Surrendering The Keys: A doctor tries to get an impaired elderly patient to stop driving (Anne Reisman)

When Mr. Daniels asked me to sign a form for a disabled parking permit from the Department of Motor Vehicles (DMV), I was puzzled. As far as I knew, he hadn’t driven at all since his fender bender the year before.

After the car accident, he and his son had come to my office. “Should he be driving?” the son had asked. I remember Mr. Daniels snorting at the absurdity of the question. He was eighty, a lanky man with thick white hair that he frequently smoothed back with one hand. Other than some mild memory loss, he was pretty healthy.

Mr. Daniels told me he was a fine driver. He’d never had any problems on the road, he added: He had never received a speeding ticket or been pulled over by the police. He then announced that he would never voluntarily give up his driver’s license. When I wouldn’t let the issue drop, he humored me and agreed to an eye exam and a memory test during the office visit.

A moment such as this was- and isawkward. 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 into the realm of public safety.

Like most of my peers, I had little experience in assessing safe driving, whether for the elderly or for patients of any age. It wasn’t covered in medical school or residency training. The only driving-related question we were trained to ask- Do you wear a seat belt?was buried in a general office-visit checklist, somewhere between Have you ever injected drugs? and Do you have a gun in the house? None of my professors or mentors had ever told me that I might bear some responsibility for deciding whether a patient should be behind the wheel.

It’s not easy hearing your doctor- supposedly, your advocate- telling you it’s time to turn in your keys. Recently, I met a patient I’d seen a couple of times. His doctor had moved away, and he was on his way to meet his new primary care doctor. He told me he was scared; he’d heard that she’d reported a friend of his to the DMV as a potentially unsafe driver.

I assured him that the doctor was a reasonable person and must have had serious concerns. What I didn’t tell him was that although he might not have seen it this way, he was lucky: When I’d seen him, I hadn’t even thought about assessing his driving.

During the office visit after the fender bender, I asked Mr. Daniels to read from an eye chart, then checked his peripheral vision. A mental status test revealed the memory loss I already knew about, which by itself was not enough to make him unfit to drive.

He could turn his neck easily and had no problems mimicking moving his right foot from gas pedal to brake. But I could only guess at how Mr. Daniels managed in traffic or handled complex tasks such as changing lanes and parallel parking. So I suggested an on-road assessment. Confident, he was happy to oblige.

In these evaluations, offered through driving rehabilitation organizations, an assessor reviews a person’s medical and driving records, then takes the person out on the road. Insurance companies generally don’t reimburse for the test, which usually costs $300-$400. Afterward, the driving assessor writes a report in which he states whether he believes the person is a safe driver; might benefit from adaptive equipment at an additional cost, such as wide-angle rearview mirrors, blind-spot mirrors, or leftfoot gas pedals; needs a remedial driving course; or should limit driving to familiar routes during daylight hours.

Mr. Daniels’s report didn’t recommend any such options; he’d flunked the test. He didn’t signal before turning, he accelerated toward yellow lights, and he failed to look over his shoulder when changing lanes. I flipped to the last page of the report to read the assessor’s overall impression. This driver, the report concluded, should not be on the road at all.

But an assessor’s report doesn’t have the force of law behind it. Here in Connecticut, only the Department of Motor Vehicles can make the official decision to take away a person’s driver’s license. Most doctors would rather negotiate with the patient and family than bring the DMV into the discussion, and most patients and families prefer that as well.

In our state, as far as I knew, there was no mandate that physicians had to report questionable drivers. And I had no idea whether physicians were protected from legal action if they reported a patient, or whether failing to report a patient had legal consequences. It was awkward enough to tell a patient that you believed that the DMV should remove his license, much less to be accused of violating his privacy and end up with a lawsuit.

It would be easier for the doctor and the family to persuade the patient to stop driving, and that was what I hoped to do with Mr. Daniels.

When I reviewed the driving assessor’s report with him and his son, Mr. Daniels was surprised.
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“I don’t know what they’re talking about,” he said. “I drove fine.”

“Not according to the report,” I said. I read the summary aloud, again. “You have to give it up. You’re putting your life at risk, and the lives of others.” I told him that I was going to include my recommendation that he stop driving in his medical record.

He cursed under his breath. “It’s nonsense,” he said. “I’m a good driver. I need to drive.”

I talked to him about alternative modes of transportation: taxis, rides from family and friends, senior citizen van services. I also told him that our hospital’s social worker could fill him in on additional resources.

His son promised that whenever he could, he’d drive his father to town. Mr. Daniels listened, his eyebrows drawn into a deep frown.

Finally, he waved a hand in front of his face. “Enough,” he said. “I’ll figure something out. I’ll stop, I’ll stop.”

Something Fishy

So why, a year later, was Mr. Daniels asking for a disabled parking permit?

He’d missed his six-month follow-up appointment, so by the time I saw him again, a full year had passed. Until his return, I had no reason to suspect that he hadn’t stopped driving; he’d said he would. We’d had the conversation with his son there, and the son had promised to help with rides. The same son who’d brought him today and who was sitting there with us, fiddling with his cell phone.

I leaned forward in my chair, elbows on knees, and looked into Mr. Daniels’s watery gray eyes. “Are you still driving?”

“Well.. .you know.” Mr. Daniels let his gaze drop to the floor. “When other people give me rides, you know, sometimes there’s. ..well.. .a long walk from the parking lot.”

This didn’t make sense as a reason for a disabled parking permit. I felt a rush of anger. If the car and the keys were accessible, what was to stop a mildly demented patient like Mr. Daniels from going for a drive?

I appreciated that he didn’t want to inconvenience relatives and friends. I knew that the threat of losing a driver’s license was hard for family members, too, and that many had no clear way to manage the new responsibility of helping a stranded parent with daily errands. But Mr. Daniels had promised to stop driving.

I told him I couldn’t sign the form.

“When your son drives you here,” I said, “he can drop you off at the front door and then go park.” After all, it wasn’t as if Mr. Daniels had severe dementia and couldn’t be left alone safely.

I glanced at his son, who continued fiddling with his cell phone. I sensed that he was avoiding looking at me. Something seemed fishy, very fishy. But I didn’t want to accuse Mr. Daniels, or his son, of lying.

I remembered feeling the same mixture of anger and doubt about what I had been told a couple of years earlier, when I’d seen another elderly man, one whose license had been taken away after he’d fallen asleep while driving. On her way out of the office with him, his companion had passed me a note that read: “He drives every day. He cannot know I told you.”

I was dumbstruck. If I’d told my patient about the note, or insisted that his companion reveal that she’d told me, I probably would have destroyed their relationship. But if I didn’t, I might be putting the safety of the public at risk.

I should have told him I knew. But I didn’t. It takes guts to ask the hard questions and make the hard statements.

I reminded Mr. Daniels again that he’d failed the driving test and that it was unsafe for him to be on the road. He swore that he wasn’t.

And so I had nothing to report. It was frustrating. I couldn’t write a letter to the DMV saying that this patient shouldn’t be driving, and in fact he told me he wasn’t driving, but that something was nagging me about it. I could just see a DMV official laughing about yet another presumptuous doctor who expected them to install a hidden camera trained on the patient’s garage.

I didn’t know what to do. I asked Mr. Daniels to come back in two months. I figured that would give me plenty of time to figure this out.

Getting Facts And Guidance

I began with research. With US life expectancy at an all-time high, there are more and more elderly drivers on the road. Estimates are that in 2020 there will be approximately forty million licensed drivers over age sixty-five.

In some ways, the elderly are safer drivers than younger people. They’re more likely to use seat belts and less likely to drive at night, after drinking, during rush hour, or in bad weather. They’re less likely to speed or to use cell phones or text while driving.

But even in the hands of the sharpest drivers, cars are dangerous and potentially lethal machines. Every year car collisions cause five million injuries that require visits to the emergency department. In 2009 there were 33,808 highway fatalities in the United States.

Many of these injuries affect the elderly. In fact, the leading cause of injury-related death in people ages 6574 is motor vehicle collisions. In people ages 75-84, driving-related injuries are the second leading cause of injuryrelated death, after falls. The fatality rate per mile is higher for the elderly than for any other group- except those under age twenty-five. And because the elderly are more fragile, they’re more susceptible to serious injury in collisions.

Some doctors might be falsely reassured by a claim of low daily mileage when many elderly patients limit or give up highway driving. But because local roads are often trickier to navigate than highways- with multiple stop signs, intersections, and traffic circles- older drivers have more collisions per mile driven than do younger drivers.

So it makes sense for the elderly, their families, and their doctors to talk about driving safety and, in some cases, driving retirement. Stopping driving, however, as Mr. Daniels anticipated, can take a significant toll. Removing access to a car, especially in a place without decent public transportation, can have a profoundly negative effect on an elderly person. Apart from being inconvenient, the resulting social isolation and loss of autonomy and independence can lead to depression and anxiety, and can increase the possibility of entering a nursing home.

Next I looked for guidance. The American Medical Association’s (AMA’s) online “Physician’s Guide to Assessing and Counseling Older Drivers” has plenty of material about the doctor’s role in assessing driving abilities in elderly patients. There is information on medications and medical conditions that can affect driving, tips on how to talk to patients with dementia who don’t want to stop driving, advice to families, summaries of the doctor’s ethical obligations, and more.

I read papers addressing the challenges of protecting both the patient and public safety. A guide put out by the insurance company The Hartford, titled “We Need to Talk.. .Family Conversations with Older Drivers,” is chock-full of advice to families trying to guide an elderly parent toward driving retirement. The American Occupational Therapy Association dedicates a section of its website to older driver safety and offers tips, handouts, resources, and various other helpful materials.

I found a number of concrete suggestions for physicians: write a prescription forbidding driving; point out the economic advantages of giving up driving; or tell the family to deliberately damage or hide the car keys, disable the engine, or get a family lawyer involved.

Some physicians advise their patients that automobile insurance policies might not cover damages if a person is in a collision after being told to stop driving by a physician. I thought I could try that one with Mr. Daniels- but of course, according to him, he wasn’t driving.

I studied the AMA’s 2010 state-bystate lists of guidelines for reporting potentially unsafe drivers. Only a few states- including California, Oregon, and Pennsylvania- have mandatory reporting requirements. Some states offer legal immunity to doctors who report their patients; others do not.

A number of states encourage but do not require physicians to report potentially unsafe drivers. In my state, Connecticut, physicians aren’t required to report patients but “may” report patients with “any chronic health problem which in the physician’s judgment will significantly affect the person’s ability to safely operate a motor vehicle.”

What I couldn’t find in all of this information was advice on dealing with a patient suspected of driving when he had been advised to stay off the road.

I talked to the social worker at our hospital. She said she’d spoken with Mr. Daniels’s son several times about the need to remove the car keys from his father’s house or disable the car battery. But the son had said that he didn’t want to anger his father.

I talked to a psychologist. He suggested a family meeting. When I raised this idea later with Mr. Daniels, he wasn’t interested. I presume he knew exactly what would happen and wanted to avoid the inevitable group pressure.

I talked to the hospital lawyer, who reiterated what I’d read: The state of Connecticut doesn’t require reporting of suspected poor drivers by health care professionals. But, the lawyer added, if there is a “clear and immediate danger,” the physician should notify the DMV, and then must inform the patient that the notification has occurred.

I was left even more confused. The phrase “clear and immediate danger” was anything but clear. True, if Mr. Daniels was driving, he was a potential danger to himself and others every time he started the car. But he wasn’t driving drunk, and he’d only had one accident, which had been minor. And, most important, he’d sworn to me that he wasn’t driving at all. If I reported him, I would be forced to show that I didn’t believe him.

I decided not to contact the DMV and to wait until Mr. Daniels’s next appointment so we could discuss the problem further. I hoped that I would become convinced of his honesty.

But he didn’t come to the next appointment, or to the one after that.

So Who’s Responsible- And For What?

Who, then, is ultimately responsible for assessing elderly drivers’ safety on the road?

Primary care doctors certainly can and do play an important role. They should discuss driving safety with every patient-not only elderly patients- and be familiar with their state’s laws about reporting potentially unsafe drivers.

Annual health screening forms need to include specific questions about driving. Patient and family education materials on how to assess driving ability and tips for family members dealing with a possibly impaired driver should be available in doctors’ waiting rooms. Highlighting the topic on the medical recertification board examinations, required every ten years for internists, would help emphasize the driving safety issue.

Primary care physicians in academic settings should teach their students and residents how to assess driving safety in the office and how to document these conversations. Many medical schools already require students to demonstrate their clinical skills with “standardized” patients- trained participants who portray specific kinds of patients. Such sessions could include an interview with an elderly patient that focuses on driving safety issues. Driving safety might also be discussed whenever an elderly patient who still drives is discharged after a hospital admission.

But asking primary care physicians to carry this burden alone is unreasonable. We’re concerned about violating patient privacy and mamtaining the doctorpatient relationship. We struggle with the ambiguous language of state guidelines. We don’t see our patients behind the wheel, and on-road driving assessments are often expensive. We need help from other stakeholders.

First, all states should provide legal immunity for physicians who, in good faith, report potentially unsafe drivers. Concern about a lawsuit could certainly discourage many physicians from reporting a patient to the DMV. Texas, for example, takes this into account. That state encourages physicians to write to the DMV about potentially unsafe drivers, and the law specifies that this is an exception to the patient-physician privilege. Doctors who do report a patient are granted full legal immunity. However, a number of states have no legal immunity for physicians who report their patients.

Second, we need a clearer and more uniform policy about which elderly drivers should have their driving tested. Currently, only fourteen states require older drivers to renew their licenses more frequently than younger drivers, and only seventeen states require additional testing for older drivers.

The interval between license renewals differs from state to state, and some states permit drivers to mail in their renewals. Requiring all elderly people to come in for renewals would offer an opportunity to retest vision, hearing, and basic driving skills and knowledge. Driving simulators might provide another cost-effective type of testing that could be done at license renewal.

Third, communities need to create better transportation options for those who no longer drive. Public transportation options are often limited, and private cars or shuttles can be costly. Options specifically designed for seniors, such as in-town shuttles, are often more user-friendly and safe for the elderly.

Whether all states should adopt mandatory reporting laws for potentially unsafe drivers is more difficult to say. For me, it would have been much easier if Mr. Daniels and I had lived in Pennsylvania or another state with mandatory reporting. It would have made my telling the DMV about Mr. Daniels a nobrainer, in the same way that physicians are required to report suspected child or elder abuse. You can’t hem and haw, as I had done in Mr. Daniels’s case. You just have to do it.

But mandatory reporting alone is not the answer. And although groups like the AARP and AAA advocate for the rights of elderly drivers and oppose tests that single them out, the current system-where doctors are loath to report their elderly patients and patients fear talking about driving with their doctors-isn’t working. We need a better framework: more affordable ways to assess drivers, legal immunity for physicians who report patients in good faith, a transparent and consistent approach to how patients are evaluated, more frequent license renewal requirements for the elderly, and more community resources for local transportation.

“Don’t ask, don’t tell” should not be the unofficial policy for driving safety and the elderly.

Still Unresolved

During the year I didn’t see Mr. Daniels, I thought about him often. I wondered where he had gone, whether he’d been driving or not, and whether I’d done the right thing in not reporting him to the DMV. I hated the uneasy feeling of being suspicious without proof.

I thought about calling him to ask if he’d been driving- but I already knew what he would say. Had I been overly concerned with Mr. Daniels’s right to privacy and put public safety at risk? Or was I right to take his word that he had stopped driving?

A year after asking for the disabled parking permit form, Mr. Daniels showed up in my clinic. I was relieved to see him alive and well.

I asked him how he’d been managing.

He knew exactly what I was talking about.

“I’m not driving. Of course not,” he said with a small chuckle, his eyes again on the floor. I pictured him driving a dented Volvo, bumping over a curb as his radio blasted Willie Nelson’s “On the Road Again,” and screeching into the parking lot of his favorite diner.

Then he changed the subject.

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