Driving home hard truths

The end-of-driving talk may be the toughest — but most necessary — conversation you have with your patients.

By Karen Auge, Contributing Editor

No one wants an elderly or visually impaired person hurt, especially in a car accident. But, no one wants to tell that person it’s likely time to hand over the car keys.

Marian Betz, MD, of the University of Colorado School of Medicine’s Department of Emergency Medicine, says physicians dread these conversations so much that they would rather have an end-of-life-care discussion with a patient than initiate the end-of-driving talk.

But, hard as those conversations may be, they are necessary. And, as the population ages — those 85 and older are the fastest growing segment of the population¹ — ophthalmologists will increasingly find themselves navigating the emotional, and in some cases legal, minefield of convincing patients to park the car for good (see sidebar, page 55).

“It’s a difficult topic,” Dr. Betz says. “We all know we’re going to die, but we tend to think we’re going to drive right up until then.”

As life expectancy grows, so too do the chances an older adult outlives her ability to drive safely, Dr. Betz says in her study on older and impaired driving.²

So physicians, especially ophthalmologists, must prepare themselves for those end-of-driving conversations. For many physicians, that means venturing into unfamiliar territory, Dr. Betz says. “Because of the way we train physicians, they haven’t had the skills to deal with it.”

THE DISCUSSION

Get the family’s help

Elena B. Roth, MD, of the Bascom Palmer Eye Institute, says it’s important to invite the patient’s family to participate — with the patient’s permission, of course. Not only are family members helpful in convincing a patient to give up driving, they may be part of the patient’s future transportation picture, she says. And, they can provide emotional support at what can be a very upsetting time.

Be straight with them

Andrew Iwach, MD, executive director of the Glaucoma Center of San Francisco, says that his approach typically is to give the facts of the patient’s condition as soon as possible. Include the prognosis for disease progression — including the consequences of that progression on the patient’s life — as well as the treatment plan.

Most importantly, he says, don’t forget the significance of what you’re asking a patient to give up — not just access to a car, but independence. “Acknowledge it’s a major loss,” Dr. Iwach says.

Better sooner than later

Even patients with degenerative conditions like glaucoma can often expect to see well for years if the condition is caught early and treated. So, having the conversation sooner rather than later gives the patient time to come to grips with the possibility of a future that doesn’t include being behind the wheel.

“I just had to have this conversation with the mom of one of my best friends,” Dr. Roth says. “I just kind of approach it directly, usually by saying, ‘what are you doing about driving?’”

Most of the time, the conversation is not unexpected, Dr. Roth says. “Over the years, I’ve had patients say, ‘I only drive to the supermarket,’ or ‘I only drive during the day.’”

If a patient is reluctant to stop driving altogether, the National Institute on Aging advises physicians to have one-on-one conversations, including family members if possible, and avoid criticisms or accusations. The institute’s website recommends a conversation along the lines of: “I am concerned about your safety when you are driving,” rather than, “You’re no longer a safe driver.”

Focus on the patient’s future

Practicing in San Francisco gives Dr. Iwach an advantage with regard to providing transportation alternatives. His patients in this area tend to be more tech-savvy than their generational counterparts elsewhere in the country and can likely download an Uber app on their smartphone and dial up a driving alternative. It helps, too, that the Bay Area hums with mass transportation.

However, not all ophthalmologists have so many options at their disposal, so Dr. Betz advises physicians to get creative. “We have to reframe the conversation so that, although it is the loss of one privilege, it doesn’t have to mean the loss of engagement in life. Hopefully we can direct the conversation to, ‘What are ways I can still get out and do things using alternatives?’”

In most communities, even if Uber drivers aren’t at the ready, there are transportation services available, Dr. Betz says. Those vary from one location to another, but can include everything from buses to faith-based options, to dial-a-ride services designed for seniors. For additional resources, visit www.buyautoinsurance.com/senior-safe-driving.

Walk a fine line

As expected, this discussion can be difficult for patients who face many frustrations when their sight is fading, Dr. Roth says. “There is so much they have to face losing — paying bills, just getting around at all and reading.”

All of which helps explain why, even when faced with the reality of a debilitating condition, some impaired and older adults resist the idea of parking permanently.

Dr. Roth acknowledges that, despite all her preparation, empathy and having the family involved, patients sometimes put up a fight. She says she even had patients ask her to lie on Department of Motor Vehicles paperwork.

In Florida, where Dr. Roth practices, drivers age 80 and over must renew their driver’s license every year. And that renewal includes an eye exam, which largely takes responsibility for forcing a driver out of the car to the DMV, she explains.

Those practicing in other states don’t have the same luxury. “Physicians may be in a conflicting role of advocating for patients and simultaneously protective of public safety,” according to a 2000 study.⁴ “However, this obligation must be in proportion to actual and relative risk . . . Otherwise, the breach of patient confidentiality by the physician cannot be justified ethically.”

The study’s authors caution against physicians taking on the role of law enforcers, primarily because it may unravel the patient-doctor relationship and make may even cause the patient to avoid care altogether.

PREPARE YOURSELF

Know the law

In 2012, an Orange County, Calif., internist was sued by the family of a man killed in a crash caused by an 85-year-old woman with dementia. The victim’s family alleged that the physician, who had treated the woman for memory loss, was liable for the accident because he didn’t stop the woman from driving.

The case went to trial, and made headlines. The jury did not hold the physician responsible. Still, physicians may be forgiven for feeling they are damned if they do, and damned if they don’t.

Beyond the ethics involved, Dr. Betz says you must educate yourself on the laws and regulations that dictate your responsibilities before you have the driving conversation with patients.

Regarding patient confidentiality, it’s a legal requirement under HIPAA. However, “There have been cases in which a physician has been held legally responsible for a crash incurred by his or her patient because there was evidence that the physician knew about a functional impairment that rendered driving unsafe and did not report it to authorities.”⁵

Fortunately, guidelines exist to help you strike a safe balance between these legal (and ethical) dilemmas. Laws regarding a physician’s responsibilities vary from state to state. As of 2000, nearly all states had policies for a physician wrestling with whether to identify impaired drivers.⁶

In most states, notification of state licensing authorities is voluntary. Delaware, New Jersey and Nevada require physicians to report patients with epilepsy. California and Utah mandate physicians to report drivers with dementia or cognitive impairment; in California, failing to do so may trigger discipline by the state medical board.

Maine has established a Medical Advisory Board to develop uniform criteria for the physical and mental competence required for driving. State lawmakers passed legislation limiting physician liability then shifted responsibility for the decision to allow a patient to continue driving from physicians to the state DMV.

For assistance, AAA offers state-by-state guidelines, including BCVA, on physicians’ legal responsibilities on its Foundation for Traffic Safety website (http://tinyurl.com/pt8q5aa).

Your new golden rule

With all the varied rules, Dr. Iwach has three words of advice for fellow physicians: Document. Document. Document.

“Absolutely document in the [patient’s] chart that you’ve had that discussion,” Dr. Iwach says. Every time it arises again, document that too.

Ultimately, though, in many states, unless dementia is involved, the final decision most often is the patient’s.

That’s why, when all else fails, Dr. Iwach says he’s willing to resort to other options. “Often what resonates most is reminding them that, ‘Not only could you hurt yourself, you could hurt someone else,’” he says. And often, all he has to say is: “How would you feel if you hurt a child?”

Hard as it can be to convince a patient to stop driving, succeeding doesn’t mean the physician’s involvement is over, Dr. Roth cautions. Follow-up is essential. Pay attention to the patient’s appearance — is it disheveled or unkempt? Ask if the patient struggles to get around. Because no matter how prepared a patient may be to give up driving, the reality of doing it can trigger depression and isolation, Dr. Roth says. “It’s that feeling of powerlessness,” that can be devastating. “So do stay involved.” OM

REFERENCES