roll back in 1977. There were likely several contributing factors to his death, and this theory is one of many.
But after this famous case researchers took a strong interest in the link between constipation and the risk of a heart attack.
This includes a recent study led by Australian researchers involving data from thousands of people.
Elvis Presley was said to have died of a heart attack while straining on the toilet. But is that true? Kraft74/Shutterstock Are constipation and heart attacks linked?
Large population studies show constipation is linked to an increased risk of heart attacks.
For example, an Australian study involved more than 540,000 people over 60 in hospital for a range of conditions. It found constipated patients had a higher risk of high blood pressure, heart attacks and strokes compared to non-constipated patients of the same age.
A Danish study of more than 900,000 people from hospitals and hospital outpatient clinics also found that people who were constipated had an increased risk of heart attacks and strokes.
It was unclear, however, if this relationship between constipation and an increased risk of heart attacks and strokes would hold true for healthy people outside hospital.
These Australian and Danish studies also did not factor in the effects of drugs used to treat high blood pressure (hypertension), which can make you constipated.
Researchers have studied thousands of people to see if there’s a link between constipation and heart attacks. fongbeerredhot/Shutterstock How about this new study?
The recent international study led by Monash University researchers found a connection between constipation and an increased risk of heart attacks, strokes and heart failure in a general population.
The researchers analysed data from the UK Biobank, a database of health-related information from about half a million people in the United Kingdom.
The researchers identified more than 23,000 cases of constipation and accounted for the effect of drugs to treat high blood pressure, which can lead to constipation.
People with constipation (identified through medical records or via a questionnaire) were twice as likely to have a heart attack, stroke or heart failure as those without constipation.
The researchers found a strong link between high blood pressure and constipation. Individuals with hypertension who were also constipated had a 34% increased risk of a major heart event compared to those with just hypertension.
The study only looked at the data from people of European ancestry. However, there is good reason to believe the link between constipation and heart attacks applies to other populations.
A Japanese study looked at more than 45,000 men and women in the general population. It found people passing a bowel motion once every two to three days had a higher risk of dying from heart disease compared with ones who passed at least one bowel motion a day.
How might constipation cause a heart attack?
Chronic constipation can lead to straining when passing a stool. This can result in laboured breathing and can lead to a rise in blood pressure.
In one Japanese study including ten elderly people, blood pressure was high just before passing a bowel motion and continued to rise during the bowel motion. This increase in blood pressure lasted for an hour afterwards, a pattern not seen in younger Japanese people.
One theory is that older people have stiffer blood vessels due to atherosclerosis (thickening or hardening of the arteries caused by a build-up of plaque) and other age-related changes. So their high blood pressure can persist for some time after straining. But the blood pressure of younger people returns quickly to normal as they have more elastic blood vessels.
As blood pressure rises, the risk of heart disease increases. The risk of developing heart disease doubles when systolic blood pressure (the top number in your blood pressure reading) rises permanently by 20 mmHg (millimetres of mercury, a standard measure of blood pressure).
The systolic blood pressure rise with straining in passing a stool has been reported to be as high as 70 mmHg. This rise is only temporary but with persistent straining in chronic constipation this could lead to an increased risk of heart attacks.
High blood pressure from straining on the toilet can last after pooing, especially in older people. Andrey_Popov/Shutterstock Some people with chronic constipation may have an impaired function of their vagus nerve, which controls various bodily functions, including digestion, heart rate and breathing.
This impaired function can result in abnormalities of heart rate and over-activation of the flight-fight response. This can, in turn, lead to elevated blood pressure.
Another intriguing avenue of research examines the imbalance in gut bacteria in people with constipation.
This imbalance, known as dysbiosis, can result in microbes and other substances leaking through the gut barrier into the bloodstream and triggering an immune response. This, in turn, can lead to low-grade inflammation in the blood circulation and arteries becoming stiffer, increasing the risk of a heart attack.
This latest study also explored genetic links between constipation and heart disease. The researchers found shared genetic factors that underlie both constipation and heart disease.
What can we do about this?
Constipation affects around 19% of the global population aged 60 and older. So there is a substantial portion of the population at an increased risk of heart disease due to their bowel health.
Managing chronic constipation through dietary changes (particularly increased dietary fibre), increased physical activity, ensuring adequate hydration and using medications, if necessary, are all important ways to help improve bowel function and reduce the risk of heart disease.
Vincent Ho, Associate Professor and clinical academic gastroenterologist, Western Sydney University
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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What is AuDHD? 5 important things to know when someone has both autism and ADHD
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You may have seen some new ways to describe when someone is autistic and also has attention-deficit hyperactivity disorder (ADHD). The terms “AuDHD” or sometimes “AutiADHD” are being used on social media, with people describing what they experience or have seen as clinicians.
It might seem surprising these two conditions can co-occur, as some traits appear to be almost opposite. For example, autistic folks usually have fixed routines and prefer things to stay the same, whereas people with ADHD usually get bored with routines and like spontaneity and novelty.
But these two conditions frequently overlap and the combination of diagnoses can result in some unique needs. Here are five important things to know about AuDHD.
Kosro/Shutterstock 1. Having both wasn’t possible a decade ago
Only in the past decade have autism and ADHD been able to be diagnosed together. Until 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM) – the reference used by health workers around the world for definitions of psychological diagnoses – did not allow for ADHD to be diagnosed in an autistic person.
The manual’s fifth edition was the first to allow for both diagnoses in the same person. So, folks diagnosed and treated prior to 2013, as well as much of the research, usually did not consider AuDHD. Instead, children and adults may have been “assigned” to whichever condition seemed most prominent or to be having the greater impact on everyday life.
2. AuDHD is more common than you might think
Around 1% to 4% of the population are autistic.
They can find it difficult to navigate social situations and relationships, prefer consistent routines, find changes overwhelming and repetition soothing. They may have particular sensory sensitivities.
ADHD occurs in around 5–8% of children and adolescents and 2–6% of adults. Characteristics can include difficulties with focusing attention in a flexible way, resulting in procrastination, distraction and disorganisation. People with ADHD can have high levels of activity and impulsivity.
Studies suggest around 40% of those with ADHD also meet diagnostic criteria for autism and vice versa. The co-occurrence of having features or traits of one condition (but not meeting the full diagnostic criteria) when you have the other, is even more common and may be closer to around 80%. So a substantial proportion of those with autism or ADHD who don’t meet full criteria for the other condition, will likely have some traits.
3. Opposing traits can be distressing
Autistic people generally prefer order, while ADHDers often struggle to keep things organised. Autistic people usually prefer to do one thing at a time; people with ADHD are often multitasking and have many things on the go. When someone has both conditions, the conflicting traits can result in an internal struggle.
For example, it can be upsetting when you need your things organised in a particular way but ADHD traits result in difficulty consistently doing this. There can be periods of being organised (when autistic traits lead) followed by periods of disorganisation (when ADHD traits dominate) and feelings of distress at not being able to maintain organisation.
There can be eventual boredom with the same routines or activities, but upset and anxiety when attempting to transition to something new.
Autistic special interests (which are often all-consuming, longstanding and prioritised over social contact), may not last as long in AuDHD, or be more like those seen in ADHD (an intense deep dive into a new interest that can quickly burn out).
Autism can result in quickly being overstimulated by sensory input from the environment such as noises, lighting and smells. ADHD is linked with an understimulated brain, where intense pressure, novelty and excitement can be needed to function optimally.
For some people the conflicting traits may result in a balance where people can find a middle ground (for example, their house appears tidy but the cupboards are a little bit messy).
There isn’t much research yet into the lived experience of this “trait conflict” in AuDHD, but there are clinical observations.
4. Mental health and other difficulties are more frequent
Our research on mental health in children with autism, ADHD or AuDHD shows children with AuDHD have higher levels of mental health difficulites than autism or ADHD alone.
This is a consistent finding with studies showing higher mental health difficulties such as depression and anxiety in AuDHD. There are also more difficulties with day-to-day functioning in AuDHD than either condition alone.
So there is an additive effect in AuDHD of having the executive foundation difficulties found in both autism and ADHD. These difficulties relate to how we plan and organise, pay attention and control impulses. When we struggle with these it can greatly impact daily life.
5. Getting the right treatment is important
ADHD medication treatments are evidence-based and effective. Studies suggest medication treatment for ADHD in autistic people similarly helps improve ADHD symptoms. But ADHD medications won’t reduce autistic traits and other support may be needed.
Non-pharmacological treatments such as psychological or occupational therapy are less researched in AuDHD but likely to be helpful. Evidence-based treatments include psychoeducation and psychological therapy. This might include understanding one’s strengths, how traits can impact the person, and learning what support and adjustments are needed to help them function at their best. Parents and carers also need support.
The combination and order of support will likely depend on the person’s current functioning and particular needs. https://www.youtube.com/embed/pMx1DnSn-eg?wmode=transparent&start=0 ‘Up until recently … if you had one, you couldn’t have the other.’
Do you relate?
Studies suggest people may still not be identified with both conditions when they co-occur. A person in that situation might feel misunderstood or that they can’t fully relate to others with a singular autism and ADHD diagnosis and something else is going on for them.
It is important if you have autism or ADHD that the other is considered, so the right support can be provided.
If only one piece of the puzzle is known, the person will likely have unexplained difficulties despite treatment. If you have autism or ADHD and are unsure if you might have AuDHD consider discussing this with your health professional.
Tamara May, Psychologist and Research Associate in the Department of Paediatrics, Monash University
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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