Patients with dementia often refuse to discontinue driving, despite safety concerns raised by their physician. States have different policies regarding the ability or obligation for physicians to report such drivers to the Department of Motor Vehicles (DMV). Some states have mandatory reporting laws for patients with certain diagnoses. Other states have optional reporting laws that provide legal protection for physicians, in the event that they choose to report a patient to the DMV. In some states, where there is no reporting policy in place, a physician may be sued for breaking confidentiality to report a driver of concern to the DMV against their will. In these instances, when a physician is unable to report a patient despite concern, it is often left to the family to consider how to address driver cessation for their loved one. The purpose of this case study is to demonstrate the ethical concerns that arise in such instances.

Gergerich E (2016) The Role of Healthcare Workers and State Policy for Drivers with Dementia. Ann Psychiatry Ment Health 4(5): 1074.

•    Driving
•    Dementia
•    Geriatrics
•    Anosognosia
•    Care giver
•    Policy

DMV: Department of Motor Vehicles

Dementia is an umbrella term used to describe a range of symptoms that involve cognitive decline and a significant impact upon activities of daily living. Alzheimer’s disease is the most common type of dementia, accounting for 60-80% of all cases of dementia [1]. In a review of research, it was determined that Alzheimer’s patients with a rating of Mild Impairment according to the Clinical Dementia Rating scale had a significant risk for poor driving performance and automobile accidents [2]. One study indicated that drivers with Alzheimer’s disease scored significantly worse on a road test than a control group of healthy older adults. The drivers with Alzheimer’s disease, however, rated their driving abilities substantially higher than they had been rated by a driving assessor [3]. This tendency in some patients with Alzheimer’s disease, to be unaware of their own deficits, is called anasognosia. While some patients with Alzheimer’s disease voluntarily restrict their driving practices, those who continue to drive often have associated anasognosia [4].

States have various policies regarding reporting procedures for patients with dementia to the Department of Motor Vehicles (DMV) [5]. These include the following: 1) Whether it is mandatory for a physician to report a patient with a diagnosis of dementia to DMV, 2) whether there is legal protection for physicians who choose to report a patient to the DMV, 3) the process of DMV follow up after a report is made, 4) what other individuals or professionals may make a report, and 5) whether such reports may be made anonymously.

Around 20 states lack both mandatory reporting policiesand legal protection for physicians who choose to make a report to the DMV [5]. In these states, a physician faces the risk of being sued for breaching confidentiality if they report a driver of concern to the DMV against their will. Without the legal support to make such a report, family members often must report their loved one to the DMV or find alternative methods to accomplish driver cessation. When the report cannot be made anonymously, family members may hesitate to make such a report.

This case presents a patient with Alzheimer’s disease who continues to drive despite minor accidents and concerns expressed by his physician and family members. Following the case presentation there is discussion regarding implications for healthcare providers and state policy.

An 81 year-old man with mild to moderate Alzheimer’s disease attended a medical appointment at a Senior Health Clinic with his daughter. During the visit, his daughter requested to speak to the geriatrician alone to discuss concerns about her father’s ability to drive safely. The geriatrician said that he would address it with the patient. He then referred the daughter to speak with the clinic social worker. During their visit, the daughter explained to the social worker that her father lives in rural Arkansas and drives into town most days, roughly ten miles, to meet friends and have coffee in a local diner. She stated that this is his only source of socialization aside from his family members or the neighbor dropping by to check in on him. The neighbor called her recently to share that he had helped tow her father’s truck out of the ditch over the weekend. The daughter reported that even before this, she had noticed dents in her father’s vehicle, as well as the side mirror being missing.When confronted by the geriatrician, the patient refused to discontinue driving or undergo driver testing at the Department of Motor Vehicles (DMV). The daughter returned to the clinic the next week to consider options with the social worker.

Arkansas is a state that has neither mandatory nor optional reporting policies in place for doctors to report drivers with dementia to the DMV without their consent.Legal representation for this Senior Health Clinichad, in fact, warned doctors not to report patients to the DMV without their documented consent. Without legal protection in place, reporting patients against their will could lead to the physicians being sued. In Arkansas, it is, however, acceptable for the DMV to receivea report from courts, police, other DMVs and family members [5].

The patient’s daughter explored various options with the social worker, to convince her father to stop driving. The social worker enquired about the possibility of disengaging or removing the car but the daughter did not wish to do this. The geriatrician wrote a prescription that stated the patient should discontinue driving. This was shared with the patient during a family meeting in which his children expressed their concern for his safety. The patient still firmly declined to stop driving. Finally, the social worker asked whether the daughter or her brother would be comfortable making a report to the DMV for driver testing.However, because the report could not be made confidentially, the children expressed that they felt this would cause even further discord among family members.

Research has consistently found that patients with dementia lose the ability to drive safely over time [6]. The act of driving is central to many older adults’ autonomy. Driver cessation may lead to difficulty in getting to medicalappointments, the pharmacy or to the grocery store. Research has indicated that older adults often suffer declines in health and physical ability after they discontinue driving [7]. Other studies have indicated that depressive symptoms worsen following driver cessation [8,9]. Research also indicates that when older adults stop driving, they are less likely to continue paid or volunteer work [10]. It is therefore important that the privilege of driving be retained as long as safely possible, in order to retain autonomy and independence.

For the sake of public safety, however, it is also important to identify when a person with dementia may pose a danger on the road. While some patients in the early stages of dementia might retain their driving ability, research has indicated that even those with mild dementia often lose the ability to drive safely [11,12]. Patients with dementia and their caregivers are often unable to remain objective in their determination of driver fitness [3].

Rather than reporting patients to the DMV based upon a diagnosis alone, a report should be based upon a measured loss of ability. Research has found that doctors specifically trained in dementia assessment were more accurate in identifying unfit drivers when compared to non-specialists [13]. One survey of neurologists and geriatricians in Arkansas found that 87% agree that the physician has a responsibility to make a medical assessment of ability to drive with patients who have dementia [14].

It is important that physicians have the ability to refer drivers with dementia to the DMV when concerned about driver safety. Qualitative findings from one study indicated that drivers with cognitive impairment wanted to decide themselves when to discontinue driving, however, they were willing to concede upon receiving advice to stop driving from their general practitioner. In a separate study, 46% of drivers with dementia showed reluctance to stop driving based only on doctor’s advice; however, 88% said that they would take a state driving exam if referred by a doctor.

Over time, there has been a trend among states to adopt optional reporting policies for drivers with dementia [15]. Still, 19 states, including Arkansas, remain without any policy in place, putting physicians in a legally difficult position if they choose to report drivers with dementia to the DMV. When surveyed, 97% of neurologists and geriatricians in Arkansas agreed that physicians should have legal protection from being sued by patients that they report to the DMV [14]. Support for mandatory reporting policy, however, was significantly lower (44%). For those remaining states without reporting policy, it is therefore proposed that optional reporting policy would likely be the most tenable option.

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