Should Our Hospice Patients Be Driving?

Dear Editor:

Does the following situation sound familiar? The setting is your interdisciplinary team meeting. The case manager is discussing Mr. Johnson, a frail 78-year-old with stage IV lung cancer. His pain and dyspnea are controlled with long-acting morphine and one or two breakthrough doses per day. He is weak and intermittently confused. At the end of the nurse's presentation, she says, “He's still driving, so if you see an old red pickup in the vicinity of Taylorsville, get off the road.” Various team members express their concern. The social worker says that Mr. Johnson's family has not been able to persuade him to stop driving: “I suggested that they take away his keys, but his kids say they are afraid that he will get mad at them.” Many of the other team members nod their heads knowingly because Mr. Johnson is not the team's only patient whose driving ability is questionable.

As our population ages, the number of drivers with advanced medical illness increases. Two articles published in the Journal of the American Medical Association address the effect of dementia ¹ and other medical illness on driving ability. ² Researchers have studied the effects of opioids^3,4 and other commonly used medications on traffic safety. ⁵ I am not aware of research examining the driving ability of hospice and palliative medicine patients. Our patients can be more complicated than other patient groups because they suffer from advanced medical illnesses, can have multiple comorbidities, and are usually taking a variety of medications for disease modification and symptom management.

The American Medical Association published an opinion regarding physicians' responsibility to recognize impairments in patients' driving ability that pose a strong threat to public safety and that ultimately may need to be reported to the Department of Motor Vehicles (DMV). “Physicians should assess patients' physical or mental impairments that might adversely affect driving abilities. Physicians should use their best judgment when determining when to report impairments that could limit a patient's ability to drive safely. In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician's advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the DMV.” ⁶ Some states mandate reporting of unsafe drivers and every physician should know their local laws. ⁷

What is the best way to assess a patient's driving ability? There are no published recommendations to help hospice and palliative medicine professionals address the problem of driving safety. I would like to propose the approach detailed in Table 1.

Although we want to ensure both patient and public safety, we must also be cognizant of the emotional and logistical complications of driving cessation. In our society, driving is part of being independent. Losing this independence may result in increased social isolation and depression. ⁸ As a field, we should lobby for coordinated efforts between medical and transportation communities, policy makers, community planners, the automobile industry, and government agencies to achieve the common goal of safe transportation for our medically disadvantaged population. ⁹

Resources available to hospice and palliative medicine providers include the “AMA Physician's Guide to Assessing and Counseling Older Drivers” published in 2010. This document contains chapters on identifying unsafe drivers, comprehensive state licensing and reporting laws, ethical and legal responsibilities of the physician, a review of medical conditions and medications that may affect driving, and recommendations on patient and family counseling. ¹⁰ Another resource is a driver rehabilitation specialist. These are professionals who coordinate evaluations and services for individuals with disabilities. They can do a formal driver and passenger vehicle evaluation, provide adaptive driving instruction or driver retraining, and coordinate recommended vehicle modifications. A listing by state is available from the Association for Driver Rehabilitation Specialists. ¹¹ The Hartford's website includes useful checklists for family and friends who are concerned about an individual's driving abilities. ¹²