What do you do when your
very own Mr Magoo parks his car on your clinic's
lawn when he arrives for his annual check-up? |
It was the worst imaginable case.
A commercial truck driver walked into Dr David Butcher's
rural northern BC practice complaining of alcohol withdrawal
seizures. "I had to inform him it wasn't safe for him
to drive because he was not dealing with his alcohol
addiction problems," recalls Dr Butcher, knowing the
assessment he was obliged by law to submit to the motor
vehicle authority would rob the man of his livelihood.
The patient spent the next year
and a half trying to get other physicians to contradict
Dr Butcher's assessment before he managed to get his
addiction under control. "It became quite adversarial,
but it did create an opportunity to talk about how he
had to deal with his addiction," Dr Butcher says, finding
the silver lining in an otherwise very unpleasant situation.
Dealing with driving cessation
can be one of your biggest headaches: the truck driver
who denies his addictions; the stroke recovery patient
who insist she's "Just fine!"; and the octogenarian
who flat-out refuses to give up the keys to his Caddy
even as his kids tell you Mr Magoo could drive circles
around him.
GP
GUIDEBOOK
That's where the CMA's recently published seventh edition
of "Determining medical fitness to operate motor vehicles,"
(free for members) comes in. The wildly popular resource
was first published over 30 years ago and it has remained
one of the most widely-used CMA products ever since,
says CMA president Colin McMillan. "Practising physicians
lean on it heavily," he notes.
Talking to patients about stopping
driving — or flying planes or piloting trains,
the guide covers it all — is never easy. "It often
takes a critical event, like a medical problem, to get
them to confront their own driving restrictions," says
Dr Butcher, the editor-in-chief of the seventh edition.
"Sometimes it can be easy and they say, 'Thank you for
reminding me,' but more often it can be quite a blow
to them."
EARLY
PLANNING
There are two common scenarios that can play out with
driving cessation, explains Dr Butcher. The first is
the question of when seniors should give up driving,
and the second is brought about by a medical event or
a worsening medical condition.
For seniors, the subject is best
approached from the broader perspective of advanced
planning for general lifestyle changes. "With the senior
driver, we are trying to encourage thinking along the
lines of end-of-life planning, to think about thresholds,
when it may be time to stop driving," says Dr Butcher,
"and to have that conversation early so it's not a shock."
If you raise the issue before it becomes urgent and
patients feel like you're stealing their independence,
you're more likely to get a constructive response and
to get your elderly patients thinking about the subject.
"It also helps to address driving
in terms of the medical, musculoskeletal and cognitive
functions involved," says Dr Butcher, "because patients
often feel experience will compensate for other shortcomings."
That is true to a point, admits Dr Butcher — but
even Jacques Villeneuve-level experience can't compensate
for legitimate functional disabilities like dementia,
macular degeneration or seizures.
"MOM,
IT'S TIME"
If the topic is not addressed early, the patient may
not recognize when it's time to give up driving —
and that's when the pressure from family members and
the concerns about safety can arise.
Dr McMillan remembers when he and
his family asked his mother to stop driving. "She felt
like we were pulling the rug out from under her in terms
of getting to the hairdresser or anything," he says.
Frustration is common when seniors must stop driving.
Physicians must be aware of the possibility of patients'
reduced activity levels and access to social engagements,
and the risk of depression. This is especially true
for rural seniors, who tend to rely on driving more.
"It's surprising how much of a shock it is for them,"
says Dr McMillan.
NOT
JUST SENIORS
Although many patients who must cease driving are elderly,
age alone is not considered a risk factor, according
to the Canadian Institutes for Health Research (CIHR).
Accordingly, the CMA guide (as well as other Canadian
driving cessation tools like CIHR's CanDrive and the
University of Alberta's DriveABLE) adopts a functional
approach to driving — one that focuses on concrete,
physical and cognitive abilities associated with driving.
Patients of any age with vision problems, severe cardiovascular
risk factors, substance abuse problems or dementia,
among other conditions, may not be safe drivers according
to the criteria set out by provincial transportation
regulatory bodies.
DR
COPPER
The matter of legal responsibility is an important one
to keep in mind. Doctors are legally required to report
unsafe drivers to their province's motor vehicle authority
in all provinces except Alberta, Nova Scotia and Quebec,
where reporting is left to the doctors' discretion.
"This creates a moral dilemma,"
acknowledges Dr Butcher. "On one hand, you are trying
to advocate for your patient's best interest, but on
the other hand you are part of the public health system
trying to protect others."
The new edition of the CMA guide
is the first one to include a section written by the
Canadian Medical Protection Association (CMPA) about
doctors' legal protection when reporting dangerous drivers.
According to the CMPA, there were at least 39 lawsuits
between the years of 2001-2005 against physicians that
dealt with fitness to drive.
Don't know who to call to report
a dangerous driver? Just flip to Appendix E in your
handy CMA guide for the number.
Title: Percentage of elderly
drivers with medical conditions
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