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.

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Vincent Wasney and his fiancée, Sarah Eberlein, had never visited the ocean. They’d never even been on a plane. But when they bought their first home in Saginaw, Michigan, in 2018, their real estate agent gifted them tickets for a Royal Caribbean cruise.

After two years of delays due to the coronavirus pandemic, they set sail in December 2022.

The couple chose a cruise destined for the Bahamas in part because it included a trip to CocoCay, a private island accessible to Royal Caribbean passengers that featured a water park, balloon rides, and an excursion swimming with pigs.

It was on that day on CocoCay when Wasney, 31, started feeling off, he said.

The next morning, as the couple made plans in their cabin for the last full day of the trip, Wasney made a pained noise. Eberlein saw him having a seizure in bed, with blood coming out of his mouth from biting his tongue. She opened their door to find help and happened upon another guest, who roused his wife, an emergency room physician.

Wasney was able to climb into a wheelchair brought by the ship’s medical crew to take him down to the medical facility, where he was given anticonvulsants and fluids and monitored before being released.

Wasney had had seizures in the past, starting about 10 years ago, but it had been a while since his last one. Imaging back then showed no tumors, and doctors concluded he was likely epileptic, he said. He took medicine initially, but after two years without another seizure, he said, his doctors took him off the medicine to avoid liver damage.

Wasney had a second seizure on the ship a few hours later, back in his cabin. This time he stopped breathing, and Eberlein remembered his lips being so purple, they almost looked black. Again, she ran to find help but, in her haste, locked herself out. By the time the ship’s medical team got into the cabin, Wasney was breathing again but had broken blood vessels along his chest and neck that he later said resembled tiger stripes.

Wasney was in the ship’s medical center when he had a third seizure — a grand mal, which typically causes a loss of consciousness and violent muscle contractions. By then, the ship was close enough to port that Wasney could be evacuated by rescue boat. He was put on a stretcher to be lowered by ropes off the side of the ship, with Eberlein climbing down a rope ladder to join him.

But before they disembarked, the bill came.

The Patient: Vincent Wasney, 31, who was uninsured at the time.

Medical Services: General and enhanced observation, a blood test, anticonvulsant medicine, and a fee for services performed outside the medical facility.

Service Provider: Independence of the Seas Medical Center, the on-ship medical facility on the cruise ship operated by Royal Caribbean International.

Total Bill: $2,500.22.

What Gives: As part of Royal Caribbean’s guest terms, cruise passengers “agree to pay in full” all expenses incurred on board by the end of the cruise, including those related to medical care. In addition, Royal Caribbean does not accept “land-based” health insurance plans.

Wasney said he was surprised to learn that, along with other charges like wireless internet, Royal Caribbean required he pay his medical bills before exiting the ship — even though he was being evacuated urgently.

“Are we being held hostage at this point?” Eberlein remembered asking. “Because, obviously, if he’s had three seizures in 10 hours, it’s an issue.”

Wasney said he has little memory of being on the ship after his first seizure — seizures often leave victims groggy and disoriented for a few hours afterward.

But he certainly remembers being shown a bill, the bulk of which was the $2,500.22 in medical charges, while waiting for the rescue boat.

Still groggy, Wasney recalled saying he couldn’t afford that and a cruise employee responding: “How much can you pay?”

They drained their bank accounts, including money saved for their next house payment, and maxed out Wasney’s credit card but were still about $1,000 short, he said.

Ultimately, they were allowed to leave the ship. He later learned his card was overdrafted to cover the shortfall, he said.

Royal Caribbean International did not respond to multiple inquiries from KFF Health News.

Once on land, in Florida, Wasney was taken by ambulance to the emergency room at Broward Health Medical Center in Fort Lauderdale, where he incurred thousands of dollars more in medical expenses.

He still isn’t entirely sure what caused the seizures.

On the ship he was told it could have been extreme dehydration — and he said he does remember being extra thirsty on CocoCay. He also has mused whether trying escargot for the first time the night before could have played a role. Eberlein’s mother is convinced the episode was connected to swimming with pigs, he said. And not to be discounted, Eberlein accidentally broke a pocket mirror three days before their trip.

Wasney, who works in a stone shop, was uninsured when they set sail. He said that one month before they embarked on their voyage, he finally felt he could afford the health plan offered through his employer and signed up, but the plan didn’t start until January 2023, after their return.

They also lacked travel insurance. As inexperienced travelers, Wasney said, they thought it was for lost luggage and canceled trips, not unexpected medical expenses. And because the cruise was a gift, they were never prompted to buy coverage, which often happens when tickets are purchased.

The Resolution: Wasney said the couple returned to Saginaw with essentially no money in their bank account, several thousand dollars of medical debt, and no idea how they would cover their mortgage payment. Because he was uninsured at the time of the cruise, Wasney did not try to collect reimbursement for the cruise bill from his new health plan when his coverage began weeks later.

The couple set up payment plans to cover the medical bills for Wasney’s care after leaving the ship: one each with two doctors he saw at Broward Health, who billed separately from the hospital, and one with the ambulance company. He also made payments on a bill with Broward Health itself. Those plans do not charge interest.

But Broward Health said Wasney missed two payments to the hospital, and that bill was ultimately sent to collections.

In a statement, Broward Health spokesperson Nina Levine said Wasney’s bill was reduced by 73% because he was uninsured.

“We do everything in our power to provide the best care with the least financial impact, but also cannot stress enough the importance of taking advantage of private and Affordable Care Act health insurance plans, as well as travel insurance, to lower risks associated with unplanned medical issues,” she said.

The couple was able to make their house payment with $2,690 they raised through a GoFundMe campaign that Wasney set up. Wasney said a lot of that help came from family as well as friends he met playing disc golf, a sport he picked up during the pandemic.

“A bunch of people came through for us,” Wasney said, still moved to tears by the generosity. “But there’s still the hospital bill.”

The Takeaway: Billing practices differ by cruise line, but Joe Scott, chair of the cruise ship medicine section of the American College of Emergency Physicians, said medical charges are typically added to a cruise passenger’s onboard account, which must be paid before leaving the ship. Individuals can then submit receipts to their insurers for possible reimbursement.

More from Bill of the Month

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He recommended that those planning to take a cruise purchase travel insurance that specifically covers their trips. “This will facilitate reimbursement if they do incur charges and potentially cover a costly medical evacuation if needed,” Scott said.

Royal Caribbean suggests that passengers who receive onboard care submit their paid bills to their health insurer for possible reimbursement. Many health plans do not cover medical services received on cruise ships, however. Medicare will sometimes cover medically necessary health care services on cruise ships, but not if the ship is more than six hours away from a U.S. port.

Travel insurance can be designed to address lots of out-of-town mishaps, like lost baggage or even transportation and lodging for a loved one to visit if a traveler is hospitalized.

Travel medical insurance, as well as plans that offer “emergency evacuation and repatriation,” are two types that can specifically assist with medical emergencies. Such plans can be purchased individually. Credit cards may offer travel medical insurance among their benefits, as well.

But travel insurance plans come with limitations. For instance, they may not cover care associated with preexisting conditions or what the plans consider “risky” activities, such as rock climbing. Some plans also require that travelers file first with their primary health insurance before seeking reimbursement from travel insurance.

As with other insurance, be sure to read the fine print and understand how reimbursement works.

Wasney said that’s what they plan to do before their next Royal Caribbean cruise. They’d like to go back to the Bahamas on basically the same trip, he said — there’s a lot about CocoCay they didn’t get to explore.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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.

Subscribe to KFF Health News’ free Morning Briefing.