A New Form of Medical Tourism – Traveling to Die

Many patients approaching the end of life face difficult decisions about dying on their own terms. In states in the United States where medical aid in dying is legal, various requirements must be met. States such as Vermont and Oregon offer patients options and, through changes such as removing residency requirements, allow more people access to this choice. This article examines how a patient named Francine Milano planned the end of her life and the challenges she encountered.

In Vermont and Oregon, patients choosing medical aid in dying must have less than six months to live, be mentally and cognitively capable, and be physically able to take the medicines that will end their lives.

Within 18 months of being diagnosed with a recurrence of ovarian cancer she thought she had beaten 20 years earlier, Francine Milano traveled twice from her Pennsylvania home to Vermont. The trips were not for skiing, hiking or viewing autumn leaves; they were to plan her death.

Milano, a 61-year-old Lancaster resident, said, “I really wanted to take control of how I leave this world. I decided this was an option for me.”

Medical aid in dying was not an option when Milano learned in early 2023 that her disease was incurable. At the time, she would have had to travel to Switzerland or live in one of the 10 states permitting medical aid in dying, or in Washington.

Vermont removed its residency requirement in May 2023, and Oregon followed two months later. (A 2009 court ruling effectively permits medical aid in dying in Montana, but does not explicitly address residency rules. New York and California also recently considered legislation allowing out-of-state residents access to medical aid in dying, but these measures did not pass.)

Despite limited options and the challenges of finding a doctor in another state, deciding where to die, and traveling when they can barely leave their rooms, dozens of people have managed to reach these two states to obtain medical aid in dying.

According to Vermont's Department of Health, at least 26 people traveled to Vermont to die between May 2023 and this June, representing approximately 25% of reported assisted deaths in the state. In Oregon, 23 out-of-state patients chose medical aid in dying in 2023, just over 6% of the state total.

In Portland, end-of-life care is the focus of oncologist Dr. Charles Blanke's clinic. He believes Oregon's figure is probably underreported and expects it to grow. Over the past year, he has seen two to four out-of-state patients weekly, approximately a quarter of his practice, and received calls from across the United States, including New York, the Carolinas, Florida and “tons from Texas.” But willingness to travel does not mean the process is easy or that patients achieve their desired outcome.

Dr. Blanke said, “The law is very strict about what has to happen.”

Like other states permitting medical aid in dying, Oregon and Vermont require patients to be assessed by two doctors. Patients must have less than six months to live, be mentally and cognitively capable, and be able to take the medicines that will end their lives. Records and documents must be reviewed within the state. Failing to do so constitutes practicing medicine out of state, violating medical licensing requirements. For the same reason, patients must be in the state for the initial examination, the request for medication and when they take it.

State legislatures impose these restrictions as safeguards, balancing the rights of patients requesting medical aid in dying against the obligation not to enact laws that could harm others, says Peg Sandeen, CEO of Death With Dignity. Like many advocates of medical aid in dying, however, she says the rules create unnecessary burdens for people already suffering.

Vermont palliative care physician Diana Barnard said some patients cannot even make it to appointments. “Patients are often very ill or do not want to travel, so appointments have to be rescheduled,” she said. “We are asking people to expend considerable energy to get here when they really deserve this option closer to home.”

Opponents of medical aid in dying include religious groups that consider taking a life immoral and medical practitioners who say their role is to make people more comfortable at the end of life, not to end it.

For her book published in 2022, “The Day I Die: The Untold Story of Assisted Dying in America,” anthropologist Anita Hannig interviewed dozens of terminally ill patients. She does not expect federal law to resolve the issue soon. As it did for abortion in 2022, the Supreme Court determined in 1997 that medical aid in dying was a matter for states.

During the 2023-24 legislative sessions, 19 states, including Milano's home state of Pennsylvania, considered laws permitting medical aid in dying. Delaware was the only state to pass such legislation, but its governor had not yet acted.

Sandeen said many states initially enacted restrictive laws, requiring, for example, 21-day waiting periods and psychiatric assessments, but later repealed provisions shown to impose unnecessary burdens. This makes her optimistic that more states will follow Vermont and Oregon.

Milano would have preferred neighboring New Jersey, where medical aid in dying has been legal since 2019, but its residency requirement made that impossible. Although Oregon has more providers than rural Vermont, she preferred a nine-hour drive to traveling across the country.

Logistics were crucial for Milano because she knew she would need to return. When she traveled to Vermont with her husband and brother in May 2023, she was not ready to die. She thought she would be ready to request medication on her next visit, after which she would need to wait 15 days before obtaining it.

The waiting period is standard, intended to provide what Barnard calls “time to reflect on the decision,” although most people have already done so. Some states have shortened this period or, like Oregon, offered a waiver.

The waiting period can be difficult for patients, particularly when they are far from their healthcare team, home and family. Blanke noted that around 25 relatives attended one Oregon resident's death, while out-of-state patients usually bring just one person. Finding a place to die can be difficult even for Oregonians in care homes or hospitals that do not permit medical aid in dying, but it is especially challenging for people from outside the state.

When Oregon removed its residency requirement, Blanke posted an advertisement on Craigslist and used the responses to compile a list of places where patients could die, including short-term accommodation. Nonprofit organizations in states with medical aid-in-dying laws maintain similar lists, Sandeen says.

Milano has not yet reached the point of finding a place to take the medicines that will end her life. After her first trip to Vermont, she had a relatively healthy year and allowed her six-month authorization to expire.

In June, however, she traveled again to open another six-month window, this time with a friend who had a camper van. They drove six hours to cross the state line, stopped at a playground and gift shop, then sat in a parking lot for a Zoom appointment with Milano's doctors rather than driving another three hours to Burlington to meet in person.

Milano said, “I don't know if they do things like GPS tracking or checking IP addresses, but I wouldn't dare be dishonest.”

That is not Milano's only fear. She worries she may become too ill to return to Vermont and, if she can return, whether she will have the courage to take the medicines. According to Blanke, approximately one-third of those approved do not proceed with medical aid in dying. For them, simply knowing they can control when to end their lives is often enough.

Milano says she is grateful to have that control now, while she remains healthy enough to travel and enjoy life. “I wish more people had this option,” she adds.