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To drive or not to drive: who decides?

By Albert J. Finestone, M.D.

A recent article published in the Journal of Gerontology revived my long time interest in problems of the older driver.

The report of Dr. Haas “Crash Course for the Elderly” (New York Times, Op. Ed Section, Monday July 17, 2006), was a tragic story of a problem confronting many physicians. Andrew L. Haas, an orthopedic surgeon, was riding his bike not far from his hometown, Armonk, NY in training for the “Ironman World Championship” in Hawaii. He stated he was in fantastic shape, just three months away from competing with the best tri-athletes in the world, when he was struck by 75-year-old man who turned left and drove directly into him. He fought for his life and after a year he is learning to walk again. He missed almost a year of work and had to restart his orthopedic surgery practice from scratch. The elderly driver was charged with failure to yield and fined $125! He was permitted to drive without restriction and without any assessment of his driving ability. He was issued a driver’s license more than a half a century ago.

There are many newspaper reports of automobile accidents involving elderly drivers. In July 2003 there was a horrific accident in Santa Monica, California, where an elderly driver sped down the length of an outdoor market killing 10 out 50 persons struck by his car. July 30, 2006, there was a small item in thePhiladelphia Inquirer which reported an 85-year-old man drove a car onto a patio of Starbuck’s Coffee Shop in El Monte, California and injured 10 people – two of them critically.

Weighing the natural diminishment of vision, hearing, mobility, reaction time, etc., plus many diseases of the elderly against the importance of a driver’s license to the patient such as independence always creates a difficult dilemma for practicing physicians. Furthermore, the geriatric patient taking prescribed and/or over-the-counter drugs may be adversely affected in the ability to operate a motor vehicle. This is a “Hobson’s choice’ for all physicians dealing with elderly patients. (FYI: I retired from clinical practice in 2003).

In making decisions about driving, three parties are involved: first the older driver, secondly the physician, and thirdly the State. Let me consider each one of these issues individually. First, the patient: in my experience it is very unlikely, although not unheard of, that older drivers voluntarily give up driving. This is particularly difficult if the older driver is a widow or widower and has no other means of transportation. It is less difficult if the significant other is able to drive without a problem. Therefore, to depend upon an older driver voluntarily giving up a driver’s license is an unlikely scenario.

The next party involved is the physician. All physicians realize that this is a profoundly difficult decision to make. We know that normal aging has a major influence on vision, hearing, reaction time and mobility. Furthermore there are a number of common diseases that impact older driver’s ability to operate a motor vehicle. Additionally, this population takes many drugs, both prescription and over-the-counter, with side effects that can influence the older driver’s ability to manage an automobile safely.

In my many years of clinical practice I had these decisions to make. In some instances I had to reluctantly report to the Pennsylvania Department of Transportation the medical fact that, in my opinion, this patient should not have a driver’s license. The results were that I never saw the patient again and, additionally, I never received a report as to the outcome of my report from the Department of Transportation. An additional consideration was the possibility of a malpractice suit for not preventing an older driver from driving which resulted in serious injury or death to another party. Furthermore, the HIPAA rules apply.

One of my solutions to this dilemma was to have a third party make these decisions to relieve the patient, the family and the physician of this onerous decision, namely, using driving schools to evaluate the patient’s ability to drive. Moss Rehab in Elkins Park, Pa., for example (fee: $190), has a driving school which I found very satisfactory during my years of clinical practice. The referring physician completes a form with the medical history and medications. The report clears the patient to drive, limits driving during daytime, or prohibits the patient from driving. I attempted to solicit support from foundations and insurance companies to underwrite the cost of this service without success. I do not believe that many of the public or even practicing physicians know of the existence of driving schools.

Albert J. Finestone, M.D., MSc, FACP, is director of Institute on Aging, associate dean of CME, and emeritus adjunct professor of medicine at Temple University School of Medicine. He is also consortium project director of the Geriatric Education Center of Pennsylvania, a consortium of University of Pittsburgh, Penn State University and Temple University.

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