Agitated Patient With Dementia and No Imaging-Specific Consent
A 79-year-old woman with moderate Alzheimer's disease arrives in a wheelchair with her daughter for a screening mammogram ordered by her physician. She had a mammogram two years ago that required no special handling. Today she is oriented to person only, becomes agitated when the technologist raises the compression paddle, pulls away, and repeatedly tries to lower the footrest to stand. Her daughter has a durable power of attorney for health care but has not signed an imaging-specific consent. Four patients are waiting and the room is not private. No interpreter is needed; the daughter is the historian.
1. What consent and patient-assessment issues must you resolve before continuing?
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Assessment first:
- Determine whether the agitation is from pain, discomfort, fear, the closed room, the wheelchair footrest, a full bladder, or simply being rushed. A reversible cause changes everything.
- Ask the daughter what usually calms her mother and whether she can follow one-step instructions on a good day.
Consent:
- The daughter's durable power of attorney for health care generally authorizes her to consent to a routine screening exam on her mother's behalf, but confirm the document covers health care decisions broadly and document that you reviewed it.
- The patient's own assent still matters. If she is resisting, a surrogate's signature does not authorize physical restraint for a non-urgent screening study.
- Screening mammography is elective. When the patient actively refuses, the correct answer is to stop, not to overpower.
Document the assessment, the surrogate's consent, and the patient's response.
2. If the daughter wants to proceed, what practical steps give you the best chance of a diagnostic-quality exam?
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Environment: move to a quiet room, close the door, dim unnecessary light, and reduce the number of people present to you and the daughter.
Communication: one instruction at a time, short sentences, name each step before you do it, allow the daughter to repeat instructions in familiar words. Tell her when you are about to compress and count down.
Positioning and timing:
- Image the easier side or the easiest view first to build tolerance; MLO is often better tolerated than CC in a wheelchair.
- Keep compression time short but adequate - do not sacrifice compression quality to speed, since a non-diagnostic film means the whole ordeal is repeated.
- Allow her to keep her hand on the machine or hold her daughter's hand; give rest breaks between views.
- Consider scheduling a dedicated slot at a quiet time of day if today fails.
Every adaptation here is aimed at adequacy, not just compliance.
3. After two views she is crying and pushing the paddle away. When do you stop and what do you document?
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Stop now. Continued attempts escalate distress, risk injury during a transfer or a fall from the chair, and will not produce interpretable images.
Documentation:
- The patient's mental status and behavior at the time, quoted where possible.
- Which views were completed and which were not, with the reason.
- That the surrogate was present, the consent basis, and the patient's refusal.
- That the radiologist and the ordering provider were notified.
Follow-up actions:
- Ask the radiologist whether the partial study answers any clinical question; if not, say so explicitly rather than letting a truncated exam pass as a screening.
- Discuss alternatives with the daughter: a longer appointment at a quieter time, a different facility with more space, or having the ordering provider address anxiety or discomfort beforehand.
- Ensure the ordering provider knows the screening was not completed, so the gap in care is visible and not silently closed.
Patient dignity and safety outrank an unfilled appointment slot.