Fitness to drive: What to know before giving patients an all-clear

Neelima Choahan

3/08/2018 2:01:16 PM

Telling someone they are not fit to drive can be challenging for both the GP and the patient. newsGP spoke with two experts about the best ways to approach a difficult situation.

Drivers may need a medical certificate to be able to drive once they have crossed a certain age or have a chronic illness or injury.
Drivers may need a medical certificate to be able to drive once they have crossed a certain age or have a chronic illness or injury.

Sam* was in his 80s and had begun to develop significant health problems, including Parkinson’s disease.
He was still driving, but his GP felt it was time for him to start thinking about giving up his licence.
According to Dr Sara Bird, MDA National Manager, Medico-legal and Advisory Services, the assessment of fitness to drive is one of the most challenging situations in medical practice. It is a situation in which the GP has to balance their duty to their patient and the less clearly defined duty to act in the ‘public interest’ – trying to ensure public safety and protect the community from harm.
‘It is a really difficult situation. For some patients it might be their livelihood,’ Dr Bird told newsGP.
‘And, certainly for a lot of elderly patients, it is something that is very important to them even psychologically, let alone from the practical ability to be able to go and do their shopping.’
The law on fitness to drive differs in each jurisdiction, but in some states drivers over the age of 75 must be medically fit to drive. An illness or an injury can also impact on the ability to get behind the wheel. 
This means going to a GP and getting an annual health assessment certifying the person is fit to drive.
According to the Australia Bureau of Statistics 2016 data, road crash fatalities declined by 24.6% in the decade to 2013, but fatalities of persons aged 65 and over increased by 8% in the same period.
Counts of drivers’ licences in the 65-and-over age group are growing more strongly than population growth. More than 60% of people aged 75 and over have a licence, up from 54% 10 years ago.
Dr Bird said legislation requires a driver to advise the Driver Licensing Authority (DLA) of any long-term or permanent injury or illness that may affect their safe driving ability.
‘In South Australia and the Northern Territory, health professionals have a positive duty to notify the DLA in writing of their belief that a patient is physically or mentally unfit to drive,’ she said.
‘In all other states … health professionals who make a report to the DLA that a patient is unfit to drive, without the patient's consent but in good faith, are protected from civil and criminal liability.’
Dr Bird said the responsibility for issuing, renewing, suspending, refusing or cancelling a driver’s licence ultimately lies with the DLA.
‘In making a decision, the DLA will seek input regarding a person’s medical fitness to drive from the driver and/or from a health professional,’ she said.
‘GPs have a number of professional obligations when assessing fitness to drive. Health professionals’ roles and responsibilities in the assessment of patients regarding fitness to drive for licensing purposes are outlined in Austroads’ guidelines, Assessing fitness to drive.’
Dr Bird said GPs have an obligation to give patients clear advice where an illness, condition or injury may affect their safe driving ability. This advice should be documented in the patient’s medical records.
‘Great care should also be taken when assessing fitness to drive in situations in which the person is not a regular patient, as some drivers may seek to deceive a GP about their medical history and health status, and “doctor-shop” for a desirable opinion,’ she said.
‘Recent disciplinary cases have highlighted that a GP acting contrary to their own professional judgement in the certification of fitness to drive can result in significant sanction against that GP.’
Associate Professor and GP Joel Rhee, Chair of the RACGP Cancer and Palliative Care Specific Interests network, mostly sees patients who are more than 80 years old.
He told newsGP the question of whether a patient is fit to drive is always lingering at the back of his mind, especially if they develop a degenerative condition like dementia.
His advice to other doctors is to prepare their patients gradually for what lies ahead.
‘Most people with dementia would need to stop driving at some time, but the question is, when do you make the decision?’ Associate Professor Rhee said.
‘A misconception may be that as soon as a person develops Alzheimer’s disease, dementia, they can’t continue driving. 
‘Obviously, in early stages they can often drive, but we need to start raising the possibility that at some stage in the future we have to restrict their driving and eventually they need to stop.’
Associate Professor Rhee said unless patients develop a major health problem – for example, have a stroke – they don’t need to go ‘cold turkey’ and give up driving immediately.
‘[With] most of my patients, I gradually get them to stop,’ he said.
‘We need to obviously make sure we do what is safe for everybody but, at the same time, as long as safety is not compromised we try not to interfere in someone’s independence, either.
‘Sometimes the compromise might be to encourage the person to change the condition of their licence so they only drive in a familiar environment, so a radius restriction around their home. You might say they can only drive during daylight hours.’
Associate Professor Rhee said the worse-case scenario is that the GP might have to report the person to the driving authorities if they continue to be non-compliant.
‘That’s obviously the last resort,’ he said.
‘Talking to the patient and convincing them to give up voluntarily and accept your recommendations is critical.’
Associate Professor Rhee said linking people to community transport programs can often help erase the patient’s reluctance to give up their licence.
‘Many people, even when they cease driving, are actually quite surprised by the fact that they can manage [to get around],’ he said.
‘Some people are under the impression that as soon as they stop driving they will be completely immobile, that they will be restricted at home and they can’t go anywhere. But then they get surprised that there are in fact many other options available.
‘GPs have a role to help identify some of the services that might be available, and practice nurses might be available to help educate the patient of some of these options, as well.’
*Not his real name

dementia disease fitness to drive Parkinson’s

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Genevieve Yates   4/08/2018 9:15:17 PM

Thank you for highlighting this important issue. It is one dear to my heart as in 2015 my spouse was killed by an elderly unfit driver. I’ve been on a mission to increase awareness of the importance of fitness to drive assessments by health professionals since that time, via social media and by conducting workshops on this for GP registrars. It is important to remember that driving is a privilege, not a right.

retired G P806   7/08/2018 8:51:23 AM

I found driving assessments by O Ts useful