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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The Menopause Risk That Nobody Talks About
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In this week’s health news round up, we cover menopausal disordered eating, air pollution & Alzheimer’s, and cold sore comebacks:
When the body starts changing…
Eating disorders are often thought of as a “teenage girl thing”. But in fact, eating disorders in girls/women mostly occur along with “the three Ps”:
- Puberty
- Pregnancy
- Perimenopause & menopause
In very many cases, it’s likely “my body is changing and I have strong opinions on how it should be”. Those opinions are often reflective of societal norms and pressures, but still, they are earnestly felt also. In the case of pregnancy, the societal pressures and standards are generally lifted while pregnant, but come back immediately postpartum, with an expectation to rebound quickly into the same shape one was in beforehand. And in the case of menopause, this is often concurrent with a sense of loss of identity, and can be quite reactionary against what is generally considered to be the ravages of time.
Of course, looking after one’s health is great at any age, and certainly there is no reason not to pursue health goals and try to get one’s body the way one wants it. However, it is all-too-easy for people to fall into the trap of taking drastic steps that are not actually that healthy, in the hopes of quick results.
Further, 13% of women over 50 report current core eating disorder symptoms, and that is almost certain vastly underreported.
Read in full: Eating disorders don’t just affect teen girls—the risk may also go up around pregnancy and menopause
Related: Body Image Dissatisfaction/Appreciation Across The Ages From Age 16 To Age 88
Where there’s smoke…
It’s been known for a while that air pollution is strongly associated with Alzheimer’s disease incidence, but exactly how this happens has not been entirely clear, beyond that it involves S-nitrosylation, in which NO-related particles bind to sulfur (S) atoms, forming SNO (and scientists being how they are, the term for the resultant brain effect has been called a SNO-STORM).
However, researchers have now found that it has to do with how certain toxins in the air (notwithstanding our heading here, they don’t have to be smoke—it can be household chemicals or other things too) cause this resultant SNO to interfere with protein CRTC1, which is critical for forming/maintaining connections between brain cells.
This is important, because it means that if a drug can be made that selectively blocks S-nitrosylatoin actions affecting CRTC1, it can reverse a lot of Alzheimer’s brain damage (as was found in the laboratory, when testing the theory with CRTC1 proteins that had been genetically engineered to resist S-nitrosylation, which is not something we can do with living human brains yet, but it is “proof of principle” and means funding will likely be forthcoming to find drugs to do the same thing).
Read in full: Study reveals how air pollution contributes to Alzheimer’s disease
Related: 14 Powerful Strategies To Prevent Dementia
The virus that comes back from the cold
Cold sores are created by the Herpes simplex virus (yes, the same one as for the genital variety), and by adulthood, most of us are either infected (and periodically get cold sores), or else infected (as an asymptomatic carrier). A noteworthy minority, but a minority nevertheless, are immune. Unless you’ve never had physical contact with other humans, it’s highly unlikely you’re not in one of the above three categories.
For those who do get cold sores, they can seem random in their reoccurrence, but in reality the virus never went away; it was just dormant for a while.
This much was known already, but scientists have now identified the trigger protein (known as “UL 12.5” to its friends) that acts as an alarm clock for the virus—which may pave the way to a greatly-improved treatment, if a way can be found to safely interfere with that wake-up call:
Read in full: Cold sore discovery identifies unknown trigger for those annoying flare-ups
Related: Beyond Supplements: The Real Immune-Boosters!
Take care!
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Metabolism Made Simple – by Sam Miller
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The author, a nutritionist, sets out to present exactly what the title promises: metabolism made simple.
On this, he delivers. Explaining things from the most basic elements upwards, he gives a well-rounded introduction to the science of metabolism and what it means for us when it comes to our dietary habits.
The book is in large part a how-to, but with a lot of flexibility left to the reader. He doesn’t advocate for any particular dietary plan, but he does give the reader the tools necessary to make an informed choice and go from there—including the pros and cons of some popular dietary approaches.
He talks a lot about getting the most out of whatever we do choose to—managing appetite, mitigating adaptation, maximizing adherence, optimizing absorption of nutrients, and so forth.
The book does also touch on things like exercise and stress management, but diet is always center-stage and is the main topic of the book.
The style is—as promised by the title—simple. However, this simply means that he avoids unnecessary jargon and explains any necessary terms along the way. As for backing up claims with science, there are 22 pages of references, which is always a good sign.
Bottom line: if you’d like a simple, practical guide to eating for metabolic health, this book will start you off on a good footing.
Click here to check out Metabolism Made Simple, and give your metabolic health a boost!
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When And Why Do We Pick Up Our Phones?
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The School of Life’s Alain de Botton makes the argument that—if we pay attention, if we keep track—there’s an understory to why we pick up our phones:
It’s not about information
Yes, our phones (or rather, the apps therein) are designed to addict us, to draw us back, to keep us scrolling and never let us go. We indeed seek out information like our ancestors once sought out berries; searching, encouraged by a small discovery, looking for more. The neurochemistry is similar.
But when we look at the “when” of picking up our phones, de Botton says, it tells a different story:
We pick them up not to find out what’s going on with the world, but rather specifically to not find out what’s going with ourselves. We pick them up to white out some anxiety we don’t want to examine, a line of thought we don’t want to go down, memories we don’t want to consider, futures we do not want to have to worry about.
And of course, phones do have a great educational potential, are an immensely powerful tool for accessing knowledge of many kinds—if only we can remain truly conscious while using them, and not take them as the new “opiate of the masses”.
De Botton bids us, when next we pick up our phone. ask a brave question:
“If I weren’t allowed to consult my phone right now, what might I need to think about?”
As for where from there? There’s more in the video:
Click Here If The Embedded Video Doesn’t Load Automatically!
Further reading
Making Social Media Work For Your Mental Health
Take care!
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MSG vs. Salt: Sodium Comparison
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It’s Q&A Day at 10almonds!
Q: Is MSG healthier than salt in terms of sodium content or is it the same or worse?
Great question, and for that matter, MSG itself is a great topic for another day. But your actual question, we can readily answer here and now:
- Firstly, by “salt” we’re assuming from context that you mean sodium chloride.
- Both salt and MSG do contain sodium. However…
- MSG contains only about a third of the sodium that salt does, gram-for-gram.
- It’s still wise to be mindful of it, though. Same with sodium in other ingredients!
- Baking soda contains about twice as much sodium, gram for gram, as MSG.
Wondering why this happens?
Salt (sodium chloride, NaCl) is equal parts sodium and chlorine, by atom count, but sodium’s atomic mass is lower than chlorine’s, so 100g of salt contains only 39.34g of sodium.
Baking soda (sodium bicarbonate, NaHCO₃) is one part sodium for one part hydrogen, one part carbon, and three parts oxygen. Taking each of their diverse atomic masses into account, we see that 100g of baking soda contains 27.4g sodium.
MSG (monosodium glutamate, C₅H₈NO₄Na) is only one part sodium for 5 parts carbon, 8 parts hydrogen, 1 part nitrogen, and 4 parts oxygen… And all those other atoms put together weigh a lot (comparatively), so 100g of MSG contains only 12.28g sodium.
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Lycopene’s Benefits For The Gut, Heart, Brain, & More
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What Doesn’t Lycopene Do?
Lycopene is an antioxidant carotenoid famously found in tomatoes; it actually appears in even higher levels in watermelon, though. If you are going to get it from tomato, know that cooking improves the lycopene content rather than removing it (watermelon, on the other hand, can be enjoyed as-is and already has the higher lycopene content).
Antioxidant properties
Let’s reiterate the obvious first, for the sake of being methodical and adding a source. Lycopene is a potent antioxidant with multiple health benefits:
Lycopene: A Potent Antioxidant with Multiple Health Benefits
…and as such, it does all the things you might reasonably expect and antioxidant to do. For example…
Anti-inflammatory properties
In particular, it regulates macrophage activity, reducing inflammation while improving immune response:
Lycopene Regulates Macrophage Immune Response through the Autophagy Pathway Mediated by RIPK1
As can be expected of most antioxidants and anti-inflammatory agents, it also has…
Anticancer properties
Scientific papers tend to be “per cancer type”, so we’re just going to give one example, but there’s pretty much evidence for its utility against most if not all types of cancer. We’re picking prostate cancer though, as it’s one that’s been studied the most in the context of lycopene intake—in this study, for example, it was found that men who enjoyed at least two servings of lycopene-rich tomato sauce per week were 30% less likely to develop prostate cancer than those who didn’t:
Dietary lycopene intake and risk of prostate cancer defined by ERG protein expression
If you’d like to see something more general, however, then check out:
Potential Use of Tomato Peel, a Rich Source of Lycopene, for Cancer Treatment
It also fights Candida albicans
Ok, this is not (usually) so life-and-death as cancer, but reducing our C. albicans content (specifically: in our gut) has a lot of knock-on effects for other aspects of our health, so this isn’t one to overlook:
The title does not make this clear, but yes: this does mean it has an antifungal effect. We mention this because often cellular apoptosis is good for an overall organism, but in this case, it simply kills the Candida.
It’s good for the heart
A lot of studies focus just on triglyceride markers (which lycopene improves), but more tellingly, here’s a 10-year observational study in which diets rich in lycopene were associated to a 17–26% lower risk of heart disease:
Relationship of lycopene intake and consumption of tomato products to incident CVD
…and a 39% overall reduced mortality in, well, we’ll let the study title tell it:
…which means also:
It’s good for the brain
As a general rule of thumb, what’s good for the heart is good for the brain (because the brain needs healthy blood flow to stay healthy, and is especially vulnerable when it doesn’t get that), and in this case that rule of thumb is also borne out by the post hoc evidence, specifically yielding a 31% decreased incidence of stroke:
Dietary and circulating lycopene and stroke risk: a meta-analysis of prospective studies
Is it safe?
As a common food product, it is considered very safe.
If you drink nothing but tomato juice all day for a long time, your skin will take on a reddish hue, which will go away if you stop getting all your daily water intake in tomato juice.
In all likelihood, even if you went to extremes, you would get sick from the excess of vitamin A (generally present in the same foods) sooner than you’d get sick from the excess of lycopene.
Want to try some?
We don’t sell it, and also we recommend simply enjoying tomatoes, watermelons, etc, but if you do want a supplement, here’s an example product on Amazon
Enjoy!
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The Food For Life Cookbook – by Dr. Tim Spector
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We’ve previously reviewed Dr. Spector’s “Food For Life”, and while that was more of an “explanatory science” book, this one takes that science (reiterating it more briefly this time, by way of introduction) and makes a cookbook of it.
The nutritional emphasis in these recipes is on two things: maximizing fiber, and maximizing plant diversity. The recipes are not all vegan or even vegetarian, but they are plant-centric, and if the reader is vegetarian/vegan, then substitutions are easy to make.
The recipes themselves are simple without being boring, and are easy to follow, with full-page photos to accompany them. The science parts are very clear, accessible, and pop-science in style.
Bottom line: if you’d like to incorporate more fiber and more plants into your diet without it being a burden, this book is great for that.
Click here to check out the Food For Life Cookbook, and get cooking for life!
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