The New Old Age - Caring and Coping
February 22, 2011, 1:32 pm
When Elderly Drivers Must Stop Driving
By JANE GROSS
When is it time to give up the car keys?

In my many years of reporting about the elderly, I found little that caused doctors more angst than confronting a patient and family about driving. When is it time for someone with physical or cognitive problems to give up the car keys? Who makes that decision? And how can it safely and compassionately be enforced?

Late into the fray, but with a comprehensive and thoughtful handbook, is the American Medical Association, in collaboration with the National Highway Traffic Safety Administration. Recently updated, the “A.M.A. Physician’s Guide to Assessing and Counseling Older Drivers” is an invaluable addition to the literature on the subject, directed to its own members but accessible and informative to the layperson as well.

The guidebook has plenty of information about assessing a patient’s driving ability; medications and medical conditions that impair mobility, vision, hearing, reflexes and judgment; tips on having the conversation with patients and caregivers; advice on how to avoid isolation and dependence when driving is no longer sensible or safe; discussion of a doctor’s ethical responsibilities; and state-by-state guidelines for reporting drivers to the state department of motor vehicles, which has the ultimate say in who remains on the road.

Alas, among the takeaways of the guidebook are the great difficulties physicians have at this fraught moment, and how much easier it would be for them if the decision did not involve them. As it is, physicians must wrestle with laws that vary by state on a variety of issues: if and how elderly drivers are assessed differently than younger ones; whether it is mandatory or optional for doctors to report their concerns; how they are supposed to go about it and strike the right balance between confidentiality and safety; and whether they risk legal liability if, on the one hand, they alert the state authorities or, on the other hand, they keep silent and a subsequent accident occurs.

In the current issue of the journal Health Affairs, Dr. Anna Reisman, an internist in Connecticut and an associate professor at the Yale School of Medicine, tells the tangled tale of a doctor (herself), an elderly patient who lied about continuing to drive and his son, who was unwilling to intervene and anger his father. “Surrendering the Keys: A Doctor Tries to Get an Impaired Elderly Patient to Stop Driving,’’ is Dr. Reisman’s guilt-ridden lament about failing to get her patient off the road after he flunked an assessment she asked him to take following a small fender-bender. The patient almost dropped her, all because of a problem that had never been raised by her professors in medical school or in residency training.

“A moment such as this was — and is — awkward,’’ she wrote. “I dreaded conversations about driving. Driving safety wasn’t something I could treat with a prescription or with how-to medical advice. It was a big messy issue that sprawled beyond the confines of the office to the realm of public safety…. Like most of my peers I had little experience in assessing safe driving…. The only driving related question we were trained to ask — ‘Do you wear a seat belt?’ — was buried in a general office checklist, somewhere between ‘Have you ever injected drugs?’ and ‘Do you have a gun in the house?’ [Nobody] had ever told me I might bear some responsibility for deciding whether a patient should be behind the wheel.’’

Dr. Reisman studied up on the issue in part by using the A.M.A. guidebook. That is where she learned that only six states — California, Delaware, New Jersey, Nevada, Oregon and Pennsylvania — have mandatory reporting requirements for doctors. Other states, Connecticut among them, do not require a doctor to report a physically or cognitively impaired driver but permit doctors to express their concerns if they fear harm to a patient or the public.

Fourteen states require greater frequency in renewing licenses after a certain age — say, every two years instead of five for those older than 70. Seventeen states make special demands of the elderly — that they renew in person rather than by mail, for instance, or take a vision test. Some states offer legal immunity to doctors who report patients, and others don’t. Some allow family members or other concerned parties to report drivers to the state motor vehicles department. Some have stringent privacy restrictions. Others permit anonymous reports. All consider such reporting permissible under the Health Insurance Portability and Accountability Act, the federal law that is supposed to guarantee medical confidentiality.

Among many recommendations in her article, Dr. Reisman urges greater legal uniformity across states in this matter, suggesting that all require in-person renewals for elderly drivers, for example. She also suggests more education for doctors about having these conversations and assessing driving competency. She calls for clarity regarding the medical privacy act, which can be more limiting than necessary in the hands of those who are poorly trained and play it safe with a law they do not understand.

“The A.M.A recognizes that the safety of older drivers is a growing health public health concern,’’ says the organization’s primer. But, it asks, “How can you fulfill these competing legal and ethical duties?” The A.M.A. goes on to tell doctors how to part with as little information as possible, and how to guard against lawsuits or deal with a patient who threatens to leave and find another doctor who won’t report him.

In its summation, the association urges doctors to remind patients, again and again, that the state D.M.V., and only the D.M.V., decides who drives. These are the bureaucracies, ensconced in dreary offices, where waits for a simple transaction can last hours. For most of us, that it is not confidence-inspiring. That said, is it fair to solely blame the California D.M.V., several years back, for renewing the license of an 86-year-old man who confused the accelerator and brake and mowed down 73 people, killing 10, including a 3-year-old girl, at a Santa Monica farmer’s market?

Jane Gross, a former New York Times reporter and founding blogger of The New Old Age, is the author of “A Bittersweet Season: Caring for Our Aging Parents — and Ourselves,’’ to be published by Knopf on April 26.

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