Helping older patients decide to stop driving
■ A column that answers questions on ethical issues in medical practice
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Feb. 2, 2004.
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Any advice for talking to older patients about driving safety and alternatives to driving?
Telling a patient that he or she should no longer drive is, at best, an uncomfortable task for most physicians and a dreaded one for many. Without specific training to assess driving skills and without clear guidelines on when driving is no longer safe for an individual, it is not surprising that doctors often lack the confidence to deliver this news, which will have a major impact on a patient's life. The physician may also be concerned that if a patient gives up driving he or she may experience diminished quality of life, depression or isolation, and may refuse to comply with recommendations or fail to return for basic medical care out of anger.
Despite these concerns, doctors are being asked to address driving safety with older patients more frequently, and in a significant minority of cases physicians' opinions will be the deciding factor. Physicians can take a number of steps to make this important duty manageable and effective.
It is essential to know your state's law regarding driving as it relates to medical conditions. For example, all states have mandatory revocation of driving privileges for significant vision impairment. On the other hand, the laws concerning driving with dementia are quite variable. Some states have mandatory reporting of people with dementia, while others offer no specific guidelines. A working knowledge of these laws and their prescribed procedures will help structure the physician's work.
Physicians should talk to patients about the need to change driving habits, including eventual cessation in driving, at the earliest stages of progressive diseases whose ravages will eventually affect driving ability, such as Parkinson's disease and macular degeneration. Passengers can monitor the patient's driving safety and alert the patient to possible problems. This strategy facilitates gradual adaptation and acceptance.
When it becomes apparent that driving is no longer safe, there should be a detailed patient-physician discussion of the risks, benefits, and alternatives to driving. As the process unfolds, it helps to acknowledge to the patient how difficult it is to offer such advice. Patients can be told how we, as doctors, struggle to balance their privilege to drive with their safety and that of the public. They can also be reminded that physicians do have professional, ethical, and, at times, legal obligations to fulfill in that regard.
Physicians should review the patient's personal history, e.g., disorientation and previous crashes, and look for physical signs, such as decreased visual acuity, motor changes or cognitive impairment, that are of concern.
Older drivers should be aware of safety risks, including higher crash rates among people their age and also that they are more likely to be injured in the event of a crash than a younger driver or passenger is. Crashes with an elderly driver are more likely to involve other vehicles, which raises the prospect of injuring others.
Any of these possible outcomes, of which the patient and his or her loved ones need to be aware, could seriously affect the patient's emotional and financial welfare and could possibly have legal consequences. The consequences may be more severe if there is a record of the patient having been counseled not to drive.
Physicians should point out to patients who are considering giving up driving that it will improve their safety and the safety of others, offer peace of mind for caregivers, and possibly save them money because they would no longer be responsible for automobile upkeep, taxes and insurance.
There are risks of driving cessation. Patients may feel socially isolated if they lack friends and family to turn to for support. Caregivers may have to shoulder added driving duties, watch as their loved ones rue their loss of driving, or experience guilt for their role in that loss. Depending on the alternative modes of transportation available to the patient, the patient may carry an increased financial burden. Loss of the independence that driving provides can make patients depressed and may necessitate a new living arrangement.
Even with some deterioration in driving skills, it may not be clear whether it is unsafe for a person to continue driving. A formal assessment by the Dept. of Motor Vehicles or a driver rehabilitation specialist is an invaluable resource to make this determination.
Some patients will respond to written instructions, such as a brief letter or an order written on a prescription pad. Physicians should follow patients over time to assess their compliance and adaptations to these lifestyle changes and to recognize and address depression, caregiver burden and social isolation. Physicians must also maintain clear and detailed medical records of their work in this area.
When a patient rejects advice to adjust his or her driving habits or to stop driving, it may be necessary to enlist others to help sway the patient's opinion.
The patient's family can be counseled to ask trusted friends, clergy, the family attorney, or even their insurance agent to intervene. If that fails, most states have a mechanism for the physician or family to report a dangerous driver to the DMV, who will then determine if revocation of the license is warranted.
There is a caveat here: Physicians must know what their state regulations have to say about the legal and ethical ramifications of reporting without the patient's consent. Many states offer legal immunity for these breaches of confidentiality. For the persistent patients who are clearly unsafe drivers but continue to drive, at times even after license revocation, families can be advised about ways to disable a car to prevent driving.
Alternative forms of transportation may help ease the burden of driving cessation. Usually this is a function provided by friends and family. Some patients may also be able to use public transportation such as buses, cabs, and trains. Many locations have transportation to medical services for the elderly for free or at discounted prices. Churches and social organizations often provide volunteers to drive. The local office of aging is another resource.
Finally, many organizations have resources available for patients, caregivers, and physicians confronting this difficult and growing problem. Among them are the AMA (link), AARP, American Automobile Assn., Alzheimer's Assn. and the U.S. Dept. of Transportation.
William H. Roccaforte, MD, associate professor of psychiatry, University of Nebraska Medical Center, Omaha; director, Creighton-Nebraska general and geriatric psychiatry residency training programs
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.