Medical Fitness to Drive

Updated by Nadine Abdullah , MD, M.Ed, FRCPC March 2007

Outline

• General objectives • CMA guidelines • Ontario regulations • Medical Condition Report • Cases • References

General objectives

• To review Ontario regulations for the reporting of patients who are assessed to be unsafe to drive • To review specific medical conditions that are commonly encountered in practice • To review the process of reporting to the Ministry of Transportation

CMA Guidelines

• Individual assessment needed and can be facilitated by referring to the CMA guidelines • If a physician deems a patient unsafe to drive they must notify the patient and inform the ministry in writing (see new online

medical condition report)

• Responsibility for issuing/taking away license rests with licensing authority • Where interest of individual driver and safety of public conflict, latter has priority • Some cases require temporary cessation of driving (eg. post anaesthetic, new time-limited prescription for sedating drug post- injury); patient must be advised, but does not necessitate notification of the ministry

Ontario Regulations

• Liability in Ontario – mandatory reporting of unfit drivers (even if they do not have a license or own a vehicle) – physicians protected from liability if they report unfit drivers – physicians liable to negligence suits for failing to report unfit drivers • Patients appeal directly to licensing authority – may have input from applicant’s physician • Restricted license (eg daylight, not highways) not available in Ontario

http://www.mto.gov.on.ca/english/dandv/driver/medreport/medreport.pdf

Case 1

You are assessing a 43 year old female for follow-up of her epilepsy. Although compliant with her medications, she reports 3 seizures in the last 2 months. You: a) advise her not to drive b) advise her not to drive on highways or during rush hour c) advise her not to drive and report this to the Ministry of Transport d) take away her driver’s license

Learning Objectives

• Understand principles behind determining patient’s ability to drive • Understand medical legal issues • Provide guidelines for driving for patients with seizure disorders

Seizures - First Seizure

• No driving for at least 3 months until complete evaluation (EEG, CT or MRI) • If alcohol withdrawl seizure, can drive if remains alcohol free and seizure free for 6 months, and completes a rehabilitation program for substance dependence • If no cause or no epileptiform activity – private driver can drive if seizure free for 3 months – professional driver can drive if seizure free for 12 months

Seizure - After Epilepsy Dx

• If patient has diagnosis of epilepsy and compliant with anti-epileptic medications – can have private license if seizure free on medications for 6 months – wait 12 months if simple partial seizures – can have commercial license if seizure free for 5 years • After medication withdrawal or change – for private license wait 3 months – commercial license wait 6 months

Back to Case 1

You are assessing a 43 year old female for follow-up of her epilepsy. Although compliant with her medications, she reports 3 seizures in the last 2 months. You a) advise her not to drive b) advise her not to drive on highways or during rush hour

c) advise her not to drive and report this to the Ministry of Transport

d) take away her driver’s license

Case 2

You are assessing a 45 year old TTC subway car driver who is 3 weeks post anterior MI. He has Gr IV systolic LV function and no reversible defects on Thallium GXT. He is medically managed and has NYHA III symptoms. He asks when he can return to driving his train. You recommend: a) 1 month from his MI b) 3 months from his MI c) 6 months from his MI d) never

Learning Objectives

• Review driving guidelines for patients with: – coronary artery disease – arrhythmias – congestive heart failure

Coronary Artery Disease

Stable Angina Acute MI/UA PTCA/stents CABG Private No restrictions Wait 1 month after discharge Wait 48 hrs Wait 1 month after discharge Professional No restrictions Wait 3 months after discharge 7 days Wait 3 months after discharge

Cardiac Arrhythmias

• Consider – frequency, – risk of malignant ventricular arrhythmias – presence of other cardiac disorders • VT/VF controlled on medications or ICD – private - wait 6 months – commercial - disqualified • Atrial arrhythmias and non-sustained VT – in general, can drive unless associated symptoms

Cardiac Arrhythmias

• AV block – disqualified for all classes if Mobitz type II, trifascicular block or acquired 3rd degree • Pacemaker – can drive if asymptomatic 1 week after implantation for private, 1 month for professional driver • ICD – All commercial driving disqualified – For private, primary prophylaxis classes I-III wait 4weeks after implant – Secondary prophylaxis without symptoms, wait 1 week – Secondary prophylaxis with symptoms, wait 6 months after event

CHF, LV Dysfunction

• Private - can’t drive if – NYHA IV symptoms • Professional - can’t drive if – NYHA III symptoms or worse – EF < 35%

Back to Case 2

You are assessing a 45 year old TTC subway car driver who is 3 weeks post anterior MI. He has Gr IV systolic LV function and no reversible defects on Thallium GXT. He is medically managed and has NYHA III symptoms. He asks when he can return to driving his train. You recommend: a) 1 month from his MI b) 3 months from his MI c) 6 months from his MI

d) never (unless LV function and symptoms improve on therapy)

Case 3

You are scheduled to see the following patients in clinic today. Assuming investigations have not been completed, who would you consider safe to drive?

a ) 62 yo with TIA 2 days ago b) 50 yo truck driver with diabetes mellitus, starting on insulin c) 65 yo with syncope 1 week ago d) 55 yo taxi driver with dyspnea at rest from COPD e) 80 yo with visual impairment

Learning Objectives

• Review driving assessments for patients with – Vascular disease – Diabetes mellitus – Syncope – Lung disease – Visual impairment • Review driving issues related to aging

Vascular Disease

• Single or recurrent TIAs – cannot drive until assessed and investigated – can drive if no loss of function and cause addressed • Completed stroke – wait 1 month if minimal loss of functional ability and underlying cause addressed – if residual loss of function - road test • Aortic aneurysm – if > 5.5 cm for men or > 5 cm for women, treat surgically before allowing to drive

Diabetes Mellitus - Insulin Treated

• Private driver - OK if – no severe hypoglycemia within last 6 months • Professional driver - OK if – no severe hypoglycemia or hypoglycemia unawareness within last 6 months – no instability of insulin regimen (e.g. starting insulin or changing dose, need 1 month wait) – no peripheral neuropathy (with loss of function), cardiac reasons, visual impairment – self monitors

Syncope

• Single episode of typical vasovagal syncope – no restriction • Diagnosed and treated cause (eg. PPM for bradycardia) – private wait 1 week; commercial wait 1 month • Situational (eg. micturition) – wait 1 week • Single episode and unexplained – private wait 1 week; commercial wait 12 months • 2 or more episodes in 12 months – private wait 3 months; commercial wait 12 months

Lung Disease

• Chronic respiratory disease – no restriction if none to moderate impairment – road test required if moderate to severe impairment or supplemental oxygen required at rest – must use supplemental oxygen if required and equipment must be safely secured in the vehicle • Obstructive sleep apnea (verified by sleep study) – OK if compliant with CPAP or successful surgery

Visual impairment

• Visual acuity (both eyes open, examine together) – private – not less than 20/50 – commercial – not less than 20/30 • Colour vision – no restrictions but need to be aware of problem to compensate • Hemianopsias - no for all classes • Uncorrected diplopia - no for all classes

Age and Driving

• Older age not a contraindication to driving • Driving may be critical to maintaining independence • Due to increased prevalence of chronic diseases which may impair driving, increase frequency of medical exam for fitness to drive needed as patient ages (eg. yearly after age 80)

Back to Case 3

You are scheduled to see the following patients in clinic today. Assuming investigations have not been completed, who would you consider safe to drive?

a ) 62 yo with TIA 2 days ago b) 80 yo with visual impairment c) 50 yo truck driver with diabetes mellitus, starting on insulin d) 65 yo with syncope 1 week ago e) 55 yo taxi driver with dyspnea at rest from COPD

Bottom line

• If you aren’t sure, advise the patient not to drive and inform the ministry of transportation • Public safety has priority over individual driver

References

• Determining Medical Fitness to Operate Motor Vehicles: CMA Driver’s Guide 7 th edition, 2006 • CCS consensus conference 2003: Assessment of the Cardiac Patient for Fitness to Drive and Fly – executive summary • Ontario Ministry of Transportation “Medical Condition Report” http://www.mto.gov.on.ca/english/dandv/drive r/medreport/medreport.pdf