Ethics case study
Dealing with older, impaired drivers
- Previously published ethics case studies are available online.
- For additional ethics resources, visit the College's Center for Ethics and Professionalism
This is the 25th in a series of case studies with commentaries by ACP-ASIM's Ethics and Human Rights Committee and Center for Ethics and Professionalism. The series uses hypothetical cases to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's "Ethics Manual" or other position statements.
Mr. Carr is a new patient. He is 85 years old, active and lives alone in a small apartment in a suburb of Cleveland. He receives leuprolide acetate (depot suspension) every three months for prostate cancer. He takes no other medication and has no other medical problems.
During a routine visit with Dr. Helms, memory problems surface in the conversation. Mr. Carr mentions that he got a little lost coming to the office, although it is less than a mile from home. On a mental state evaluation, he loses points for orientation, attention, calculation, recall and visuospatial tasks. His total score is 18 out of 30. His blood pressure in the office is elevated at 180/85, and his physical, including neuromuscular, vision and funduscopic exams, is normal.
Dr. Helms recommends a driver's evaluation, but Mr. Carr refuses. "Why do that? What if that test doesn't turn out so good? I've got to be able to get out of my apartment. Got to be able to get to the grocery and to the drug store," he says.
Dr. Helms explains her concerns about Mr. Carr's ability to drive safely. Mr. Carr says he only drives during the day and always in his own neighborhood. He says he has no moving traffic violations. Still, Dr. Helms worries about Mr. Carr being injured or getting lost, and about his driving responsiveness, especially in poor weather. "I don't think I would want him to be out driving where my kids are walking home from school," she says to herself. But she is also concerned about restricting Mr. Carr's ability to get around and about patient confidentiality issues.
Elderly individuals are more likely to be involved in accidents during the day, in good weather, at intersections, close to home and involving two vehicles.
It becomes difficult to continue a candid conversation. Dr. Helms makes a note to call Mr. Carr's only son in Arizona for more information after receiving Mr. Carr's permission to do so. In Ohio, there is no mandatory reporting law regarding drivers who are impaired by cognitive limitations. What else, if anything, should Dr. Helms do?
Physicians may face several potential ethical conflicts when the issue of driver safety arises. The topic may surface where there is evidence of impaired cognition during an office visit or when a patient's family member approaches the physician to ask the physician to "order" a patient not to drive. Ethical issues of autonomy, beneficence and nonmaleficence, as well as public health concerns, can be clearly identified in these scenarios. There are also implications for the physician's relationship with the patient and family.
Respect for the patient and for his decision to choose driving as a method of transportation and as a means of independence are important, as is patient confidentiality. Beneficence in certain settings may necessitate that physicians suggest altered driving patterns to improve driver safety, since the oldest drivers have the highest per capita fatalities. Nonmaleficence suggests preventing the loss of independence, level of functioning and possible depression that may ensue if driving is limited. Alternative transportation could even be dangerous if it requires waiting at secluded bus stops or crossing busy intersections. Physicians must balance the rights and privileges of individual patients with their responsibility to the community and the public health.
It is clear, however, that driving safety is a purview of the physician. It is an instrumental activity of daily living, necessary for a person's independent functioning in the community. There is no single predictor of adverse driving events (moving violations, motor vehicle accidents) that can be applied in the office. Nevertheless, research suggests certain prognostic indicators. Therefore, health care providers must query, examine and counsel their patients with respect to driving safety.
As a group, older drivers are involved in motor vehicle accidents at a rate equal to or less than middle-aged drivers. However, the rate of older persons involved in fatal crashes rises after age 70. Compared with the fatality rate for drivers between the ages of 25 and 69, drivers 70 and over have a per mile fatality rate nine times as high. For drivers age 85 and over, the per mile fatality rate exceeds all groups, including that of teenagers.1
The most common contributing factors in accidents and moving violations in older individuals include pulling out from the side of the road or changing lanes, careless backing, inaccurate turning and difficulty giving right of way and reading traffic signs.2
These accidents seldom involve high speeds or alcohol. Rather, problem driving in older adults involves visual, cognitive and motor skills, which may decline with age. When compared with younger drivers, elderly individuals are more likely to be involved in accidents during the day, in good weather, at intersections, close to home and involving two vehicles. In addition, they are more likely to be determined to be at fault by investigating officers.3
The high fatality rate in the elderly population may be related to diminished physiologic reserve. The higher mortality and morbidity with head trauma in the older patient may be explained by pre-existing central nervous system (CNS) conditions such as degenerative brain disease or hydrocephalus, cerebrovascular disease or CNS hypoperfusion. There is often concomitant chronic medical disease, including cardiovascular, pulmonary and immunologic disorders. Osteoporosis increases the risk of fracture. Corrected for severity of injury, elderly patients are five to six times more likely to die of similar injuries than younger drivers.3
Here are other pertinent issues regarding elderly drivers that physicians should note:
State laws. State reporting laws vary regarding potentially unsafe drivers. Seven states (Pennsylvania, New Jersey, Delaware, Georgia, Nevada, Oregon and California) require doctors to report health conditions that are hazardous to driving to licensing agencies. Some states require physicians to specify conditions such as epilepsy or dementia. All seven states give physicians who report unsafe drivers immunity from litigation. Ten states permit physician reporting, but Ohio and North Dakota do not grant immunity. Other jurisdictions permit physician reporting only after the patient has refused to report himself.4
In states without immunity, physicians may be reluctant to report a potentially unsafe driver. Physicians should nonetheless report impaired drivers who clearly endanger themselves and/or the safety of the public and use their best judgment in determining when to report.
Confidentiality. Confidentiality and respect for patient privacy are fundamental to medical care and the patient-physician relationship. Confidentiality, however, is not absolute and may have to be breached to protect individuals or the public, or to disclose information required by law. Before breaching confidentiality, physicians must ensure that they have made every effort to talk to patients about the issues. If confidentiality is to be breached, it should be done in a manner that minimizes harm to the patient.5
Obligation to the potentially unsafe driver. Assessment of patient impairments that might result in unsafe driving is an ethical obligation. The goal of identifying the potentially unsafe older driver is to try to alter the driving behavior pattern before an adverse event occurs. Studies have not shown that chronic illness, functional status or mental impairment consistently predict adverse events.
One recent study, however, demonstrated that the presence of heart disease, when adjusted for age, gender and miles driven, predicted the adaptation of driving as well as the incidence of adverse driving events. It is not clear if it is the presence of heart disease or the side effect of the medications to treat the illness that is responsible for these predictions. 6 Research has also shown that the inability to draw intersecting five-sided polygons was a better predictor than the Folstein Mini Mental Status Exam score or patients' recall ability, and this inability did identify those who quit vs. those currently driving.
There is even controversy about the safety of drivers who have been diagnosed with Alzheimer's disease. Post and Whitehouse suggest that persons diagnosed with probable Alzheimer's disease may be able to continue driving for three years after the initial diagnosis.7 Other experts feel that even early in the disease, there can be difficulty attending to multiple visual sources of input. Such a deficit in attending to and inhibiting appropriate stimuli could place even a mildly demented individual at risk as a driver.8
Driver assessment courses have been developed to evaluate the visual and motor coordination and behind-the-wheel abilities of older persons. The most sophisticated courses are run by occupational therapists (OTs) who are certified in driver assessment and rehabilitation. These assessments are not designed to predict crash risk. Rather, they are designed to directly measure the effect of specific cognitive or physical deficits on driving skills. Many metropolitan areas have such programs.
Older driver rehabilitation. Typical recommendations of a licensed OT driver evaluation include resume driving; refrain from driving; resume driving with vehicle adaptations; or begin OT driver rehabilitation. Typically, OT driver rehabilitation for the elderly consists of four to 16 hours of treatment. This is a systematic program of therapy specifically designed to decrease a person's driving risk. It is only offered to those who demonstrate a good prognosis for resuming independent driving. Programs such as AARP's "55 Alive" also provide education programs for older drivers. (Some insurance companies discount policies for drivers who take such courses.)
The physician should consider counseling the partner of a slightly impaired older driver to continue or resume an equal share of the driving, with the patient's permission. Typically, married women do very little driving if the couple owns one car. However, it is important for married women to maintain their driving skills so they can maintain their independence if the husband's driving skills decline.
The physician must keep in mind that although these are reasonable recommendations, there are no hard data to show that these interventions will reduce future accidents.
Counseling. Counseling a patient regarding driving behavior, even when the data are clear, can be difficult. Telling an older person to alter his driving habits and consider alternative forms of transportation can be devastating. It has been shown that people who relinquish their driving privileges suffer a sense of loss. It threatens self-esteem and personal dignity, and it implies social disability and dependency on others. Patients may deny the problem and resent what they see as physician intrusion.
Nonetheless, physicians must try to have an open conversation with their patients. The counseling process can be more effective and comfortable when the patient is prepared to deal with difficult news and when the physician provides information slowly in small amounts, as if providing an abnormal biopsy report.9
Once the patient is willing to consider a change in driving behavior, the physician may offer recommendations, which may include a referral to a licensed driver evaluation program. The physician should provide information about transportation alternatives. This information can be found at the Alzheimer's Association, the Office of the Aging and your local department of transportation. (For more resources, see "Driving safety resources," this page.)
Dr. Helms needs to develop a continuing relationship with her patient, talk more with the patient and/or family, broaden her understanding about the nature and extent of the patient's cognitive and physical deficits and help acquire information on transportation options that the patient may use if his driving ability is restricted in the future. Only then can she give her patient advice about driving.
Dr. Helms must balance the rights and privileges of her individual patient with her responsibility to the community and to the public health. If she determines that reporting is necessary because of a clear danger to the patient and/or the public, she must discuss this first with Mr. Carr. Even if it is too soon for that action, it is not too early to encourage Mr. Carr to think about how he will function without driving when the time comes.
Acknowledgments: The Ethics and Human Rights Committee would like to thank Barbara Messinger-Rapport, FACP; Lois Snyder, JD; and Risa Lavizzo-Mourey, FACP, authors of the case history and commentary. The authors would like to thank Harvey L. Sterns, PhD, professor of psychology, University of Akron, and Ronni S. Sterns, PhD, adjunct fellow, Institute for Life-Span Development and Gerontology, University of Akron.
References 1. U.S. Department of Transportation, National Highway Traffic Safety Administration, Traffic Safety Facts. DOT HS 808 955, 1998.
2. Assessing the Driving Ability of the Elderly: A Preliminary Investigation. Ellen D. Taira (ed). The Haworth Press, New York, 1989.
3. Mandavia D, Newton K. Geriatric Trauma. Emergency Medicine Clinics of North America. 1998;16:257-274.
4. U.S. Department of Transportation, National Highway Traffic Safety Administration, Safe Mobility for Older People Notebook. DOT HS 808 853, April 1999.
5. American College of Physicians Ethics Manual, fourth ed., Ann Intern Med. 1998;128:576-594.
6. Gallo JJ, Rebok GW, Lesikar SE. The Driving Habits of Adults Aged 60 years and older. J Am Geriatr Soc. 1999;47:335-341.
7. Post and Whitehouse. Journal of the American Geriatrics Society. 1995;43:1423-1429.
8. Duchek JM, et al. The role of selective attention in driving and dementia of the Alzheimer type. Alzheimer Disease and Associated Disorders. 1997;11 Suppl 1:48-56.
9. Faulkner A, et al. Breaking bad news-a flow diagram. Palliative Medicine, 1994;8(2):145-151.
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