Ethics of Clinical Decision-Making for Older Drivers: Reporting Health-Related Driving Risk

[Sondage sur les pratiques des médecins de famille et sur la collaboration interprofessionnelle avec des ergothérapeutes en GMF quant au dépistage des conducteurs à risque]

Cette étude a sondé 46 médecins de famille québécois quant à leurs pratiques pour l'évaluation et le dépistage des conducteurs à risque afin 1) de mieux comprendre leur niveau de compétence perçu; 2) de recenser les difficultés rencontrées dans le processus de prise de décision et 3) de documenter leurs besoins et attitudes quant à une collaboration plus étroite avec les ergothérapeutes. Les participants (femmes : 84,8 %; moyenne d'expérience : 15,7 (±12,1) ans) ont répondu à un sondage en ligne de 30 questions. Les résultats de cette étude démontrent que malgré un certain confort à effectuer l'évaluation et le dépistage des conducteurs à risque, les médecins ne se considèrent pas comme les professionnels les mieux qualifiés pour ce faire. Ils reconnaissent également le rôle que jouent les ergothérapeutes dans le dépistage de cette clientèle et l'intervention auprès d'elle. Ils voient ainsi la pertinence d'avoir accès aux services de ces professionnels en soins de première ligne.

Nurse practitioners' preferences for online learning regarding driving and dementia

ABSTRACT

With a growing population of older adults living with dementia in the community, nurse practitioners (NPs) are increasingly expected to address issues of medical fitness to drive (MFTD) and driving cessation within their clinical practice. With their expertise in clinical assessment and communication skills, NPs are well suited to this area of practice. Studies that examined MFTD and/or driving cessation suggest that NPs want and need further knowledge and training with this population. As part of our aim to develop an online educational program on driving and dementia for health care providers, including NPs, this mixed-methods study explored NPs' preferences regarding the format and content for the proposed online program. Results from an online survey completed by 90 NPs and interviews with six NPs highlighted key areas of focus for virtual modules, where communication strategies, tools to assess MFTD, and the reporting process for medically unfit drivers were emphasized. Reflecting on their team approach to care, participants in this study preferred a hybrid approach of asynchronous and synchronous learning delivery for this educational program. The next step will be to evaluate this program and its impact on both NP knowledge and skills in terms of its real-world application.

Neuropsychological domains and fitness to drive in mild cognitive impairment or Alzheimer's disease

Cognitive deficits associated with mild cognitive impairment (MCI) or Alzheimer's disease (AD) can impact driving. This integrative review investigated which cognitive domains were associated with poor driving performance or unfitness to drive in studies with outcomes measured in simulator or on-road driving in patients with MCI or AD. The review was conducted by searching for articles published between 2001 and 2020 in the MEDLINE (via PubMed), EMBASE, and SCOPUS databases. Studies addressing patients with other dementias (e.g., vascular or mixed dementia, Lewy body dementia, Parkinson's disease) were excluded. Of 404 articles initially selected, 17 met the eligibility criteria for this review. Based on the findings of this integrative review, attentional capacity, processing speed, executive functions and visuospatial skills were the functions whose declines were most frequently reported in a context of unsafe driving by older adults with MCI or AD. Reports were remarkably heterogeneous in methodological aspects whereas quite limited in cross-cultural coverage and in sample recruited, what prompts for further trials in the field.

Linking people and activities through community mobility: an international comparison of the mobility patterns of older drivers and non-drivers

Community mobility using private and public transportation is important for maintaining health, social participation and living well in later life. This international cross-sectional cohort study (N = 246) reported on the health and driving status of older adults from seven countries where the mobility patterns of drivers and non-drivers were compared in terms of city and rural areas, weather, as well as their respective differences in the number of out-of-home places accessed and quality of life. Older adults participated in a semi-structured interview and completed four standardised instruments: the EQ-5D-5L, modified PULSES health profile, modified Transportation Questionnaire, and the Transport – Participation in Activities and Places Outside the Home. Results suggested inclement weather and place of residence negatively impacted out-of-home activities but did not increase use of public transportation. Drivers accessed more out-of-home activities than non-drivers, suggesting higher community participation among this group, and quality of life was generally high among all participants, but slightly higher for drivers. Findings indicate that a complex myriad of factors can influence community mobility in older adults and further investigations are needed to understand patterns of transport in later life, particularly with regard to those factors that promote and maintain transport mobility, and relationships between transport mobility, community participation and quality of life.

'We're not doing it to be nasty': Caregivers' ethical dilemmas in negotiating driving safety with older adults

The purpose of this research was to investigate how informal caregivers of older adults cope with and negotiate driving safety when their loved one is no longer safe to drive. Fifteen informal caregivers of an older adult living at home took part in the present study. Participants cared for individuals with a range of health conditions that significantly impaired driving safety, including dementia, Parkinson's disease, macular degeneration, and stroke. A thematic analysis of participants' accounts identified the complex interpersonal, social, and organisational context they encountered when their loved one did not recognise or acknowledge limitations in their ability to drive. This analysis highlights the ethical dilemma at the heart of caregivers' experiences and identifies stake and blame as key considerations in the development of sensitive and effective policies and practices.

Standardized on-road tests assessing fitness-to-drive in people with cognitive impairments: A systematic review

Objective

The on-road assessment is the gold standard because of its ecological validity. Yet existing instruments are heterogeneous and little is known about their psychometric properties. This study identified existing on-road assessment instruments and extracted data on psychometric properties and usability in clinical settings.

Method

A systematic review identified studies evaluating standardized on-road evaluation instruments adapted for people with cognitive impairment. Published articles were searched on PubMed, CINHAL, PsycINFO, Web of Science, and ScienceDirect. Study quality and the level of evidence were assessed using the COSMIN checklist. The collected data were synthetized using a narrative approach. Usability was subjectively assessed for each instrument by extracting information on acceptability, access, cost, and training.

Results

The review identified 18 published studies between 1994 and 2016 that investigated 12 different on-road evaluation instruments: the Performance-Based Driving Evaluation, the Washington University Road Test, the New Haven, the Test Ride for Practical Fitness to Drive, the Rhode Island Road Test, the Sum of Manoeuvres Score, the Performance Analysis of Driving Ability, the Composite Driving Assessment Scale, the Nottingham Neurological Driving Assessment, the Driving Observation Schedule, the Record of Driving Errors, and the Western University’s On-road Assessment. Participants were mainly male (64%), between 48 and 80 years old, and had a broad variety of cognitive disorders. Most instruments showed reasonable psychometric values for internal consistency, criterion validity, and reliability. However, the level of evidence was poor to support any of the instruments given the low number of studies for each.

Conclusion

Despite the social and health consequences of decisions taken using these instruments, little is known about the value of a single evaluation and the ability of instruments to identify expected changes. None of the identified on-road evaluation instruments seem currently adapted for clinical settings targeting rehabilitation and occupational priorities rather than road security alone.

Study registration

PROSPERO registration number CRD42018103276.

When a patient's choices entail risks for others: third-party risks, relational ethics, and responsibilities of rehabilitation professionals

PURPOSE

Patients receiving rehabilitation care may act in ways that pose risks to the wellbeing of others. There are numerous situations when patients' actions might pose risks to others, including family members, other patients, or society. For example, such risks arise if patients wish to return home to living in an apartment but risk starting a fire while cooking, or if they insist on driving but their health condition makes doing so unsafe. These situations give rise to ethical challenges, including for health professionals as they seek to promote their patient's autonomy while minimizing risks for the patient and others.

METHODS

We develop a conceptual analysis examining how relational ethics can inform understanding of rehabilitation professionals' responsibilities in responding to third-party risk.

RESULTS

Relational ethics foregrounds the situated, dynamic, and interdependent nature of relationships between people, and supports dialogic approaches to clarify how best to respond. We present a set of 10 questions linked to the concepts of relational autonomy and relational social justice that can contribute to ethical reflection and deliberation among providers, patients, families, and others involved.

CONCLUSION

Relational ethics provides a distinctive angle of view on challenging issues of third-party risk in rehabilitation care.Implications for rehabilitationManaging risk is a recurrent source of ethical challenge in rehabilitation care.Risks to third parties give rise to significant ethical tensions.We propose ten questions that can support a relational ethics approach for responding to situations of third-party risk.