When a delightful long-term elderly patient, frail but fiercely independent, fails his vision test, you’re the one who must report him to local health officials. You know that the report will mean the end of his driving freedom— and you also know that this life-altering decision is necessary to protect your patient and the general public.

Safety issues linked to elderly drivers have recently been the subject of high-profile news stories. In a 2003 accident in Santa Monica, California, an 85-year-old who confused his accelerator and brake pedal crashed into a farmer’s market, killing 10 and injuring 63. The incident triggered a flurry of studies that highlighted the growing danger.

As America’s elderly population booms, a highway safety crisis is emerging. In 2003, more than 5,300 Americans older than 70 died in highway accidents, according to a study conducted by the National Highway Traffic Safety Administration (NHTSA). With the number of Americans over 65 expected to double to 72 million by 2030, NHTSA estimates that senior highway fatalities will also soar.

A Legal and Ethical Requirement
As sobering as the issue is for all Americans, it also can be ethically challenging for physicians who treat elderly patients. Currently, California and five other states require doctors to report drivers who have conditions that could hinder their ability to operate a motor vehicle safely.

According to the American Medical Association’s Council on Ethical and Judicial Affairs, physicians have a responsibility to recognize impairments in patients’ driving ability that pose a strong threat to public safety; the council also maintains that these impairments may need to be reported.

Before reporting a patient, physicians should have a tactful but candid discussion with that individual and his or her family about the risks of driving. Informing patients and their families about available transportation options and negotiating a workable plan may render reporting unnecessary.

Or not. There’s no question that losing the right to drive is emotionally devastating for many elderly people. For physicians, making the decision to report an older patient can be extremely difficult as well, even if it clearly is necessary to protect both the patient and the general public. Some physicians worry about being sued by patients they report. Under California law, however, a physician may not be held civilly or criminally liable for making any such reports— whether the reporting was mandated by law or done on a discretionary basis in a good-faith effort to serve the public interest.

Rather than worrying about being sued by patients, California physicians should be concerned with the legal ramifications of not reporting patients who ought to be reported. Physicians may be subject to civil liability if an injured person can establish that the failure to report was the legal cause of his or her injuries. In addition, the physicians’ inaction may be considered unprofessional conduct by the Medical Board of California.

Disorders That Should Be Reported
California Health and Safety Code §103900 requires physicians and surgeons to report to the local health officer the identity of “every patient at least 14 years of age or older whom the physician and surgeon has diagnosed as having a case of a disorder characterized by lapses of consciousness.”

The disorders must involve all of the following:

• A loss of consciousness or a marked reduction of alertness or responsiveness to external stimuli
• The inability to perform one or more activities of daily living
• The impairment of the sensory motor functions used to operate a motor vehicle. Medical conditions that may, but do not always, progress to the required level of functional disability include Alzheimer’s disease and related disorders, seizure disorders, brain tumors, narcolepsy, sleep apnea and abnormal metabolic states, including diabetes-related hypoglycemia and hyperglycemia.

Reports should be made on a Confidential Morbidity Report form, the same form used to report communicable diseases to local health officials; the forms are available from local health departments. Once a physician makes a report, the local health officer transmits the information directly to the Department of Motor Vehicles (DMV), which then evaluates whether the patient should continue to have driving privileges (see box below).

The California statute clearly requires only physicians who actually diagnose the disorders to make a report. Physicians who only consult on cases or otherwise do not diagnose the conditions have no duty to act.

However, the law explicitly allows any physician to report a case if he or she reasonably and in good faith believes it will serve the public interest. The law exempts physicians from reporting patients who are unable to ever operate a motor vehicle, or who are otherwise unlikely to represent a danger that requires reporting.

If a patient who has been reported recovers from a chronic confused state or is functionally stabilized by medical treatment, or if the patient’s condition was misdiagnosed in the first place, either the physician or the patient may ask the DMV to reevaluate the patient’s competence to drive. This can be done by sending a request to the nearest DMV Regional Driver Safety Office.

Available Educational Materials
Without a doubt, reporting patients who probably should not be driving can put physicians in an uncomfortable position. The AMA has prepared educational materials on the subject—including a practical guide that can help doctors assess and counsel older patients on their medical fitness to drive. The “Physicians’ Guide to Assessing and Counseling Older Drivers” can be downloaded from the AMA’s website at www.ama-assn.org.

How the DMV Handles Reports on Elderly Drivers
In California, the Department of Motor Vehicles uses the following guidelines when it receives a report on an elderly driver from a local health department:

• A computer search for the individual’s name and driving record is conducted.
• The individual is contacted by letter and sent a driver medical evaluation form.
• A driver safety hearing officer reviews the form. If the individual fails to submit the requested medical documentation within 26 days, all driving privileges are suspended.
• The individual undergoes a reexamination involving two phases: a written test and an interview. The written test helps ascertain the individual’s knowledge of driving laws—and even more important, his or her mental competency, cognitive skills and language skills. The face-to-face interview focuses on the individual’s medical documentation, as well as on his or her long-term and short-term memory of events.
• An individual who does well up to this point is then given a driving test. The test is designed to evaluate the skills needed to drive safely— skills that might be affected by mild dementia.
• In most cases, if the individual passes the driving test, the license is not suspended. However, driving restrictions are sometimes imposed— for example, no freeway driving, no night driving or no driving beyond a certain radius. The DMV will review the individual’s driving skills again in six to 12 months.
• If the license is suspended, an appeals process is available for the individual or family to contest the suspension.