Reporting epileptic drivers to licensing authorities is unnecessary and counterproductive

Some legal aspects of epilepsy

INTRODUCTION

Legal aspects of epilepsy are jurisdiction-dependent, and this analysis has focused on an Australian context;however, the reader can extrapolate to his/her local jurisdiction and/or legal system.

EPILEPSY AND DRIVING

The AUSTROADS Guidelines have codified the fitness to drive restrictions to be imposed for both private and commercial drivers. They set out the default positions and the considerations that can be applied to deviate from the default of at least 1year seizure freedom for private license holders and 10years seizure freedom for commercial drivers.

EPILEPSY AND EMPLOYMENT

People with epilepsy are broadly excluded from all employment requiring the wearing of a uniform. Only where preemployment medical examination mandates disclosure does the person with epilepsy has to disclose epilepsy to a prospective employer. There are specific laws that control workplace and employment standards that cover occupational health and safety, protection for the disabled, and antidiscrimination.

NEGLIGENCE

Negligence relies on establishing: duty of care; breach of that duty; and damage that is not too remote. Once ascertained, liability is established by the relative causation. The Civil Liability Acts served to redefine negligence, causation, and liability. Added consideration attaches to vicarious liability of the employer for the employee and nondelegable duty of care.

CONCLUSIONS

This overview has examined three legal aspects of epilepsy, namely, driving, employment, and negligence. The concepts and interpretations should have relative applicability well beyond any narrow confines, limited to a single jurisdiction.

Mandatory reporting by doctors of medically unsafe drivers is unpopular and poorly adhered to: a survey of sleep physicians and electro-physicians

BACKGROUND

Medical fitness to drive is one way governments control the issuing and renewal of driving licences, and some jurisdictions demand mandatory reporting (MR) of unsafe drivers by doctors.

AIM

To determine the views, adherence rate and experiences of sleep physicians and electro-physicians with regards to South Australia's (SA) MR law.

METHODS

Self-administered surveys were delivered by post and email to all SA Medical Board-registered sleep physicians (n = 49) and electro-physicians (n = 11). Twenty-nine sleep physicians and six electro-physicians returned surveys, giving a 61% response rate.

RESULTS

Of the doctors, 8 agreed with MR, 19 thought reporting should be voluntary and 6 that doctors should never report. Four doctors had reported all reportable patients, five had never reported any and the rest inconsistently applied the law. MR affected doctors' relationships with their patients as follows: 28 had experienced abuse by patients, 25 suspected patients of doctor shopping and 33 suspected patients of withholding information for fear of loss of licence. Only eight thought they were the most appropriate person to determine their patient's fitness to drive; 29 had not received any training with regards to making such determinations, yet, of these, 27 desired training.

CONCLUSIONS

Widely disliked and causing deterioration of doctor-patient relationships, the MR law is ignored by some and inconsistently applied by most of the doctors surveyed. Further clinician and community education is required regardless of whether the law is abandoned, modified or left unchanged.

Assessing fitness to drive in brain tumour patients: a grey matter of law, ethics, and medicine

BACKGROUND

Neurocognitive deficits from brain tumours may impair the ability to safely operate a motor vehicle. Although certain jurisdictions in Canada legally require that physicians report patients who are unfit to drive, criteria for determining fitness are not clearly defined for brain tumours.

METHODS

Patients receiving brain radiotherapy at our institution from January to June 2009 were identified using the Oncology Patient Information System. In addition to descriptive statistics, details of driving assessment were reviewed retrospectively. The Fisher exact test was used to determine factors predictive of reporting a patient to the Ontario Ministry of Transportation (mto) as unfit to drive. A logistic regression model was constructed to further determine factors predictive of reporting.

RESULTS

Of the 158 patients available for analysis, 48 (30%) were reported to the mto, and 64 (41%) were advised to stop driving. With respect to the 53 patients with seizures, a report was submitted to the mto for 30 (57%), and a documented discussion about the implications of driving was held with 35 (66%). On univariate analysis, younger age, a central nervous system primary, higher brain radiotherapy dose, unifocal disease, and the presence of seizures were predictive of physician reporting (p < 0.05). On logistic regression modelling, the presence of seizures (odds ratio: 3.9) and a higher radiotherapy dose (odds ratio: 1.3) remained predictive of reporting.

INTERPRETATION

Physicians frequently do not discuss the implications of driving with brain tumour patients or are not properly documenting such advice (or both). Clear and concise reporting guidelines need to be drafted given the legal, medical, and ethical concerns surrounding this public health issue.

Disobedience and driving in patients with epilepsy

OBJECTIVE

Motor vehicle accidents direct legislators to ensure pubic safety. We attempted to characterize and quantify driving risk in patients with seizures (PWS).

METHODS

We delivered 12-question surveys to 287 consecutive PWS at an epilepsy clinic in Florida. Illegal and disobedient driving practices were analyzed.

RESULTS

Eighty-three of 236 (35.2%) PWS were eligible to drive and 62.3% were ineligible with a seizure in <6 months (P<0.001, 95% CI: 0.57-0.70). Among the ineligible responders, 23.8% (35/147) of ineligible responders were illegally driving (14.83% of cohort); 11.86% (28/236) of PWS were disobedient refusing to obey the law, and 8.9% (21/236) of PWS were defiant and knew the law. Sadness (75/236, 31.8%) was the most common reaction to restriction, but disobedient PWS were angry (10/28, 35.7%).

CONCLUSION

Overall, a small number of PWS are disobedient and illegally driving. A targeted approach to high-risk drivers with repeated verbal and supplemental driving information may help avoid unnecessary universal physician reporting for PWS.

Impact of mandatory physician reporting on accident risk in epilepsy

BACKGROUND

In some jurisdictions, physicians are required by law to report patients with seizures to the department of motor vehicles. We assessed the hypothesis that mandatory reporting reduces the risk of automobile accidents in people with epilepsy.

METHODS

A retrospective survey of driving and accident rates was done by mailed questionnaire to two groups of subjects with epilepsy in Canada, one living in Ontario where reporting is mandatory and the other in Alberta where it is not. Responses were obtained from a control group without epilepsy for comparison.

RESULTS

The epilepsy (n = 425) and control (n = 375) groups were comparable in age and sex. Seventy-three percent of the epilepsy group were or had been licensed drivers compared to 94% of the controls (rr 0.77, 95% CI 0.73-0.83, p < 0.001). Lifetime accident rate of licensed drivers was 58% in epilepsy and 60% in controls (rr 0.99, 95%CI 0.82-1.19, ns) while 9% of the epilepsy group and 9% of the controls had an accident in the previous year (rr 1.00, 95%CI 0.95-1.06, ns). All those with epilepsy in Ontario (n = 202) and Alberta (n = 223), also comparable in age and sex, had equal lifetime accident rates of 45 and 46% (rr 0.99, 95%CI 0.67-1.47, ns) and 1-year rates of 11 and 8% (rr 1.38, 95%CI 0.59-3.27, ns). In Ontario, 20% of drivers were unlicensed compared to 9% in Alberta (rr 2.39, 95%CI 1.17-4.89, p = 0.01)

CONCLUSION

Although it is clearly dangerous for many people with ongoing seizures to drive, the findings provide no support for the hypothesis that mandatory reporting of patients by physicians reduces accident risk and suggest that concerns about the impact of epilepsy on driving compared to other medical and nonmedical risk factors may be excessive.

Privacy and confidentiality in emergency medicine: obligations and challenges

Respect for privacy and confidentiality have been professional responsibilities of physicians throughout recorded history. This article reviews the moral, religious, and legal foundations of privacy and confidentiality and discusses the distinction between these two closely related concepts. Current federal and state laws are reviewed, including HIPAA regulations and their implications for research and care in the emergency department. In the emergency department, privacy and confidentiality often are challenged by physical design, crowding, visitors, film crews, communication, and other factors. These problems are reviewed, and advice and guidelines are offered for helping preserve patients' dignity and rights to privacy and confidentiality.

Physician reporting of medically impaired drivers

Emergency physicians frequently encounter patients whose medical conditions represent a risk of loss of control while driving, e.g., epilepsy and diabetes. In certain states, physicians are under a legal obligation to report such drivers to the motor vehicular authorities. To determine the uniformity of legislated reporting requirements for physicians caring for patients whose medical conditions represent an automotive hazard, we conducted a survey of Department of Motor Vehicles (DMV) legal departments of all the states in the United States for the academic year 1999-2000 regarding physician reporting of patients with medical conditions that might predispose them to a motor vehicle crash (MVC) and compared the results to a similar study done in 1986. Six (12%) of the states had mandatory reporting laws, 25 (49%) had permissive reporting laws, and 20 (39%) had no laws regarding physician reporting. There was a significant difference between the distribution of laws by year. There was no uniformity on a national level concerning such legislation.