Exploring the Final Journey: Unconventional Medical Tourism Trend
"I had a strong desire to dictate my own departure from this world," expressed the 61-year-old residing in Lancaster. "I concluded that this was a feasible option for me."
When Milano was informed in the first half of 2023 that her illness was incurable, going through medical assistance in dying wasn't an option due to the requirement to travel to Switzerland or live in specific areas such as the District of Columbia or 10 states where medical aid in dying was authorized.
However, Vermont eliminated its residency prerequisite in May 2023, followed closely by Oregon two months later. Although Montana technically allows aid in dying through a 2009 court judgment, the guidelines regarding residency are not clear. And despite recent considerations in New York and California to permit out-of-state residents to receive aid in dying, neither proposal was approved.
Despite the limited options and the complications, such as locating doctors in a foreign state, choosing a location for dying, and traveling when too ill to move to the next room, numerous individuals have embarked on this journey to the two states that had opened their doors to non-resident terminally ill individuals seeking medical help in dying.
At least 26 individuals have journeyed to Vermont to meet their end, representing approximately 25% of the reported assisted deaths in the state from May 2023 through mid-2023, according to the Vermont Department of Health. In Oregon, 23 non-residents utilized medical assistance to end their lives in 2023, accounting for just over 6% of the state's total, according to the Oregon Health Authority.
Oncologist Charles Blanke, whose Portland clinic primarily focuses on end-of-life care, believes that Oregon's total is likely an underestimate and expects the numbers to increase. Over the past year, he has seen two to four non-resident patients every week (approximately a quarter of his practice) and has fielded calls from various parts of the U.S., including New York, the Carolinas, Florida, and "countless from Texas." However, just because patients are willing to travel does not imply that the process is easy or that they achieve their desired outcome.
"The legislation is quite stringent about what is mandatory," Blanke said.
As with other states that permit what some refer to as physician-assisted death or assisted suicide, Oregon and Vermont require patients to undergo evaluations by two doctors. Patients must have a life expectancy of less than six months, demonstrate mental and cognitive wellness, and have the physical ability to consume the drugs to end their lives. Medical records must be reviewed in the state; failure to do so constitutes practicing medicine out of state, which violates medical licensing requirements. For similar reasons, patients must be in the state for the initial examination, when they request the drugs, and when they consume them.
State legislatures include these restrictions as safeguards—to balance the rights of patients seeking aid in dying with an obligation not to pass laws harmful to anyone, said Peg Sandeen, CEO of the group Death With Dignity. Like many aid-in-dying advocates, however, she argued that these rules create unnecessary burdens for people who are already suffering.
Palliative care physician Diana Barnard in Vermont stated that 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 portion of their energy to come here when they really deserve to have the option closer to home."
Those opposed to aid in dying encompass religious groups that view taking a life as immoral, and medical practitioners who assert their role is to make people more comfortable at life's end rather than to end life itself.
Anthropologist Anita Hannig, who spent time interviewing terminally ill patients while researching her 2022 book, “The Day I Die: The Untold Story of Assisted Dying in America,” stated that she does not anticipate federal legislation to resolve the issue anytime soon. Just like 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 stated that many states initially enact restrictive laws—requiring 21-day wait times and psychiatric evaluations, for instance—only to eventually revoke provisions that prove too burdensome. This makes her optimistic that more states will 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 this impossible. And although Oregon has more providers than Vermont, a largely rural state, Milano opted for the nine-hour car ride to Burlington because it was less physically and financially exhausting than an extended cross-country trip.
The logistics were essential because Milano understood that she would need to return. When she traveled to Vermont in May 2023 with her husband and her brother, she was not near death. She presumed that the next time she was in Vermont, it would be to request the medication. Then she would have to wait 15 days to receive it.
The waiting period is standard to provide a person with "thoughtful time to contemplate the decision," although many have already done so, Barnard said. Some states have shortened the period or, like Oregon, offer a waiver option.
The time span before death can be challenging for patients, with absences from medical team, home, and loved ones causing strain. According to Blanke, up to 25 relatives may attend an Oregon resident's death, but non-residents typically bring only one person. locating a suitable place to die proves tricky for Oregonians in care homes or hospitals restricting aid-in-dying, but it's significantly more complex for outsiders.
After Oregon abolished its residency requirement, Blanke advertised on Craigslist, generating a list of temporary accommodations, such as Airbnbs, permitting patients to expire there. Nonprofit organizations in aid-in-dying law-abiding states maintain these lists, as per Sandeen.
Milano hasn't reached the stage of finding a place to administer the meds and initiate her own demise yet. Surprisingly, she allowed her six-month approval period to expire due to a healthy year after her initial Vermont trip.
In June, she revisited Vermont to restart another six-month period. She went with a friend possessing a camper van, driving for six hours to transcend state borders, stopping at a playground and gift shop before parking in a location facilitating a Zoom appointment with her doctors rather than traveling an additional three hours to meet them personally in Burlington.
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"I'm uncertain whether they employ GPS tracking or IP address monitoring, but I'd be reluctant not to be forthright," she stated.
Fear isn't limited to that concern. She frets about being too ill to return to Vermont when she's ready to die. Moreover, even if she manages to return, she wonders whether she'll have sufficient fortitude to consume the medication. Around one-third of people granted aid-in-dying approvals choose not to proceed, Blanke shared, typically satisfied merely knowing they possess the control to end their lives whenever they wish.
Milano is grateful for this power while she's still healthy enough to travel and relish life. "I just wish more people had this option," she said.
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Due to the incurable nature of her illness, Milano was initially unable to consider going through medical assistance in dying in areas where it was authorized. However, after Vermont and Oregon removed their residency requirements, she had the option to travel to these states for medical aid in dying.
Despite the challenges of traveling and the stringent requirements in states like Oregon and Vermont, numerous terminally ill individuals are choosing to journey to these two states for medical assistance in dying.
