Intended for healthcare professionals

Careers

My patient’s condition could affect their fitness to drive. What should I do?

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1622 (Published 09 April 2019) Cite this as: BMJ 2019;365:l1622

Observations column

Should healthcare professionals breach confidentiality when a patient is unfit to drive?

  1. Abi Rimmer
  1. The BMJ

It is often difficult to know what to do when a patient continues to drive despite medical advice but guidance is available, three experts tell Abi Rimmer

Consider how to support safe driving

Desmond O’Neill, consultant physician and director of the National Office for Traffic Medicine, Dublin, says, “The UK and Ireland have helpful and regularly updated guidelines on medical fitness to drive. These are supportive of continued safe driving and over recent decades have reduced restrictions on driving. This is recognition of better evidence and of how many medical interventions, from cataract surgery to therapy for obstructive sleep apnoea, can improve driving safety.

“The first step is to check the online guidelines on medical fitness to drive on the Driver and Vehicle Licensing Agency (DVLA) website (or, in Ireland, the National Driver Licence Service).12 It’s worth remembering that certain conditions may involve several elements of the guidelines, such as vision and neuropathy problems for drivers with diabetes. Equally, it’s important to factor in multimorbidity, and the guidelines will usually clarify which element has the most significant impact on medical fitness to drive.

“The resulting discussion with the patient will be based on the understanding that they can only continue to drive for as long as they follow medical advice, comply with treatment, and maintain their health. This includes a declaration of their medical condition to the relevant licensing agency, as required.

“Consider what care elements may support safe driving, from drug compliance to car adaptations. If in doubt, a further opinion from another specialist, such as an occupational therapist or driving assessor, may be helpful. The DVLA also offers advice.

“Relatively small numbers of patients refuse to follow medical advice and DVLA and National Driver Licence Service guidance gives useful advice on how to proceed when there is a significant risk to the driver and the public.”

Remember your duty to protect the patient and the public

Colin Melville, medical director and director of education and standards for the General Medical Council, says, “Doctors have a vital role in public protection and should keep up to date with disorders and conditions that can impair a person’s fitness to drive. The DVLA regularly updates its guidance.

“If a patient’s condition or treatment could affect their safety as a driver, you should alert them to their legal duty to inform the relevant licensing agency, and encourage them to act on it. This may be difficult news for patients but they must put safety first.

“If a patient disputes the diagnosis, you can suggest they seek a second opinion and help them to arrange this but be clear they should not drive in the meantime. Ultimately, it’s for the DVLA advisers to determine whether someone is fit to drive.

“If you learn that a patient has continued to drive, you should make every reasonable effort to persuade them to stop. If those warnings are ignored, you should consider the risk of the patient’s actions—to themselves and to the wider public.

“If you think their refusal to stop driving leaves others exposed to a risk of death or serious harm, contact the DVLA and disclose any relevant medical information, in confidence, to the medical adviser.

“Wherever and whenever possible, inform the patient before you make your disclosure and consider any objections they raise. You should also advise your patient in writing once you have done so, and make a note in their record. Remember that, while respecting patient confidentiality is important, you also have a wider duty to protect the patient and the public.”

Keep records of your discussions with the patient

Edward Farnan, Medical Defence Union medico-legal adviser, says, “Drivers are legally required to notify the relevant licensing agency of anything that would have a likely impact on safe driving ability. Doctors and other healthcare professionals may need to advise patients if they should notify a particular medical condition.

“DVLA guidance Assessing fitness to drive: a guide for medical professionals will help you decide if a patient’s ability to drive might be impaired by a medical condition; treatment; certain medications, particularly those affecting the central nervous system; or alcohol or drug misuse.

“Be aware that different standards apply to professional drivers, such as HGV drivers and bus drivers.

“If you’re unsure, get advice from an experienced colleague or your medical defence organisation. Alternatively, discuss the case anonymously with a medical adviser at the DVLA or, in Northern Ireland, the Driver and Vehicle Agency (DVA).

“Advise the patient, in accordance with GMC guidance, that their condition or treatment may affect their ability to drive and that they have a legal obligation to inform the DVLA or DVA, and to stop driving. It’s a criminal offence for the driver to fail to do so. The decision on whether the patient’s licence will be withdrawn rests with the DVLA or DVA.

“If the patient refuses to accept your assessment and advice, suggest they seek a second opinion and advise them they must not drive while waiting for the second opinion.

“If you become aware of the patient continuing to drive, try to persuade them to stop, and warn them you may be obliged to disclose relevant medical information to the DVLA or DVA if they persist. If you believe a patient’s refusal to stop driving leaves others exposed to a risk of death or serious harm or they do not have the capacity to understand your advice, you should contact the DVLA or DVA promptly.

“Ideally, inform the patient of your intention to disclose information before doing so and consider any objections they have. If disclosure remains appropriate write to the patient afterwards to inform them of your actions.”

“Keep clear and comprehensive records of your discussions with the patient.”

References

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