Indexing Title: ROJOSON’s Medical Anecdotal Report [06-03] 

MAR Title: Informed Refusal on Routine Cardiopulmonary Clearance  

Date of Observation: September 2005 to April, 2006 

Narration: 

A 50-year-old Filipino female was scheduled for elective cholecystectomy.  During induction, the anesthesiologist noted plenty of oropharyngeal secretions and signs of impending laryngeal spasm.  He decided to abort the induction of anesthesia. The cholecystectomy was thus deferred.  The patient went home alive but disappointed. After the operation, she registered a written complaint against practically all the members of the medical and nursing staff who attended to her for poor quality medical and nursing care.    

This medical anecdotal report will limit itself to only one of the many complaints of the patient, that is, the non-performance of cardiopulmonary clearance by the attending surgeon (yours truly).  Despite repeated explanation, the patient insisted that cardiopulmonary clearance should have been done as she considered this a routine preoperative procedure and if done, could have avoided the laryngeal spasm and cancellation of her operation.  The issue was settled when the medical director and the chairman of the department of surgery declared that preoperative cardiopulmonary clearance is not routine.

INSIGHT: (Discovery, Stimulus, Reinforcements) (Physical, Psychosocial, Ethical) 

Despite the presence of evidence-based recommendation stating otherwise, preoperative cardiopulmonary clearance is still rampantly being practiced to the point that it gives the community the impression that it is a routine procedure.    

Surgeons who don’t practice routine preoperative cardiopulmonary clearance may experience the same dilemma as that seen in the narration above.  To avoid such a dilemma, many surgeons tend to just go along with the tide.   

Personally, during my residency in the Philippine General Hospital from 1976 to 1981, I was working under a system where preoperative cardiopulmonary clearance was routine.  Since 1982 or 1983, after a year in private practice, I stopped practicing routine preoperative cardiopulmonary clearance in all my patients, both pay and charity.  When indicated, I refer patients to other specialists for assistance in selective preoperative evaluation (commonly, cardiac, pulmonary, diabetic, or renal) and supportive management and not a blanket cardiopulmonary clearance.  This is the first time in my more than 20 years of practice that I had a patient filed a complaint against me for not doing a routine cardiopulmonary clearance. With this experience, I could have just decided to go for a routine cardiopulmonary clearance to avoid the possibility of a patient complaining for not doing it and the hassle of explaining and defending myself in a suit. NO. I decided to stick to my principle of rationale medical practice. However, after the above experience, I now practice informed refusal for routine cardiopulmonary clearance, meaning, after explaining the pros and cons and the evidence-based recommendations against routine cardiopulmonary clearance, I make the patient affix a signature on a decision not to have routine cardiopulmonary clearance anymore.  If despite my explanations, the patient  insists on having one, then I let him have it.