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January 23, 2009

By Bill Kettler

Mail Tribune

If you couldn't make your wishes known during a medical emergency, who would you trust to speak for you?

Oregon law allows each of us to appoint a "health-care representative" to speak for us when we can't. People need to make sure the person they choose really knows what they want, says a medical ethicist visiting Southern Oregon this week.

The ideal health-care representative brings compassion and common sense to the task, says the Rev. John Tuohey, director of the Center for Health Care Ethics for Providence Health & Services in Oregon.

"If you're going to pick a health-care representative, pick someone who's not in a hurry to get rid of you, but not unwilling to let you go," Tuohey says.

He's in the Rogue Valley this week to speak to several groups about medical ethics and will be conducting a training session today at Providence Medford Medical Center.

Choosing a health-care representative is an option under Oregon's "advance directive" law, which allows people to give instructions to physicians about what kinds of care to provide when the patient is unable to communicate. The form includes a place to name a health-care representative who can speak for the patient should the instructions be unclear or fail to cover an unusual situation.

"You want to be sure families understand what you're doing," Tuohey says. "That encourages more discussion."

Misconceptions about advance directives still abound, Tuohey says. They apply only in specific circumstances: when a patient is close to death or permanently unconscious; during the end stage of a progressive, fatal illness, and when the patient faces extraordinary suffering and severe pain.

"If you appoint someone to be your health-care representative, you're not signing your life away," Tuohey says. "They can't commit you (to an institution); they can't do shock therapy."

The forms are available at hospitals and many physicians' offices.

Appointing an agent also reduces the uncertainty that might arise if someone thinks the patient might have had a sudden change of heart and failed to change the form.

Talking about end-of-life care and preparing advance directives reduces the chances of conflict over decision-making, Tuohey says. There's a legal "pecking order" for who makes decisions for those who haven't designated an agent, and the most available person may not necessarily be the one you might choose.

At the top is a legal guardian (if any), followed by a spouse; an adult designated by others such as the spouse or adult children; a majority of the adult children; a parent; a majority of adult siblings; or an adult relative or friend.

It's important to make your wishes known because family members' judgment can be clouded by ideas they get from popular culture, which don't necessarily reflect medical reality, he says.

"A lot of us learn about health care on television," he says, "and it's very inaccurate."

Tuohey says patients and their health-care representative should have a relationship with the physician that allows them to trust the doctor's advice — or find a different doctor, he says.

"If you trust your doctors, listen to them," he says. "If you don't trust them, fire them."

Health-care representatives must be willing to make hard decisions, Tuohey says.

"They don't want to make a mistake with grandma," he says. "They end up doing nothing, which is often a mistake."

Reach reporter Bill Kettler at 776-4492 or e-mail bkettler@mailtribune.com.

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