Approach to evaluating patients' fitness to drive during an ED encounter. Review of health advocacy and legal obligations from a Quebec standpoint Audience: Medical students and residents in a small group environment

1. Our role as health advocates and our legal
responsibilities
Farooq Khan MDCM
PGY2 FRCP-EM
McGill University
July 19 2010

2. Objectives
 To review common conditions that may
impair driving
 To employ a simple approach towards
evaluating fitness to drive in the ED
 To understand the health advocate role
and legal obligations of the EP within the
Quebec healthcare system with regards
to driving fitness

3. Common concern..?
 21 year old male presents with delayed
seizures post-TBI
 58 year female with lupus presents with with
CRAO
 47 year old male with new onset Parkinson’s
disease
 68 year old female presenting with a
mechanical fall who is found to have early
dementia
 29 year old female with pseudotumor cerebri
who undergoes dilatation for fundoscopy

4. Should these patients be driving?
 What is our role as physicians in
determining fitness to drive?
 How do we go about doing it?
 What, if any, are our legal obligations?

5. Why do we care?
 Medically unfit drivers contribute to 100 motor vehicle
related fatalities every day in North America
 Worldwide 5000 pedestrians per year are killed by
medically unfit drivers
 Doctors have a responsibility to protect the public and
serve as health advocates
 These drivers and their victims end up in our EDs
 An epidemiological study at Sunnybrook trauma center in
2008 found
 37% of drivers admitted for MVC had reportable conditions
 Fewer than 3% were actually reported
 85% of those patients had visited a doctor in the past year
 In most of Canada and the US, reporting medical
conditions that impair driving is mandated by law

6. How?
 Think of whether or not the patient can
fulfill all the required functions of driving
Can they operate the various controls?
(pedals, steering wheel, indicators, mirrors,
etc)
○ Motor skills, coordination, balance
Is their sensory perception adequate?
○ Audition, vision, touch/proprioception
Do they possess the mental faculties?
○ Memory, judgment, vigilance

7. Observe your patients as they enter
the examining room
 General appearance: hygiene, grooming,
hemiplegia, glasses, involuntary
movements
 Mobility: gait, speed, posture, balance,
need for assistance, transfers
 Handshake: grip strength, upper extremity
ROM
 Conversation: audition, confusion,
coherence, mental status, dysarthria, EOM,
social appropriateness

8. Historical elements of concern
 PMH:
CVA, DM, CAD, arrythmias pacer/ICD,
aneurysms (all types), dementia, epilepsy,
neurodegenerative disorders, glaucoma,
cataracts, macular degeneration, sleep
apnea, substance abuse
 Medications:
psychotropics (benzos), antiarrhythmics,
anticonvulsants, narcotics, muscle relaxants,
EtOH and illicit drugs, mydriatics,
cycloplegics

9. Historical elements of concern
 Prior visual/auditory problems
 Unexplained LOC
 Evidence of memory loss (especially in
elderly, obtain collateral history)
 Decrease in ADLs, IADLs
 Pain, limited neck movements
 Vertigo/dizziness
 Palpitations

10. Driving history
 How the patient arrived
 Type of vehicle (truck, motorcycle, etc.)
 Previous accidents, infractions
 Change in driving habits
Voluntarily imposed limits (avoiding rush
hour, or driving at night)
Long distance driving
Races
 Presence of alternate driver
 Professional driver (bus, taxi, etc)

11. Physical exam
 VS: arrythmias, bradycardia, hypotension
 Visual acuity and gross visual fields
 Neck mobility (particularly rotation)
 CVS: aortic stenosis murmur
 Abdo: AAA
 Extremities: sensory/motor deficits, limited
ROM, amputation
 Gait: assisted, antalgic, paretic, loss of
balance
 Mental status: low MMSE, psychomotor
retardation, attention deficit, apraxia, lack
of judgment or planning

12. So now recap
 Is there a medical condition (intrinsic to the patient
or acquired through therapy) that decreases the
patients aptitude to drive or renders it unsafe?
 What kind of conversation should you be having
with your patient?
 How long should they avoid driving?
 Should they be giving up driving altogether?
 What kind of modifications will allow them to retain their
licenses?
 What resources can help you and your patients?
 Occupational therapy, neuropsychiatric evaluation,
specialized evaluating MDs.
 Public transit, Transport adapté, community services

13. Ethical and legal considerations
 Ethical principles at odds
Patient privacy, confidentiality and autonomy
Public health, protecting other citizens from
dangerous drivers
 Physicians in Québec do not revoke
licenses. The SAAQ makes that decision.
Reporting is discretionary not mandatory
 The Code de sécurité routière authorizes
physicians to break confidentiality and
inform the SAAQ when patients are judged
to be inapt at driving

14. Ethical and legal considerations
 Our ethical and professional obligation is to inform our
patients of their condition and the risk if they continue
to drive
 Recommend that they discontinue driving until an
exhaustive evaluation can be carried out
 If it is felt that the patient will not respect the
recommendation and continues to be a danger to
others, then the physician is duty bound to inform the
SAAQ
 Inform patients of your decision to report and document
carefully!
 Seizure disorders, EtOH and drug abuse, and
psychiatric disorders are high risk diagnoses for
litigation
 Physicians have been found liable for failure to report

15. Take home messages
 Keep fitness to drive in the back of your
mind
 When a condition of concern presents
itself, take a couple of extra minutes to
assess the situation
 Advise your patients of the risk involved,
and take action if the patient’s behaviour
is a danger to self or others

16. Contact the SAAQ
 SAAQ: Service de l'évaluation médicale - QUÉBEC
Postal address :
Société de l'assurance automobile du Québec
Service de l'évaluation médicale
C. P. 19500
QUÉBEC (Québec)
G1K 8J5
Telephone: 418 643-5506 or 1 800 561-2858
 Highway Safety Code: Regulation respecting access to driving a
road vehicle in connection with the health of drivers, R.S.Q., c. C-
24.2, r.0.1.0001
http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=3&file=/C_24_2/C24

17. References
 Collège des médecins du Québec, L’évaluation médicale de l’aptitude à conduire un véhicule automobile, Guide
d’exercice, Montreal, Collège des médecins du Québec, mars 2007 [En Ligne]
http://www.cmq.org/fr/MedecinsMembres/Ateliers/~/media/9DADF56514BB48D2B0C70568F96FB8FF.ashx?41016
 American Medical Association National Highway Traffic Safety Administration. Physician’s Guide to Assessing
and Counseling Older Drivers, [Chicago (Illinois), American Medical Association, September 2003]. [Online]
http://www.nhtsa.dot.gov/people/injury/olddrive/physician_guide/PhysiciansGuide.pdf.
 Canadian Medical Association. Determining Medical Fitness to Operate Motor Vehicles, CMA Driver's Guide 7th
edition., Ottawa, Canadian Medical Association, 2006. [Online]
http://www.cma.ca/index.php/ci_id/18223/la_id/1.htm
 Canadian Cardiovascular Society Consensus Conference 2003. Assessment of the Cardiac Patient for Fitness
to Drive and Fly: Final Report, [Ottawa, Canadian Cardiovascular Society], 2003. [Online]
http://www.ccs.ca/download/consensus_conference/consensus_conference_archives/2003_Fitness.pdf
 Collège des médecins du Québec. Aspects légaux, déontologiques, et organisationnels de la pratique médicale
au Québec: ALDO-Québec, Montréal, Collège des médecins du Québec, mai 2006. [En ligne]
http://www.cmq.org/aldofrancais.aspx
 Société de l’assurance automobile du Québec. Guide de l’évaluation médicale et optométrique des conducteurs
au Québec, 1re
éd. rév., Québec, Société de l’assurance automobile du Québec, 1999. [En ligne]
http://www.saaq.gouv.qc.ca/documents/documents_pdf/permis/guidemed.html
 Redelmeier, D., Venkatesh, V., Stanbrook, M.. Mandatory Reporting by Physicians of Patients Potentially Unfit
to Drive. Open Medicine, North America, 2, Feb. 2008. [Online] http://www.openmedicine.ca/article/view/141
 European Commission. Transport, Road Safety
 Diabetes and Driving in Europe: A Report of the Second European Working Group on Diabetes and Driving,
[Brussels,European Commission, July 2006]. [Online]
http://ec.europa.eu/transport/roadsafety/behavior/doc/diabetes_and_driving_in_europe_final_1.pdf.
 Epilepsy and Driving in Europe: A Report of the Second European Working Group on Epilepsy and Driving,
[Brussels, European Commission], April 3rd
2005. [Online]
http://ec.europa.eu/transport/roadsafety/behavior/doc/epilepsy_and_driving_in_europe_
final_report_v2_en.pdf.
 New Standards for the Visual Functions of Drivers: Report of the Eyesight Working Group, [Brussels,
European Commission], May 2005. [Online]
http://ec.europa.eu/transport/roadsafety/behavior/doc/new_standards_final_version_en.pdf