Navigating tough conversations about fitness to drive

Structured and in-depth communication between GPs and patients with dementia could help them prepare and adjust to challenging decisions over their fitness to drive, research shows.
 
The study by Flinders University researchers investigated the reactions of 12 older people with dementia and mild cognitive impairment, in the hope of finding a process that best supports the person with dementia.
 
The findings highlight a need for structured and comprehensive communication by health professionals over several phases leading up to driving cessation, followed by improved support for people with dementia and their families.
 
In Australia, people with dementia cannot hold an unconditional licence, but may qualify for a conditional licence which is subject to at least an annual review.
 
Health professionals, including GPs, assess a person’s fitness to drive and must notify licensing authorities if they believe the driver may present a danger to the public.
 
Dr Stephanie Daly, Chair of RACGP Specific Interests Dementia, said assessing fitness to drive in patients with cognitive impairment is challenging.
 
‘The conversations about driving can be very complex – it is dependent on the person’s previous relationship with driving, support of alternatives to driving and also, in some cases, the person concerned may be the driver for the household, which impacts their spouse as well,’ she told newsGP.
 
‘People fear the loss of driving as it directly affects and challenges independence making the conversation tricky.
 
‘People with cognitive impairment often talk about memory as the key impairment but cognitive impairment affects our concentration attention and visuospatial awareness as well as executive functioning panning and judgement which are all hugely important to be able to drive safely.’
 
To help navigate conversations around this complexity, the study highlights a need for ‘structured and comprehensive communication by health professionals over several phases’ leading up to driving cessation, followed by improved support for people with dementia and their families.
 
The first phase involves preparing the patient before driving is unsafe.
 
‘A collaborative decision-making approach should involve an Advance Driving Directive to document the person’s preferences for future decision-making about their fitness to drive, including their preferred decision-makers – a GP or medical specialist, with input from family or a friend,’ the authors explain.
 
The second stage – navigating fitness-to-drive decisions – is about providing patients with information and choices about the available options, such as pursuing practical assessment or relinquishing their licence.
 
‘Involve the family in discussions, if the person wishes. Apply shared decision-making that supports meaningful patient involvement in driving safety discussions, while retaining responsibility as health professionals for the decision-making of fitness to drive recommendations,’ the researchers said.
 
Delivering a recommendation to discontinue driving is the third stage, and researchers recommend the use of ‘simple, straightforward language, while showing compassion’.
 
The final phase is about adjusting to life without driving, where researchers recommend practical and emotional support be provided to help connect patients to available services.
 
Dr Daly said the key take-home message for GPs from this study is ‘don’t avoid the conversation’.
 
‘Early conversations and diagnosis of cognitive impairment help people to plan and come to terms with the prospect of not driving,’ she said.
 
‘When someone has the capacity to still drive but [can] engage in the conversation around stopping, it is much easier to approach cessation of driving.
 
‘Leaving it later causes significant distress particularly if people lack insight into their loss of cognitive ability.’
 
She also recommends helping family members identify changes in function in other aspects of person’s life that might indicate changes to driving ability.
 
‘Look for warning signs – accidents, knocks and scraps, hesitancy, changes in driving practices. Speak out early if there are concerns so a conversation can start.’
 
While Dr Daly likes the idea of using an Advance Driving Directive, she said that ‘this takes time and we need to have better remuneration for MBS items for longer consults to be able to have time to have these discussions’.
 
The researchers said they hope the findings will guide the design of tools and resources to support health professionals manage driving safety concerns more effectively with people who dementia or mild cognitive impairment, and their families.
 
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