What to do when a patient with a severe heart condition, such as coronary artery disease, refuses open heart surgery and wants to use traditional/herbal medication (DAMA - Do Not Attempt Major Surgery) instead?

Managing Patient Refusal of Open Heart Surgery

You must respect the patient's autonomy to refuse surgery while ensuring they understand the serious mortality and morbidity consequences, then document their informed refusal and implement the best available medical alternatives. 1

Immediate Steps: Ensure Informed Refusal

Document that the patient understands the specific risks of refusing surgery for their condition:

• Patients with severe symptomatic aortic stenosis who refuse surgery face approximately 10% mortality risk even during noncardiac procedures, and progressive heart failure with substantially increased long-term mortality 2, 1
• Severe mitral regurgitation left untreated leads to irreversible left ventricular dysfunction, atrial fibrillation, and 4% per year cardiac death risk 1
• Coronary artery disease requiring bypass has documented 15-year survival rates that decline significantly without intervention, particularly with triple-vessel or left main disease 3

Clearly explain that herbal/traditional medications have no proven efficacy for severe structural heart disease and carry their own perioperative risks including bleeding, cardiovascular instability, and drug interactions 4, 5, 6

Critical Documentation Requirements

Complete a formal informed refusal process that includes:

• Specific diagnosis and why surgery is indicated 1
• Documented explanation of mortality risk (approximately 10% for severe aortic stenosis during any procedure, higher for coronary disease) 2, 1
• Natural history without surgery: progressive symptoms, heart failure, irreversible cardiac damage, and high likelihood of death 1
• Patient's stated reasons for refusal 7
• Alternatives discussed and their limitations 1
• Patient signature acknowledging understanding of consequences 7

Alternative Management Strategy

If the patient maintains refusal after informed discussion, implement aggressive medical therapy:

For Valvular Disease:

• Optimize medical management with diuretics for congestion, beta-blockers for rate control if atrial fibrillation develops 2
• Strict endocarditis prophylaxis for any procedures that may cause bacteremia 2, 1
• Optimal anticoagulation if atrial fibrillation develops (high risk in untreated valvular disease) 2, 1
• Consider less invasive alternatives only if anatomically appropriate: percutaneous balloon valvuloplasty for aortic stenosis may serve as bridge therapy in hemodynamically unstable patients, though this is palliative, not curative 2, 8

For Coronary Artery Disease:

• Maximize anti-ischemic therapy: beta-blockers (Class I recommendation for symptom control), statins, aspirin, nitrates as needed 2
• Aggressive risk factor modification: smoking cessation, blood pressure control, diabetes management 2
• Consider percutaneous coronary intervention if anatomy suitable and patient willing 2

Regarding Herbal Medications:

Strongly counsel against herbal medications, particularly perioperatively:

• The American Society of Anesthesiologists recommends discontinuing all herbal medications 1-2 weeks before any surgical procedure due to risks of bleeding (garlic, ginkgo), cardiovascular instability (ginseng, ephedra), and drug interactions 4, 5
• 50-70% of patients fail to disclose herbal medication use, creating dangerous perioperative situations 5
• No herbal medication has proven efficacy for structural heart disease requiring surgical correction 4, 6

Common Pitfalls to Avoid

Do not proceed with elective noncardiac surgery if the patient refuses necessary cardiac surgery - mortality risk is unacceptably high (approximately 10% even for noncardiac procedures in severe aortic stenosis) 2, 1, 8

Do not assume the patient will change their mind - research shows 16% of patients with advanced disease refuse recommended interventions, often due to fear of side effects, and refusal is associated with nearly 2-fold increased mortality risk 7

Do not fail to document thoroughly - this protects both patient autonomy and medicolegal standing 7

Do not underestimate herbal medication risks - over 100 herbogenic deaths have occurred in the past two decades, with serious complications requiring dialysis and transplantation 4

Follow-Up Strategy

Arrange close cardiology follow-up (every 3-6 months depending on severity) to monitor for:

• Progressive symptoms or decompensation 1
• Development of atrial fibrillation (significantly increases mortality) 1
• Changes in left ventricular function 1
• Reconsideration of surgical intervention as disease progresses 7

The patient's decision may change as symptoms worsen or with repeated education - maintain open communication and offer reevaluation of surgical options at each visit 7