By Debby Waldman

KFF Health News

In the 18 months after Francine Milano was diagnosed with a relapse of the ovarian cancer she thought she had beaten 20 years ago, she traveled twice from her home in Pennsylvania to Vermont. She traveled not to ski, hike or leaf peek, but to prepare for her death.

“I really wanted to have control over how I left this world,” said the 61-year-old, who lives in Lancaster. “I decided this was an option for me.”

When Milano learned in early 2023 that her disease was incurable, dying with medical assistance was not an option. At that point, she would have had to travel to Switzerland – or live in the District of Columbia or one of the ten states where physician-assisted suicide was legal.

But Vermont lifted its residency requirement in May 2023, and Oregon followed two months later. (Montana allows assisted dying through a 2009 court ruling, but that ruling does not include rules on the residency requirement. And although New York and California recently considered legislation that would allow out-of-state residents to receive assisted dying, neither provision has passed.)

Despite the limited options and challenges – such as finding doctors in a new state, deciding where to die and traveling when too sick to go into the next room, let alone get in a car – dozens have made the trek to the two states that have opened their doors to terminally ill out-of-towners seeking assisted dying.

At least 26 people have traveled to Vermont to die, representing nearly 25 percent of the reported assisted dying in the state from May 2023 to June of this year, according to the Vermont Department of Health. In Oregon, 23 people from out of state died with medical assistance in 2023, representing just over 6 percent of the state’s total, according to the Oregon Health Authority.

Oncologist Charles Blanke, whose Portland clinic specializes in end-of-life care, believes Oregon’s total is probably an underestimate and expects the numbers to rise. Over the past year, he has seen two to four out-of-state patients a week — about a quarter of his practice — and has fielded calls from all over 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’ll get the outcome they want.

“The law is pretty strict about what needs to be done,” Blanke said.

The Death Expo lifts the veil on the myths and mysteries of the final event in life.

Like other states that allow so-called physician-assisted dying or assisted suicide, patients in Oregon and Vermont must be examined by two physicians. Patients must have less than six months to live, be mentally and cognitively healthy, and be physically able to take the medication to end their life. Medical records and health records must be verified in-state. Failure to do so is considered practicing medicine out of state, which violates medical licensing requirements. For the same reason, patients must be in-state for the initial examination, when the medication is requested, and when it is taken.

State legislatures impose these restrictions as a safeguard — to balance the rights of patients seeking assisted dying with the legislative imperative not to pass laws that harm anyone, says Peg Sandeen, executive director of the group Death With Dignity. But like many assisted-dying advocates, she says such rules impose an undue burden on people who are already suffering.

Diana Barnard, a palliative care physician in Vermont, said some patients can’t even make it to their appointments. “They’re sick or don’t feel like traveling, so they have to reschedule their appointments,” she said. “People have to spend a lot of their energy coming here when they really deserve an option closer to home.”

Opponents of euthanasia include religious groups who believe that killing a person is immoral and medical professionals who argue that their job is to make it easier for people to end their lives, not to end life itself.

Anthropologist Anita Hannig, who interviewed dozens of terminally ill patients as part of her research for her 2022 book, “The Day I Die: The Untold Story of Assisted Dying in America,” said she does not expect the issue to be resolved by federal legislation any time soon. As the Supreme Court did with abortion in 2022, it ruled in 1997 that assisted dying was a matter for the states to decide.

According to the advocacy group Compassion & Choices, 19 states (including Milano’s home state of Pennsylvania) have considered assisted suicide legislation during the 2023-24 legislative session. Delaware was the only state to pass the bill, but the governor has not yet voted on it.

Sandeen said many states initially enact restrictive laws — such as 21-day waiting periods and mental health evaluations — and then eventually repeal provisions that prove to be overly burdensome. That makes her optimistic that more states will follow the lead of Vermont and Oregon, she said.

Milano would have preferred to travel to neighboring New Jersey, where assisted suicide has been legal since 2019, but residency requirements made that impossible. And although there are more providers in Oregon than in the largely rural state of Vermont, Milano chose the nine-hour drive to Burlington because it was less physically and financially demanding than traveling across the country.

Logistics were crucial because Milano knew she had to return. She wasn’t close to death when she traveled to Vermont with her husband and brother in May 2023. She figured the next time she was in Vermont, she would request the drug. Then she would have to wait 15 days to receive it.

The waiting period is standard to ensure a person has enough time to think about the decision, as Barnard calls it, though she said most would have done so long before then. Some states have shortened the period or, like Oregon, created an exemption.

That wait can be hard on patients, in addition to being separated from their health care team, home and family. Blanke said he’s seen as many as 25 relatives present at the death of an Oregon resident, but out-of-towners typically bring only one person. And while finding a place to die can be a problem for Oregonians living in nursing homes or hospitals where assisted dying is prohibited, it’s especially difficult for non-residents.

When Oregon lifted the residency requirement, Blanke posted an ad on Craigslist and used the results to create a list of short-term shelters, including Airbnbs, that let patients die. Nonprofits in states with assisted dying laws also maintain such lists, Sandeen says.

Milano is not yet at the point where she needs to find a place to take the drugs and end her life. Because she had a relatively healthy year after her first trip to Vermont, she let her six-month approval period pass.

In June, however, she headed back to open another six-month window. This time, she was traveling with a friend who has a trailer. They drove six hours to cross the state line, stopped at a playground and a gift shop, then sat in a parking lot where Milano had a Zoom appointment with her doctors, rather than driving another three hours to Burlington to meet in person.

“I don’t know if they do GPS tracking or things like that with IP addresses, but I would have been afraid of not being honest,” she said.

But that’s not all that scares her. She fears she’ll be too sick to return to Vermont when she’s ready to die. And even if she makes it there, she wonders if she’ll have the courage to take the medication. About a third of people who are approved for assisted dying don’t go through with it, Blanke says. For them, knowing they have the medication – the control – to end their lives when they want is often enough.

Milano said she is grateful to have this opportunity now and to still be healthy enough to travel and enjoy life. “I just wish more people had this opportunity,” she said.

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