Obtaining Medically Necessary Imaging in Non-Compliant and Incompetent Patients
Primary Strategy: Coordination and Sedation
For patients who are non-compliant and lack decision-making capacity, coordinate closely with the managing physician and family members to facilitate successful diagnostic imaging, and consider procedural sedation when medically necessary imaging cannot be obtained through non-pharmacological approaches. 1
Practical Approach Algorithm
Step 1: Assess Medical Necessity and Urgency
Determine if imaging is truly medically necessary by applying evidence-based appropriateness criteria specific to the clinical scenario (e.g., suspected intracranial pathology with altered mental status, suspected pneumonia with abnormal vital signs, or suspected cauda equina syndrome). 1
Identify urgent/emergent indications that cannot be delayed, such as suspected stroke, intracranial bleeding in anticoagulated patients, cauda equina syndrome, or suspected infection/mass with elevated intracranial pressure. 1, 2
For non-urgent imaging, consider whether the study can be safely deferred until the patient's mental status improves or cooperation can be obtained. 1, 2
Step 2: Optimize the Imaging Environment
Tailor the examination to minimize patient distress and maximize cooperation:
Shorten scan times by decreasing the number of sequences to answer only the specific clinical question. 1
Use motion-reducing sequences when available to decrease sensitivity to patient movement. 1
For MRI specifically, recognize that longer examination lengths, smaller bore sizes, and loud sounds exacerbate symptoms in anxious, claustrophobic, or confused patients. 1
Consider alternative modalities when appropriate—for example, CT instead of MRI when MRI safety screening cannot be reliably obtained due to altered mental status, or ultrasound for certain indications like pneumonia or appendicitis. 1
Step 3: Engage Family and Care Team
Coordination of care with the patient's managing physician and family members is frequently critical to successful diagnostic imaging in patients with altered mental status, delirium, or psychosis. 1
Obtain collateral history from family regarding the patient's baseline mental status, prior imaging tolerance, and any contraindications (especially for MRI safety screening when the patient cannot provide accurate history). 1, 3
Involve family members in calming and reassuring the patient during the procedure when feasible. 1
Step 4: Consider Procedural Sedation When Necessary
When medically necessary imaging cannot be obtained through environmental modifications and behavioral approaches, procedural sedation may be required:
Midazolam is commonly used for sedation in adults and pediatric patients, but requires careful titration with multiple small doses, allowing 3-5 minutes between doses to achieve peak CNS effect and minimize oversedation. 4
Continuous monitoring of respiratory and cardiac function is required (pulse oximetry at minimum) regardless of intended sedation level, as patients may move from light to deep sedation with potential loss of protective reflexes. 4
Immediate availability of resuscitative drugs and age-appropriate equipment with personnel trained in airway management must be assured before administering sedation. 4
For deeply sedated pediatric patients, a dedicated individual other than the practitioner performing the procedure should monitor the patient throughout. 4
Intravenous access should be established before sedation in most cases, though for some pediatric patients the difficulty of IV placement may outweigh benefits—emphasis should be on having IV equipment and skilled personnel immediately available. 4
Step 5: Document Decision-Making
Document the medical necessity of the imaging study based on appropriateness criteria. 1
Document attempts at non-pharmacological approaches and the rationale for sedation if used. 4
For patients lacking capacity, document discussions with surrogate decision-makers and the clinical reasoning supporting the imaging decision. 1
Common Pitfalls to Avoid
Avoid ordering imaging that is not medically necessary simply because the patient is already sedated for another procedure—each imaging study should independently meet appropriateness criteria. 1, 5
Do not assume all non-compliant patients require sedation—many can undergo imaging successfully with environmental modifications, shortened protocols, and family support. 1
Avoid excessive or rapid sedation administration, which increases risk of respiratory depression, airway obstruction, and arrest, especially in debilitated patients or those receiving concomitant CNS depressants. 4
Do not proceed with MRI without adequate safety screening—if the patient cannot provide history and collateral sources are unavailable, consider CT as an alternative when clinically appropriate. 1, 3
Special Considerations by Clinical Scenario
Altered Mental Status with Suspected Intracranial Pathology
Non-contrast head CT is first-line and can be performed rapidly in all patients, including those who are combative or non-compliant. 1
CT does not require the same level of cooperation as MRI and is less sensitive to motion artifact. 1
Suspected Pneumonia in Non-Compliant Patients
Chest radiograph is usually appropriate and can often be obtained even in minimally cooperative patients. 1
Point-of-care ultrasound may be considered as it can be performed at bedside with minimal patient cooperation required. 1