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 Sugar Alcohol That Reduces BMI!
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Inositol Does-It-Ol’!
First things first, a quick clarification up-front:
Myo-inositol or D-chiro-inositol?
We’re going to be talking about inositol today, which comes in numerous forms, but most importantly:
- Myo-inositol (myo-Ins)
- D-chiro-inositol (D-chiro-Ins)
These are both inositol, (a sugar alcohol!) and for our purposes today, the most relevant form is myo-inositol.
The studies we’ll look at today are either:
- just about myo-inositol, or
- about myo-inositol in the presence of d-chiro-inositol at a 40:1 ratio.
You have both in your body naturally; wherever supplementation is mentioned, it means supplementing with either:
- extra myo-inositol (because that’s the one the body more often needs more of), or
- both, at the 40:1 ratio that we mentioned above (because that’s one way to help balance an imbalanced ratio)
With that in mind…
Inositol against diabetes?
Inositol is known to:
- decrease insulin resistance
- increase insulin sensitivity
- have an important role in cell signaling
- have an important role in metabolism
The first two things there both mean that inositol is good against diabetes. It’s not “take this and you’re cured”, but:
- if you’re pre-diabetic it may help you avoid type 2 diabetes
- if you are diabetic (either type) it can help in the management of your diabetes.
It does this by allowing your body to make better use of insulin (regardless of whether that insulin is from your pancreas or from the pharmacy).
How does it do that? Research is still underway and there’s a lot we don’t know yet, but here’s one way, for example:
❝Evidence showed that inositol phosphates might enhance the browning of white adipocytes and directly improve insulin sensitivity through adipocytes❞
Read: Role of Inositols and Inositol Phosphates in Energy Metabolism
We mentioned its role in metabolism in a bullet-point above, and we didn’t just mean insulin sensitivity! There’s also…
Inositol for thyroid function?
The thyroid is one of the largest endocrine glands in the body, and it controls how quickly the body burns energy, makes proteins, and how sensitive the body should be to other hormones. So, it working correctly or not can have a big impact on everything from your mood to your weight to your energy levels.
How does inositol affect thyroid function?
- Inositol has an important role in thyroid function and dealing with autoimmune diseases.
- Inositol is essential to produce H2O2 (yes, really) required for the synthesis of thyroid hormones.
- Depletion of inositol may lead to the development of some thyroid diseases, such as hypothyroidism.
- Inositol supplementation seems to help in the management of thyroid diseases.
Read: The Role of Inositol in Thyroid Physiology and in Subclinical Hypothyroidism Management
Inositol for PCOS?
A systematic review published in the Journal of Gynecological Endocrinology noted:
- Inositol can restore spontaneous ovarian activity (and consequently fertility) in most patients with PCOS.
- Myo-inositol is a safe and effective treatment to improve:
- ovarian function
- healthy metabolism
- healthy hormonal balance
While very comprehensive (which is why we included it here), that review’s a little old, so…
Check out this cutting edge (Jan 2023) study whose title says it all:
Inositol for fertility?
Just last year, Mendoza et al published that inositol supplementation, together with antioxidants, vitamins, and minerals, could be an optimal strategy to improve female fertility.
This built from Gambiole and Forte’s work, which laid out how inositol is a safe compound for many issues related to fertility and pregnancy. In particular, several clinical trials demonstrated that:
- inositol can have therapeutic effects in infertile women
- inositol can also be useful as a preventive treatment during pregnancy
- inositol could prevent the onset of neural tube defects
- inositol also reduces the occurrence of gestational diabetes
Due to the safety and efficiency of inositol, it can take the place of many drugs that are contraindicated in pregnancy. Basically: take this, and you’ll need fewer other drugs. Always a win!
Read: Myo-Inositol as a Key Supporter of Fertility and Physiological Gestation
Inositol For Weight Loss
We promised you “this alcohol sugar can reduce your BMI”, and we weren’t making it up!
Zarezadeh et al conducited a very extensive systematic review, and found:
- Oral inositol supplementation has positive effect on BMI reduction.
- Inositol in the form of myo-inositol had the strongest effect on BMI reduction.
- Participants with PCOS and/or who were overweight, experienced the most significant improvement of all.
Want some inositol?
As ever, we don’t sell it (or anything else), but for your convenience, here’s myo-inositol and d-chiro-inositol at a 40:1 ratio, available on Amazon!
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What Does Lion’s Mane Actually Do, Anyway?
10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.
Peripheral neuropathy (and what can be done about it)
Peripheral neuropathy is nerve damage, usually of the extremities. It can be caused by such things as:
- Diabetes
- Alcoholism
- Infection
- Injury
The manifestations can be different:
- In the case of diabetes, it’s also called diabetic neuropathy, and almost always affects the feet first.
- In the case of alcoholism, it is more generalized, but tends towards affecting the extremities first.
- In the case of infection, a lot depends on the nature of the infection and the body’s response.
- In the case of injury, it’ll naturally be the injured part, or a little “downstream” of the injured part.
- This could be the case of a single traumatic injury (e.g. hand got trapped in a slammed door)
This could be the case of a repetitive injury (carpal tunnel syndrome is a kind of peripheral neuropathy, and is usually caused by consistent misalignment of the carpal tunnel, the aperture through which a bundle of nerves make their way from the forearm to the hand)
Prevention is better than cure
If you already have peripheral neuropathy, don’t worry, we’ll get to that. But, if you can, prevention is better than cure. This means:
- Diabetes: if you can, avoid. This may seem like no-brainer advice, but it’s often something people don’t think about until hitting a pre-diabetic stage. Obviously, if you are Type 1 Diabetic, you don’t have this luxury. But in any case, whatever your current status, take care of your blood sugars as best you can, so that your blood can take care of you (and your nerves) in turn. You might want to check out our previous main feature about this:
- Alcoholism: obviously avoid, if you can. You might like this previous edition of 10almonds addressing this:
- Infection: this is so varied that one-liner advice is really just “try to look after your immune health”.
- We’ll do a main feature on this soon!
- Injury: obviously, try to be careful. But that goes for the more insidious version too! For example, if you spend a lot of time at your computer, consider an ergonomic mouse and keyboard.
- There are many kinds available, so read reviews, but here’s an example product on Amazon
Writer’s note: as you might guess, I spend a lot of time at my computer, and a lot of that time, writing. I additionally spend a lot of time reading. I also have assorted old injuries from my more exciting life long ago. Because of this, it’s been an investment in my health to have:
A standing desk
A vertical ergonomic mouse
An ergonomic split keyboard
A Kindle*
*Far lighter and more ergonomic than paper books. Don’t get me wrong, I’m writing to you from a room that also contains about a thousand paper books and I dearly love those too, but more often than not, I read on my e-reader for comfort and ease.
If you already have peripheral neuropathy
Most advice popular on the Internet is just about pain management, but what if we want to treat the cause rather than the symptom?
Let’s look at the things commonly suggested: try ice, try heat, try acupuncture, try spicy rubs (from brand names like Tiger Balm, to home-made chilli ointments), try meditation, try a warm bath, try massage.
And, all of these are good options; do you see what they have in common?
It’s about blood flow. And that’s why they can help even in the case of peripheral neuropathy that’s not painful (it can also manifest as numbness, and/or tingling sensations).
By getting the blood flowing nicely through the affected body part, the blood can nourish the nerves and help them function correctly. This is, in effect, the opposite of what the causes of peripheral neuropathy do.
But also don’t forget: rest
- Put your feet up (literally! But we’re talking horizontal here, not elevated past the height of your heart)
- Rest that weary wrist that has carpal tunnel syndrome (again, resting it flat, so your hand position is aligned with your forearm, so the nerves between are not kinked)
- Use a brace if necessary to help the affected part stay aligned correctly
- You can get made-for-purpose wrist and ankle braces—you can also get versions that are made for administering hot/cold therapy, too. That’s just an example product linked that we can recommend; by all means read reviews and choose for yourself, though. Try them and see what helps.
One more top tip
We did a feature not long back on lion’s mane mushroom, and it’s single most well-established, well-researched, well-evidenced, completely uncontested benefit is that it aids peripheral neurogenesis, that is to say, the regrowth and healing of the peripheral nervous system.
So you might want to check that out:
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Peas vs Green Beans – Which is Healthier?
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Our Verdict
When comparing peas to green beans, we picked the peas.
Why?
Looking at macros first, peas have nearly 6x the protein, nearly 2x the fiber, and nearly 2x the carbs, making them the “more food per food” choice.
In terms of vitamins, peas have more of vitamins A, B1, B2, B3, B5, B6, B7, B9, C, and choline, while green beans have more of vitamins E and K. An easy win for peas.
In the category of minerals, peas have more copper, iron, magnesium, manganese, phosphorus, potassium, selenium, and zinc, while green beans have more calcium. Another overwhelming win for peas.
In short, enjoy both (diversity is good), but there’s a clear winner here and it’s peas.
Want to learn more?
You might like to read:
Peas vs Broad Beans – Which is Healthier?
Take care!
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Turmeric (Curcumin) Dos and Don’ts With Dr. Kim
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Turmeric is a fabulous spice, most well-known for its anti-inflammatory powers; its antioxidant effects benefit all of the body, including the brain. While it fights seemingly everything from arthritis to atherosclerosis to Alzheimer’s and more, it also boosts brain-derived neurotrophic factor, looks after your cardiovascular health, holds back diabetes, reduces the risk of cancer, fights depression, slows aging, and basically does everything short of making you sing well too.
Dr. Leonid Kim goes over the scientific evidence for these, and also talks about some of the practicalities of taking turmeric, and safety considerations.
For the most part, turmeric is very safe even at high doses (up to 8g at least); indeed, at smaller doses (e.g. 500mg) it largely does the same job as non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, with fewer problems.
It also does the job of several antidiabetic medications, by increasing uptake of glucose (thus reducing blood sugar levels) while simultaneously decreasing the glucose secretion from the liver. It does this by regulating the AMPK signalling pathway, just like metformin—while again, being safer.
Dr. Kim also looks at the (good!) evidence for turmeric in managing PCOS and undoing NAFLD; so far, so good.
Dosage: he bids us pay attention whether we’re taking it as turmeric itself or as curcumin standardized extract. The latter is the active compound, and in principle more powerful, but in practice it can get metabolized too quickly and easily—before it can have its desired effect. So, turmeric itself is a very good choice.
Absorption: since we do want it to be absorbed well, though, he does recommend taking it with piperine (as in black pepper).
You may be thinking: isn’t this going to cause the same problem you were just talking about, and cause it to be metabolized too quickly? And the answer is: no! How piperine works is almost the opposite; it protects the curcumin in the turmeric from our digestive enzymes, and thus allows them to get absorbed without being broken down too quickly—thus increasing the bioavailability by slowing the process down.
Lipophilia: no, that’s not a disease (or a fetish), rather it means that curcumin is soluble in fats, so we should take it near in time to a meal that contains at least a tablespoon of oil in total (so if you’re cooking a curry with your turmeric, this need is covered already, for example).
Supplement provenance: he recommends picking a supplement that’s been tested by a reputable 3rd party, as otherwise turmeric can be quite prone to impurities (which can include lead and arsenic, so, not great).
Contraindications: for some people, curcumin can cause gastrointestinal issues (less likely if taking with meals), and also, it can interact with blood-thinners. While taking aspirin or curcumin alone might help avoid circulatory problems, taking both could increase the bleeding risk for some people, for example. Similarly, if taking curcumin and metformin while diabetic, one must watch out for the combination being too effective at lowering blood sugar levels, and thus causing hypoglycemia instead. Similar deal with blood pressure medications.
There’s more in the video though (yes really; we know we wrote a lot but it’s information-dense), so do check it out:
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Want to know more?
You can also check out our related articles:
Why Curcumin (Turmeric) Is Worth Its Weight In Gold
Black Pepper’s Impressive Anti-Cancer Arsenal (And More)Don’t Forget…
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Anxiety Attack vs Panic Attack: Do You Know The Difference?
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The terms are sometimes used incorrectly, but have quite different meanings. Dr. Julie Smith, psychologist, explains in this short video:
Important distinctions
Anxiety attacks are not clinically recognized terms and lack a clear definition, often used to describe a build-up of anxiety before anticipated stressful events (e.g. social gatherings, medical appointments, etc, though of course what it is will vary from person to person—not everyone finds the same things stressful, or has the same kinds of anticipations around things).
Panic attacks, in contrast, are sudden surges of intense fear or discomfort that peak within minutes. They are characterized by symptoms including at least 4 of:
- palpitations
- sweating
- shortness of breath
- chest pain
- dizziness
- fear of losing control or dying
There’s a misconception that panic attacks never have identifiable triggers while anxiety attacks always do.
In reality, both can occur with or without a clear cause. Panic attacks can arise from various conditions, including trauma, OCD, or phobias, and don’t necessarily mean you have a panic disorder. They can also occur as a drug response, without any known underlying psychological condition.
You may also notice that that list of symptoms has quite a bit of overlap with the symptoms of a heart attack, which a) does not help people to calm down b) can, on the flipside, cause a heart attack to be misdiagnosed as a panic attack.
In terms of management:
- In the moment: breathing exercises, like extending your exhalation (a common example is the “7-11” method, inhaling for 7 seconds and exhaling for 11 seconds), can calm the body and reduce panic symptoms.
- More generally: to prevent panic attacks from becoming more frequent, avoid avoiding safe environments that triggered an attack, like supermarkets or social gatherings. Gradual exposure helps reduce anxiety over time, while avoidance can worsen it.
If panic attacks persist, Dr. Smith advises to seek help from a doctor or psychologist to understand their root causes and develop effective coping strategies.
For more on all of this, enjoy:
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Want to learn more?
You might also like to read:
Take care!
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Five Advance Warnings of Multiple Sclerosis
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Five Advance Warnings of Multiple Sclerosis
First things first, a quick check-in with regard to how much you know about multiple sclerosis (MS):
- Do you know what causes it?
- Do you know how it happens?
- Do you know how it can be fixed?
If your answer to the above questions is “no”, then take solace in the fact that modern science doesn’t know either.
What we do know is that it’s an autoimmune condition, and that it results in the degradation of myelin, the “insulator” of nerves, in the central nervous system.
- How exactly this is brought about remains unclear, though there are several leading hypotheses including autoimmune attack of myelin itself, or disruption to the production of myelin.
- Treatments look to reduce/mitigate inflammation, and/or treat other symptoms (which are many and various) on an as-needed basis.
If you’re wondering about the prognosis after diagnosis, the scientific consensus on that is also “we don’t know”:
Read: Personalized medicine in multiple sclerosis: hope or reality?
this paper, like every other one we considered putting in that spot, concludes with basically begging for research to be done to identify biomarkers in a useful fashion that could help classify many distinct forms of MS, rather than the current “you have MS, but who knows what that will mean for you personally because it’s so varied” approach.
The Five Advance Warning Signs
Something we do know! First, we’ll quote directly the researchers’ conclusion:
❝We identified 5 health conditions associated with subsequent MS diagnosis, which may be considered not only prodromal but also early-stage symptoms.
However, these health conditions overlap with prodrome of two other autoimmune diseases, hence they lack specificity to MS.❞
So, these things are a warning, five alarm bells, but not necessarily diagnostic criteria.
Without further ado, the five things are:
- depression
- sexual disorders
- constipation
- cystitis
- urinary tract infections
❝This association was sufficiently robust at the statistical level for us to state that these are early clinical warning signs, probably related to damage to the nervous system, in patients who will later be diagnosed with multiple sclerosis.
The overrepresentation of these symptoms persisted and even increased over the five years after diagnosis.❞
Read the paper for yourself:
Hot off the press! Published only yesterday!
Want to know more about MS?
Here’s a very comprehensive guide:
National clinical guideline for diagnosis and management of multiple sclerosis
Take care!
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