SACRAMENTO, Calif. -- A case which could put so-called "death doulas" out of business gets a hearing this week before a federal judge in Sacramento.

Death doulas support families emotionally through the process of losing a loved one, educate people on their options and sometimes wash and dress the body and assist with home funerals or green burials. The state wants to require them to get a funeral director's license.

Jess Pezley, staff attorney for the nonprofit Compassion and Choices, which has filed an amicus brief to join the case, said the license would require doulas to spend hundreds of thousands of dollars to buy a funeral home equipped to embalm and store bodies.

"They don't embalm. They aren't transporting the body. They aren't offering crematorium services," Pezley outlined. "And they're not doing anything that would put themselves or others at risk of blood-borne viruses, things like that."

Two years ago, the California Cemetery and Funeral Bureau ordered the doulas at Full Circle of Living and Dying in Nevada County to become licensed funeral directors or cease operations. The doulas sued, and a preliminary injunction allowed them to stay in business. The bureau declined to comment.

Pezley noted the state's order was spurred by an anonymous complaint.

"It would make sense that it was somebody in the conventional funeral industry who has this vested financial interest in dissuading people from home burials or green burials," Pezley contended.

Meagan Williams, a death doula and senior media associate with Compassion and Choices, said if the doulas are required to become funeral directors, it would effectively shut down the field and deny families an important option.

"Doulas can bring comfort and peace," Williams stated. "Knowing that they're not alone, knowing that there's somebody who is educated who understands the process, understands what's coming up ahead of them, and can help them plan."

This week both sides are asking for a summary judgment, and a decision is expected early next year.

By Kate Ruder for KFF Health News.
Broadcast version by Eric Galatas for Colorado News Connection reporting for the KFF Health News-Public News Service Collaboration

During cheerleading practice in April, Jana Duey’s sixth grade daughter, Karter, sustained a concussion when she fell several feet headfirst onto a gym floor mat. Days after, Karter still had a headache, dizziness, and sensitivity to light and noise.

Karter rested for a week and a half at home in Centennial, Colorado, then returned to school when her concussion symptoms were tolerable — initially for just half-days and with accommodations allowing her to do schoolwork on paper instead of a screen and take extra time to get to and from classes. Karter went to the nurse’s office when she had a headache, Duey said. She began physical therapy to rehab her neck and regain her balance after the accident left her unsteady on her feet.

After children get concussions, a top concern for them and their parents or caregivers is when they can go back to sports, said Julie Wilson, Karter’s doctor and a co-director of the Concussion Program at Children’s Hospital Colorado in Aurora. Returning to school as quickly as possible, with appropriate support, and getting light exercise that doesn’t pose a head injury risk are important first steps in concussion recovery, and in line with the latest research.

“It’s really important to get children and teens back to their usual daily activities as soon as possible, and as soon as they can tolerate them,” Wilson said.

In August, the Colorado Department of Education updated guidelines dispelling common myths about concussions, such as a loss of consciousness being necessary for a concussion diagnosis. The revised guidelines reflect evidence-based best practices on how returning to school and exercise can improve recovery. Educating families and schools about the new guidelines is critical, according to medical experts, particularly during autumn’s uptick in concussions from sports such as football and soccer.

More than 2 million children nationwide had been diagnosed at some point with a concussion or brain injury, according to the 2022 National Health Interview Survey. A flurry of studies in the past decade have shown that adolescents recover more quickly from concussions and decrease the risk for prolonged symptoms by exercising lightly, for example on a stationary bike or with a brisk walk, two days after a concussion. That time frame may also be the sweet spot for getting back to the classroom, as long as the kids can tolerate any remaining concussion symptoms.

“Even though the brain is not a muscle, it acts like one and has a use-it-or-lose-it phenomenon,” said Christina Master, a pediatrician and sports medicine and brain injury specialist at Children’s Hospital of Philadelphia.

Instead of waiting at home to fully recover, Master said, students should return to school with extra support from teachers and breaks in their schedule to relieve symptoms such as headaches or fatigue, with a goal of gradually doing more.

Every state has return-to-play laws for student-athletes that include policies such as removal from sports, medical clearance to return, and education about concussions. While some states, such as Virginia and Illinois, have “return-to-learn” policies, Colorado is not among them. It and 15 other states have community-based concussion management protocols.

That is what Colorado updated this summer. REAP — which stands for Remove/Reduce; Educate; Adjust/Accommodate; and Pace — is a protocol for families, health care providers, and schools to help students recover during the first four weeks after a concussion. For example, school personnel can use an email-based system to alert teachers that a student sustained a concussion, then send weekly updates with details about how to manage symptoms, like difficulty concentrating.

“We have new protocols to support these kiddos,” said Toni Grishman, senior brain injury consultant at the Colorado Department of Education. “They might still have symptoms of concussion, but we can support them.”

Symptoms of concussion resolve in most patients in the first month. However, patients with ongoing symptoms, called persistent post-concussive symptoms, can benefit from a multidisciplinary care team that may include physicians, physical therapists, psychologists, and additional school support, Wilson said.

David Howell, director of the Colorado Concussion Research Laboratory at the University of Colorado Anschutz Medical Campus, is studying how children and their families cope with the physical, cognitive, social, and emotional impacts of concussions. In some studies, adolescents wear sensors to measure exercise intensity and volume, as well as common symptoms of concussion, like sleep and balance problems. In others, children and their parents answer questions about their perceptions and expectations of the recovery process.

“What you bring to an injury is oftentimes exacerbated by the injury,” Howell said, citing anxiety, depression, or just going through a difficult time socially. Recovery can be influenced by peer and family relationships.

Duey said the most difficult part of Karter’s recovery was her not being able to participate in cheer for nine weeks, including her team’s final competition in Florida. Karter, now 12, watched practice and supported her teammates in the spring, but missing out tore her up inside, Duey said.

“There were a lot of tears,” Duey said.

While recognizing a concussion and acting quickly can help anyone, in practice, more than half of students in Colorado may slip through the cracks with undiagnosed concussions, according to Grishman’s estimates.

The reasons for missed diagnoses are many, Grishman said, including lack of education, barriers to medical care, parental reluctance to inform schools about a concussion for fear their child will be excluded from activities, or not taking symptoms seriously in a student with a history of behavioral issues.

Getting schools to follow concussion guidelines, in general, is a challenge, Grishman said, adding that some districts still do not. She said it was hard to track the number of schools that followed Colorado education department guidelines last year but hopes improved data collection will provide more specifics this year. During the past school year, Grishman and her colleagues trained 280 school personnel in concussion management across 50 school districts in Colorado.

Whenever possible, athletic trainers should be on the sidelines to support student-athletes, Master said, and athletes should be aware of concussion symptoms in themselves and their teammates and seek care right away.

But concussions are not limited to the school athletic field or sports like football or soccer. Adventure sports like parkour, slacklining, motocross, rodeo, skiing, and snowboarding also pose concussion risks, Wilson and Grishman said. “Cheerleading is actually one that has a lot of concussions associated with it,” Howell added.

Duey said Karter occasionally has headaches, but her balance returned with help from physical therapy and she no longer experiences symptoms of her concussion. She is back to flying with her cheerleading squad and preparing to compete.


Kate Ruder wrote this story for KFF Health News.


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By Sarah Varney for KFF Health News.
Broadcast version by Brett Peveto for Maryland News Connection reporting for the KFF Health News-Public News Service Collaboration

In the two counties around nurse practitioner Samantha Marsee's clinic in rural northeastern Maryland, there's not a single clinic that provides abortions. And until recently, Marsee herself wasn't trained to treat patients who wanted to end a pregnancy.

"I didn't really have a lot of knowledge about abortion care," she said.

After Roe v. Wade was overturned, she watched state after state ban abortion, and Marsee decided to take part in the first class of a new training program offered by the University of Maryland School of Medicine and the University of Maryland-Baltimore.

Marsee learned how to administer medication abortion pills, procedural abortions, and highly effective birth control methods, including hormonal implants and intrauterine devices.

She cares for patients with all sorts of everyday ailments and health conditions, including pregnancy. "I do have patients who come in for confirmation of pregnancies and then disclose they don't want to continue with the pregnancy for whatever reason," Marsee said.

Now, with her new training, she can help.

Expanding the pool of health care providers with reproductive health care skills outside of the state's urban centers is vital, said Mary Jo Bondy, associate dean of the School of Graduate Studies at the University of Maryland-Baltimore. She helped create the new training program.

In 2022, Maryland lawmakers passed the Abortion Care Access Act, expanding the type of medical care nurse practitioners, physician assistants, and certified nurse-midwives could offer, including abortion, and the training program "prioritized that group," Bondy said.

Those types of professionals have long provided abortions to rural patients in other states, Bondy said, and "we have proof that receiving this care from an advanced practice clinician is safe."

As many as 120 health care providers will be trained over the next two years. Some participants have said they are returning to communities that are hostile to abortion rights.

On Nov. 5, voters approved a ballot measure to protect reproductive rights in the Maryland Constitution, by an overwhelming margin, preliminary results show. The state is widely considered a safe haven for patients who live in states with abortion bans. The number of abortions in Maryland increased 29% from 2019 to 2023, driven largely by out-of-state residents. But one training participant, a family physician from the Eastern Shore, said providing abortions makes her concerned for her physical safety and asked not to be identified.

"The rural catchment and politics really drive it either out or at least into the quiet," she said of abortion availability where she lives. She worries that her employer will question the prescriptions she writes for medication abortion pills and said pharmacists often refuse to give the medication to her patients.

Even in Maryland, pharmacists are allowed to refuse to dispense medication abortion pills.

As more health care providers are trained in abortion care, they need help from the state's medical schools and health officials to overcome these barriers, the family physician said. She wants help with "access to medication and pushing in some ways the hand of our employers, or normalizing, 'This is just health care.'"

For Marsee, the next step is to figure out how to let her patients know she can provide abortions. She plans to tell her current patients and hopes they'll tell others.

"I'm working on a way to let people know that I'm here and can provide it," Marsee said. "This is a conservative area, so it's walking that line. I want people to know I'm here, but I don't want to cause too much outrage and attention."


Sarah Varney wrote this story for KFF Health News.


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With flu and COVID-19 cases increasing during the holiday season, a Georgia doctor said now is the time to take steps to protect yourself and your loved ones.

Dr. Michael Satchell, family medicine physician at Phoebe Putney Memorial Hospital, encouraged everyone to consider flu and COVID-19 vaccinations to reduce the risk of serious illness, especially for those most vulnerable.

"Those who are vaccinated are actually 60% less likely to get a serious form of COVID or to be hospitalized," Satchell pointed out. "We're seeing that the vast majority and greater than 90% of those who are hospitalized are those who have not been vaccinated."

Satchell recommended everyone six months and older think about getting vaccinated, especially older adults and those with existing health conditions, to stay safer during the holiday season.

He acknowledged symptoms of flu and COVID-19 can overlap with a common cold but Satchell advised testing if you have symptoms like persistent cough, fatigue, or loss of taste and smell. He noted COVID-19 tests are still available online, and added it is important to consult with a provider if symptoms persist or exposure is suspected.

"It's important because there are still people dying from COVID," Satchell emphasized. "In Georgia, almost 300 people died in the last 3 months. So we're still seeing a lot of hospitalizations last season, the 2023-24 season, we had over 900,000 people across the country were hospitalized with COVID. So it's still out there."


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