1. Medical Fitness to Drive Updated by Nadine Abdullah, MD, M.Ed, FRCPC March 2007

2. Outline General objectivesGeneral objectives CMA guidelinesCMA guidelines Ontario regulationsOntario regulations Medical Condition ReportMedical Condition Report CasesCases ReferencesReferences

3. General objectives To review Ontario regulations for the reporting of patients who are assessed to be unsafe to drive To review specific medical conditions that are commonly encountered in practice To review the process of reporting to the Ministry of Transportation

4. CMA Guidelines Individual assessment needed and can be facilitated by referring to the CMA guidelinesIndividual assessment needed and can be facilitated by referring to the CMA guidelines If a physician deems a patient unsafe to drive they must notify the patient and inform the ministry in writing (see new online medical condition report)If a physician deems a patient unsafe to drive they must notify the patient and inform the ministry in writing (see new online medical condition report) Responsibility for issuing/taking away license rests with licensing authorityResponsibility for issuing/taking away license rests with licensing authority Where interest of individual driver and safety of public conflict, latter has priorityWhere interest of individual driver and safety of public conflict, latter has priority Some cases require temporary cessation of driving (eg. post anaesthetic, new time-limited prescription for sedating drug post- injury); patient must be advised, but does not necessitate notification of the ministrySome cases require temporary cessation of driving (eg. post anaesthetic, new time-limited prescription for sedating drug post- injury); patient must be advised, but does not necessitate notification of the ministry

5. Ontario Regulations Liability in OntarioLiability in Ontario –mandatory reporting of unfit drivers (even if they do not have a license or own a vehicle) –physicians protected from liability if they report unfit drivers –physicians liable to negligence suits for failing to report unfit drivers Patients appeal directly to licensing authorityPatients appeal directly to licensing authority –may have input from applicant’s physician Restricted license (eg daylight, not highways) not available in OntarioRestricted license (eg daylight, not highways) not available in Ontario

6. http://www.mto.gov.on.ca/english/dandv/driver/medreport/medreport.pdf

7. Case 1 You are assessing a 43 year old female for follow-up of her epilepsy. Although compliant with her medications, she reports 3 seizures in the last 2 months. You: a) advise her not to drive b) advise her not to drive on highways or during rush hour c) advise her not to drive and report this to the Ministry of Transport d) take away her driver’s license

8. Learning Objectives Understand principles behind determining patient’s ability to driveUnderstand principles behind determining patient’s ability to drive Understand medical legal issuesUnderstand medical legal issues Provide guidelines for driving for patients with seizure disordersProvide guidelines for driving for patients with seizure disorders

9. Seizures - First Seizure No driving for at least 3 months until complete evaluation (EEG, CT or MRI)No driving for at least 3 months until complete evaluation (EEG, CT or MRI) If alcohol withdrawl seizure, can drive if remains alcohol free and seizure free for 6 months, and completes a rehabilitation program for substance dependenceIf alcohol withdrawl seizure, can drive if remains alcohol free and seizure free for 6 months, and completes a rehabilitation program for substance dependence If no cause or no epileptiform activityIf no cause or no epileptiform activity –private driver can drive if seizure free for 3 months –professional driver can drive if seizure free for 12 months

10. Seizure - After Epilepsy Dx If patient has diagnosis of epilepsy and compliant with anti-epileptic medicationsIf patient has diagnosis of epilepsy and compliant with anti-epileptic medications –can have private license if seizure free on medications for 6 months –wait 12 months if simple partial seizures –can have commercial license if seizure free for 5 years After medication withdrawal or changeAfter medication withdrawal or change –for private license wait 3 months –commercial license wait 6 months

11. Back to Case 1 You are assessing a 43 year old female for follow-up of her epilepsy. Although compliant with her medications, she reports 3 seizures in the last 2 months. You a) advise her not to drive b) advise her not to drive on highways or during rush hour c) advise her not to drive and report this to the Ministry of Transport d) take away her driver’s license

12. Case 2 You are assessing a 45 year old TTC subway car driver who is 3 weeks post anterior MI. He has Gr IV systolic LV function and no reversible defects on Thallium GXT. He is medically managed and has NYHA III symptoms. He asks when he can return to driving his train. You recommend: a) 1 month from his MI b) 3 months from his MI c) 6 months from his MI d) never

13. Learning Objectives Review driving guidelines for patients with:Review driving guidelines for patients with: –coronary artery disease –arrhythmias –congestive heart failure

14. Coronary Artery Disease PrivateProfessional Stable Angina No restrictions Acute MI/UA Wait 1 month after discharge Wait 3 months after discharge PTCA/stents Wait 48 hrs 7 days CABG Wait 1 month after discharge Wait 3 months after discharge

15. Cardiac Arrhythmias ConsiderConsider –frequency, –risk of malignant ventricular arrhythmias –presence of other cardiac disorders VT/VF controlled on medications or ICDVT/VF controlled on medications or ICD –private - wait 6 months –commercial - disqualified Atrial arrhythmias and non-sustained VTAtrial arrhythmias and non-sustained VT –in general, can drive unless associated symptoms

16. Cardiac Arrhythmias AV blockAV block –disqualified for all classes if Mobitz type II, trifascicular block or acquired 3rd degree PacemakerPacemaker –can drive if asymptomatic 1 week after implantation for private, 1 month for professional driver ICDICD –All commercial driving disqualified –For private, primary prophylaxis classes I-III wait 4weeks after implant –Secondary prophylaxis without symptoms, wait 1 week –Secondary prophylaxis with symptoms, wait 6 months after event

17. CHF, LV Dysfunction Private - can’t drive ifPrivate - can’t drive if –NYHA IV symptoms Professional - can’t drive ifProfessional - can’t drive if –NYHA III symptoms or worse –EF < 35%

18. Back to Case 2 You are assessing a 45 year old TTC subway car driver who is 3 weeks post anterior MI. He has Gr IV systolic LV function and no reversible defects on Thallium GXT. He is medically managed and has NYHA III symptoms. He asks when he can return to driving his train. You recommend: a) 1 month from his MI b) 3 months from his MI c) 6 months from his MI d) never (unless LV function and symptoms improve on therapy)

19. Case 3 You are scheduled to see the following patients in clinic today. Assuming investigations have not been completed, who would you consider safe to drive? a ) 62 yo with TIA 2 days ago b) 50 yo truck driver with diabetes mellitus, starting on insulin c) 65 yo with syncope 1 week ago d) 55 yo taxi driver with dyspnea at rest from COPD e) 80 yo with visual impairment

20. Learning Objectives Review driving assessments for patients withReview driving assessments for patients with –Vascular disease –Diabetes mellitus –Syncope –Lung disease –Visual impairment Review driving issues related to agingReview driving issues related to aging

21. Vascular Disease Single or recurrent TIAsSingle or recurrent TIAs –cannot drive until assessed and investigated –can drive if no loss of function and cause addressed Completed strokeCompleted stroke –wait 1 month if minimal loss of functional ability and underlying cause addressed –if residual loss of function - road test Aortic aneurysmAortic aneurysm –if > 5.5 cm for men or > 5 cm for women, treat surgically before allowing to drive

22. Diabetes Mellitus - Insulin Treated Private driver - OK ifPrivate driver - OK if –no severe hypoglycemia within last 6 months Professional driver - OK ifProfessional driver - OK if –no severe hypoglycemia or hypoglycemia unawareness within last 6 months –no instability of insulin regimen (e.g. starting insulin or changing dose, need 1 month wait) –no peripheral neuropathy (with loss of function), cardiac reasons, visual impairment –self monitors

23. Syncope Single episode of typical vasovagal syncopeSingle episode of typical vasovagal syncope –no restriction Diagnosed and treated cause (eg. PPM for bradycardia)Diagnosed and treated cause (eg. PPM for bradycardia) –private wait 1 week; commercial wait 1 month Situational (eg. micturition)Situational (eg. micturition) –wait 1 week Single episode and unexplainedSingle episode and unexplained –private wait 1 week; commercial wait 12 months 2 or more episodes in 12 months2 or more episodes in 12 months –private wait 3 months; commercial wait 12 months

24. Lung Disease Chronic respiratory diseaseChronic respiratory disease –no restriction if none to moderate impairment –road test required if moderate to severe impairment or supplemental oxygen required at rest –must use supplemental oxygen if required and equipment must be safely secured in the vehicle Obstructive sleep apnea (verified by sleep study)Obstructive sleep apnea (verified by sleep study) –OK if compliant with CPAP or successful surgery

25. Visual impairment Visual acuity (both eyes open, examine together)Visual acuity (both eyes open, examine together) –private – not less than 20/50 –commercial – not less than 20/30 Colour visionColour vision –no restrictions but need to be aware of problem to compensate Hemianopsias - no for all classesHemianopsias - no for all classes Uncorrected diplopia - no for all classesUncorrected diplopia - no for all classes

26. Age and Driving Older age not a contraindication to drivingOlder age not a contraindication to driving Driving may be critical to maintaining independenceDriving may be critical to maintaining independence Due to increased prevalence of chronic diseases which may impair driving, increase frequency of medical exam for fitness to drive needed as patient ages (eg. yearly after age 80)Due to increased prevalence of chronic diseases which may impair driving, increase frequency of medical exam for fitness to drive needed as patient ages (eg. yearly after age 80)

27. Back to Case 3 You are scheduled to see the following patients in clinic today. Assuming investigations have not been completed, who would you consider safe to drive? a ) 62 yo with TIA 2 days ago b) 80 yo with visual impairment c) 50 yo truck driver with diabetes mellitus, starting on insulin d) 65 yo with syncope 1 week ago e) 55 yo taxi driver with dyspnea at rest from COPD

28. Bottom line If you aren’t sure, advise the patient not to drive and inform the ministry of transportationIf you aren’t sure, advise the patient not to drive and inform the ministry of transportation Public safety has priority over individual driverPublic safety has priority over individual driver

29. References Determining Medical Fitness to Operate Motor Vehicles: CMA Driver’s Guide 7 th edition, 2006Determining Medical Fitness to Operate Motor Vehicles: CMA Driver’s Guide 7 th edition, 2006 CCS consensus conference 2003: Assessment of the Cardiac Patient for Fitness to Drive and Fly – executive summaryCCS consensus conference 2003: Assessment of the Cardiac Patient for Fitness to Drive and Fly – executive summary Ontario Ministry of Transportation “Medical Condition Report” http://www.mto.gov.on.ca/english/dandv/driv er/medreport/medreport.pdfOntario Ministry of Transportation “Medical Condition Report” http://www.mto.gov.on.ca/english/dandv/driv er/medreport/medreport.pdf http://www.mto.gov.on.ca/english/dandv/driv er/medreport/medreport.pdf http://www.mto.gov.on.ca/english/dandv/driv er/medreport/medreport.pdf