Early stage dementia and Alzheimer's patients may have a licence to kill
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Some doctors are refusing to sign fitness-to-drive certificates as concerns escalate over where to draw the line.
The last thing Patsy Templeton wanted on her family's conscience was the heartbreak of a major road smash. So she tried to talk her husband, Ronald, out of driving when it became clear Alzheimer's disease was affecting his judgment.
They didn't see eye to eye, but eventually he agreed to an independent driving test, which forced him off the road. It was a decision with a price: Ronald still blames his wife. "It is the hardest thing," she says. "Each thing they lose is something you lose. But to finish off your life with a fatal accident hanging over you is just ghastly."
At least by biting the bullet, the Templetons avoided that far worse outcome. Not so for two elderly drivers given suspended jail terms in two separate NSW court cases last month.
An 85-year-old woman received a six-month suspended term after an accident that caused the death of a newborn and seriously injured her mother. In the other case, a 66-year-old man received a 12-month suspended sentence after an accident that caused the deaths of three people in another vehicle.
Both defendants were banned from driving for 10 years, but during sentencing Newcastle magistrate Michael Morahan said neither driver should be given another licence. He said the NSW Roads and Traffic Authority should have taken their licences away years ago.
And in Queensland late last year an epileptic driver suffered a seizure and caused the death of a two-year old boy and seriously injured his seven-year-old brother and the boys' mother, prompting the Beattie Government to consider making it mandatory for doctors to report risky drivers. That driver was jailed for four years for dangerous driving causing death and grievous bodily harm.
But while recent court cases have sparked debate about when elderly drivers should be taken off the roads and whether those with medical conditions are slipping through the cracks, neurologists have brought the issue into sharp focus by deciding to boycott fitness-to-drive certificates.
The Australian and New Zealand Association of Neurologists (ANZAN) and the Epilepsy Society of Australia have both advised their members to stop certifying patients as fit to drive unless their ability to get behind the wheel is"beyond doubt''.
And they've also predicted members might stop assessing patients altogether if their concerns are not addressed.
They say that while officially, driver licensing authorities in each state are responsible for awarding or removing driving privileges, doctors are effectively forced into the role of de facto licence cops, since in many cases their medical advice is the crucial information the authorities rely on to make the decision.
This, they argue, has a major impact on the doctor-patient relationship, as doctors feel torn between juggling what's best for the patient and the potential road risk.
Patsy Templeton knows just how they feel - and says it's vital for families to have an independent third party, such as a doctor or a driving assessor, take the decision.
But neurologists say they have their own conflict of interest, which not only impairs the quality of decisions they make on whether a patient is fit to drive, but also deters patients from owning up about any medical conditions.
And it's feared that threats in Queensland to make it mandatory for doctors to report patients they suspect of being unfit to drive will just make the problem worse. Such systems operate in South Australia and the Northern Territory, and have been widely criticised by doctors for deterring patients from telling the truth. "In conditions like epilepsy it is a long-term relationship of trust and respect you build with your patients, and then you undermine it by recommending their licence be removed," says Professor Roy Beran, a practising neurologist and president of the Australian College of Legal Medicine.
He and other neurologists are calling for a system where fitness-to-drive decisions are no longer sheeted home to treating doctors. They meet the transport regulation reform body, the National Transport Commission (NTC), next week to discuss a way forward.
Beran says he's pretty strict on licence issues - "you have to be able to sleep at night" - even though he's been threatened and abused by patients for his position.
But he knows other doctors far more lenient than him and, unfortunately for public road safety, so do his patients.
"Doctor shopping most definitely goes on," Beran says.
Professor Ernest Sommerville, chairman of ANZAN's driving committee, has seen this happen too.
"I had a patient who was extremely unhappy and angry about my certifying him unfit to drive - this was someone I knew owned a gun - and he subsequently saw another neurologist, told him a different story and was certified fit," he says. "There is a lot of emotion about this because driving is considered a basic right."
"You have to have a positive relationship with the patient if you are going to get them to follow your advice, which might include accepting side effects of medication. It is easy to give patients the benefit of the doubt in terms of their driving fitness."
Recent research led by Beran and published last month in the Internal Medicine Journal (2007;37:251-57) shows doctors appear to be doing just that. The study of 236 neurologists showed that they were more lenient in assessing fitness to drive than national guidelines said they should be. Three-quarters said they would report patients whom they suspected of driving despite being told they should not, but in reality most of them (64 per cent) rarely, or never, did.
Current guidelines suggest doctors should consider reporting patients counselled not to drive, but who ignore the advice. In SA and NT this reporting is mandatory.
While most states indemnify doctors for reporting someone, there's concern that similar legal protection doesn't apply if they don't. And recent court cases have brought the issue to a head.
In one case in NSW, a coroner has referred to the Director of Public Prosecutions a case in 2002 in which an epileptic bus driver slammed into a tree, killing himself and three of his passengers. ANZAN says this referral to the DPP concerns the actions of a specialist doctor who had been treating the bus driver, and who certified him fit to drive.
According to Beran, this has raised some serious alarm bells in the medical profession."Doctors are scared,'' he says."If action against a colleague who acted in good faith succeeds, then I don't think any doctor would be prepared to assess fitness to drive.''
The NTC has the unenviable task of considering these and other issues as part of its review of the national guidelines on assessing fitness to drive. While it's not due to report until next year, an interim review found there were complex unresolved issues surrounding medical driver assessments and is seeking legal advice.
The review also called for the lack of a national approach to driver assessment to be addressed. But this could well be wishful thinking. Each jurisdiction has its own approach and the NTC has no power to force the states to comply.
Options for assessing driver competence differ across the country, and for elderly drivers the rules are many and varied.
In NSW for example, once you hit 80 you need a medical assessment to assess your fitness. In SA you are medically assessed at age 70, and in Victoria there is no age limit.
The NTC says there doesn't seem to be any real will to address these inconsistencies, despite predictions from the Victorian Parliament's Inquiry into Road Safety for Older Road Users of a marked increase in death and injury due to the ageing population.
One thing the states do appear to have in common is a lacklustre performance on educating drivers about their responsibilities.
Some patient groups, such as Alzheimer's Australia, offer information on driving responsibilities (national helpline 1800 100 500), but proactive information coming from licensing authorities is limited.
In Beran's study, three-quarters of neurologists believe displaying prominent warnings on drivers' licences would help.
Geriatrician Mark Yates acknowledges the tough call neurologists must make, given the difficulty of assessing risk for epileptic drivers. However, he makes judgments on patients because there aren't enough resources to refer every patient with a mild memory problem for outside assessment, costing up to $500 in the private sector.
"The relationship with patients can become fraught," he agrees."This is a major, major decision and has enormous psychological and social impact on the patient you are treating. It is an absolute no-win."
Adelaide GP David Tye, however, accuses neurologists of being"wimps''. Tye, who helped devise the National Transport Commission's current fitness-to-drive guidelines, agrees that deciding if someone should drive can be tough. But, he says, doctors who really don't want to can suggest a second opinion. "We all torment ourselves at times, but ultimately we are the best people to judge."
There may be scope for a national solution, however, in a model currently operating in Victoria, where expert medical panels review difficult driving assessment cases. The scheme runs through the Victorian Institute of Forensic Medicine, which contracts its services to VicRoads and reviews about 6000 files a year.
The institute's head of clinical forensic medicine, associate professor David Wells, says anyone can refer a case - police, concerned family members, and doctors.
"These concerns raised by neurologists are absolutely legitimate,'' he says."People can be highly motivated not to tell their doctor the whole truth about their health."
The beauty of the Victorian system, he says, is that the expert panels have access to information that treating doctors don't, such as driving records. And doctors can step back from the process and keep the trust of their patients. This model is being considered by the NTC and is supported by Austroads, the national peak body for road transport and traffic authorities. But there's no guarantee all states will agree to replicate the system, particularly since it is likely to cost them money.
Also see Killers lurk the back streets