Medical Fitness Medical Fitness to Driveto Drive

Updated byUpdated byNadine AbdullahNadine Abdullah, MD, M.Ed, , MD, M.Ed,

FRCPCFRCPC

March 2007March 2007

OutlineOutline

• General objectivesGeneral objectives• CMA guidelinesCMA guidelines• Ontario regulationsOntario regulations• Medical Condition ReportMedical Condition Report• CasesCases• ReferencesReferences

General objectivesGeneral 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

CMA GuidelinesCMA Guidelines

• Individual assessment needed and can be facilitated Individual assessment needed and can be facilitated by referring to the CMA guidelinesby referring to the CMA guidelines

• If a physician deems a patient unsafe to drive they If a physician deems a patient unsafe to drive they must notify the patient and inform the ministry in must notify the patient and inform the ministry in writing writing (see new online medical condition report)(see new online medical condition report)

• Responsibility for issuing/taking away license rests Responsibility for issuing/taking away license rests with licensing authoritywith licensing authority

• Where interest of individual driver and safety of Where interest of individual driver and safety of public conflict, latter has prioritypublic conflict, latter has priority

• Some cases require temporary cessation of driving Some cases require temporary cessation of driving (eg. post anaesthetic, new time-limited prescription (eg. post anaesthetic, new time-limited prescription for sedating drug post- injury); patient must be for sedating drug post- injury); patient must be advised, but does not necessitate notification of the advised, but does not necessitate notification of the ministryministry

Ontario RegulationsOntario Regulations• Liability in OntarioLiability in Ontario

– mandatory reporting of unfit drivers (even if they mandatory reporting of unfit drivers (even if they do not have a license or own a vehicle)do not have a license or own a vehicle)

– physicians protected from liability if they report physicians protected from liability if they report unfit driversunfit drivers

– physicians liable to negligence suits for failing to physicians liable to negligence suits for failing to report unfit driversreport unfit drivers

• Patients appeal directly to licensing authorityPatients appeal directly to licensing authority– may have input from applicant’s physicianmay have input from applicant’s physician

• Restricted license (eg daylight, not highways) Restricted license (eg daylight, not highways) not available in Ontarionot available in Ontario

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

Case 1Case 1You are assessing a 43 year old female for You are assessing a 43 year old female for follow-up of her epilepsy. Although follow-up of her epilepsy. Although compliant with her medications, she reports compliant with her medications, she reports 3 seizures in the last 2 months. You:3 seizures in the last 2 months. You:a) advise her not to drivea) advise her not to drive

b) advise her not to drive on highways or during b) advise her not to drive on highways or during rush hourrush hour

c) advise her not to drive and report this to the c) advise her not to drive and report this to the Ministry of Transport Ministry of Transport

d) take away her driver’s licensed) take away her driver’s license

Learning ObjectivesLearning Objectives

• Understand principles behind Understand principles behind determining patient’s ability to drivedetermining patient’s ability to drive

• Understand medical legal issuesUnderstand medical legal issues• Provide guidelines for driving for Provide guidelines for driving for

patients with seizure disorderspatients with seizure disorders

Seizures - First SeizureSeizures - First Seizure• No driving for at least 3 months until No driving for at least 3 months until

complete evaluation (EEG, CT or MRI)complete evaluation (EEG, CT or MRI)• If alcohol withdrawl seizure, can drive if If alcohol withdrawl seizure, can drive if

remains alcohol free and seizure free for 6 remains alcohol free and seizure free for 6 months, and completes a rehabilitation months, and completes a rehabilitation program for substance dependenceprogram for substance dependence

• If no cause or no epileptiform activity If no cause or no epileptiform activity – private driver can drive if seizure free for 3 private driver can drive if seizure free for 3

monthsmonths– professional driver can drive if seizure free for professional driver can drive if seizure free for

12 months12 months

Seizure - After Epilepsy Seizure - After Epilepsy DxDx

• If patient has diagnosis of epilepsy and If patient has diagnosis of epilepsy and compliant with anti-epileptic medicationscompliant with anti-epileptic medications– can have private license if seizure free on can have private license if seizure free on

medications for 6 monthsmedications for 6 months– wait 12 months if simple partial seizureswait 12 months if simple partial seizures– can have commercial license if seizure free for 5 can have commercial license if seizure free for 5

yearsyears

• After medication withdrawal or changeAfter medication withdrawal or change– for private license wait 3 monthsfor private license wait 3 months– commercial license wait 6 monthscommercial license wait 6 months

Back to Case 1Back to Case 1You are assessing a 43 year old female for You are assessing a 43 year old female for follow-up of her epilepsy. Although follow-up of her epilepsy. Although compliant with her medications, she reports compliant with her medications, she reports 3 seizures in the last 2 months. You3 seizures in the last 2 months. Youa) advise her not to drivea) advise her not to drive

b) advise her not to drive on highways or during b) advise her not to drive on highways or during rush hourrush hour

c) advise her not to drive and report this to c) advise her not to drive and report this to the Ministry of Transportthe Ministry of Transport

d) take away her driver’s licensed) take away her driver’s license

Case 2Case 2

You are assessing a 45 year old TTC subway car You are assessing a 45 year old TTC subway car driver who is 3 weeks post anterior MI. He has Gr IV driver who is 3 weeks post anterior MI. He has Gr IV systolic LV function and no reversible defects on systolic LV function and no reversible defects on Thallium GXT. He is medically managed and has Thallium GXT. He is medically managed and has NYHA III symptoms. He asks when he can return to NYHA III symptoms. He asks when he can return to driving his train. You recommend:driving his train. You recommend:

a) 1 month from his MIa) 1 month from his MIb) 3 months from his MIb) 3 months from his MIc) 6 months from his MIc) 6 months from his MId) neverd) never

Learning ObjectivesLearning Objectives

• Review driving guidelines for Review driving guidelines for patients with:patients with:– coronary artery diseasecoronary artery disease– arrhythmiasarrhythmias– congestive heart failurecongestive heart failure

Coronary Artery DiseaseCoronary Artery Disease

PrivatePrivate ProfessionalProfessional

Stable Stable AnginaAngina

No No restrictionsrestrictions

No No restrictionsrestrictions

Acute MI/UAAcute MI/UA Wait 1 month Wait 1 month after after dischargedischarge

Wait 3 Wait 3 months after months after dischargedischarge

PTCA/stentsPTCA/stents Wait 48 hrsWait 48 hrs 7 days7 days

CABGCABG Wait 1 month Wait 1 month after after dischargedischarge

Wait 3 Wait 3 months after months after dischargedischarge

Cardiac ArrhythmiasCardiac Arrhythmias• Consider Consider

– frequency, frequency, – risk of malignant ventricular arrhythmiasrisk of malignant ventricular arrhythmias– presence of other cardiac disorderspresence of other cardiac disorders

• VT/VF controlled on medications or ICDVT/VF controlled on medications or ICD– private - wait 6 monthsprivate - wait 6 months– commercial - disqualifiedcommercial - disqualified

• Atrial arrhythmias and non-sustained VTAtrial arrhythmias and non-sustained VT– in general, can drive unless associated in general, can drive unless associated

symptomssymptoms

Cardiac ArrhythmiasCardiac Arrhythmias

• AV blockAV block – disqualified for all classes if Mobitz type II, disqualified for all classes if Mobitz type II,

trifascicular block or acquired 3rd degreetrifascicular block or acquired 3rd degree• PacemakerPacemaker

– can drive if asymptomatic 1 week after can drive if asymptomatic 1 week after implantation for private, 1 month for professional implantation for private, 1 month for professional driverdriver

• ICDICD– All commercial driving disqualifiedAll commercial driving disqualified– For private, primary prophylaxis classes I-III wait For private, primary prophylaxis classes I-III wait

4weeks after implant4weeks after implant– Secondary prophylaxis without symptoms, wait 1 Secondary prophylaxis without symptoms, wait 1

weekweek– Secondary prophylaxis with symptoms, wait 6 Secondary prophylaxis with symptoms, wait 6

months after eventmonths after event

CHF, LV DysfunctionCHF, LV Dysfunction

• Private - can’t drive ifPrivate - can’t drive if– NYHA IV symptomsNYHA IV symptoms

• Professional - can’t drive if Professional - can’t drive if – NYHA III symptoms or worseNYHA III symptoms or worse– EF < 35%EF < 35%

Back to Case 2Back to Case 2You are assessing a 45 year old TTC subway car You are assessing a 45 year old TTC subway car driver who is 3 weeks post anterior MI. He has Gr driver who is 3 weeks post anterior MI. He has Gr IV systolic LV function and no reversible defects on IV systolic LV function and no reversible defects on Thallium GXT. He is medically managed and has Thallium GXT. He is medically managed and has NYHA III symptoms. He asks when he can return NYHA III symptoms. He asks when he can return to driving his train. You recommend:to driving his train. You recommend:

a) 1 month from his MIa) 1 month from his MIb) 3 months from his MIb) 3 months from his MIc) 6 months from his MIc) 6 months from his MI

d) neverd) never (unless LV function and (unless LV function and symptoms improve on therapy)symptoms improve on therapy)

Case 3Case 3 You are scheduled to see the following You are scheduled to see the following patients in clinic today. Assuming patients in clinic today. Assuming investigations have not been completed, who investigations have not been completed, who would you consider safe to drive?would you consider safe to drive?aa)) 62 yo with TIA 2 days ago 62 yo with TIA 2 days ago b)b) 50 yo truck driver with diabetes mellitus,50 yo truck driver with diabetes mellitus,

starting on insulinstarting on insulinc) 65 yo with syncope 1 week agoc) 65 yo with syncope 1 week agod) 55 yo taxi driver with dyspnea at rest from d) 55 yo taxi driver with dyspnea at rest from

COPDCOPDe) 80 yo with visual impairmente) 80 yo with visual impairment

Learning ObjectivesLearning Objectives• Review driving assessments for Review driving assessments for

patients withpatients with– Vascular disease Vascular disease – Diabetes mellitusDiabetes mellitus– SyncopeSyncope– Lung diseaseLung disease– Visual impairmentVisual impairment

• Review driving issues related to Review driving issues related to agingaging

Vascular DiseaseVascular Disease• Single or recurrent TIAs Single or recurrent TIAs

– cannot drive until assessed and investigatedcannot drive until assessed and investigated– can drive if no loss of function and cause addressedcan drive if no loss of function and cause addressed

• Completed strokeCompleted stroke– wait 1 month if minimal loss of functional ability and wait 1 month if minimal loss of functional ability and

underlying cause addressedunderlying cause addressed– if residual loss of function - road testif residual loss of function - road test

• Aortic aneurysm Aortic aneurysm – if > 5.5 cm for men or > 5 cm for women, treat if > 5.5 cm for men or > 5 cm for women, treat

surgically before allowing to drivesurgically before allowing to drive

Diabetes Mellitus - Insulin Diabetes Mellitus - Insulin TreatedTreated

• Private driver - OK ifPrivate driver - OK if– no severe hypoglycemia within last 6 monthsno severe hypoglycemia within last 6 months

• Professional driver - OK ifProfessional driver - OK if– no severe hypoglycemia or hypoglycemia no severe hypoglycemia or hypoglycemia

unawareness within last 6 monthsunawareness within last 6 months– no instability of insulin regimen (e.g. starting no instability of insulin regimen (e.g. starting

insulin or changing dose, need 1 month wait)insulin or changing dose, need 1 month wait)– no peripheral neuropathy (with loss of function), no peripheral neuropathy (with loss of function),

cardiac reasons, visual impairmentcardiac reasons, visual impairment– self monitorsself monitors

SyncopeSyncope

• Single episode of typical vasovagal syncopeSingle episode of typical vasovagal syncope– no restrictionno restriction

• Diagnosed and treated cause (eg. PPM for Diagnosed and treated cause (eg. PPM for bradycardia)bradycardia)– private wait 1 week; commercial wait 1 monthprivate wait 1 week; commercial wait 1 month

• Situational (eg. micturition)Situational (eg. micturition)– wait 1 weekwait 1 week

• Single episode and unexplainedSingle episode and unexplained– private wait 1 week; commercial wait 12 monthsprivate 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 monthsprivate wait 3 months; commercial wait 12 months

Lung DiseaseLung Disease

• Chronic respiratory disease Chronic respiratory disease – no restriction if none to moderate impairmentno restriction if none to moderate impairment– road test required if moderate to severe road test required if moderate to severe

impairment or supplemental oxygen required at impairment or supplemental oxygen required at restrest

– must use supplemental oxygen if required and must use supplemental oxygen if required and equipment must be safely secured in the vehicleequipment must be safely secured in the vehicle

• Obstructive sleep apneaObstructive sleep apnea (verified by sleep study) (verified by sleep study)– OK if compliant with CPAP or successful surgeryOK if compliant with CPAP or successful surgery

Visual impairmentVisual impairment• Visual acuity (both eyes open, examine Visual acuity (both eyes open, examine

together) together) – private – not less than 20/50private – not less than 20/50– commercial – not less than 20/30commercial – not less than 20/30

• Colour visionColour vision – no restrictions but need to be aware of problem no restrictions but need to be aware of problem

to compensateto compensate

• Hemianopsias - no for all classesHemianopsias - no for all classes• Uncorrected diplopiaUncorrected diplopia - no for all classes- no for all classes

Age and DrivingAge and Driving• Older age not a contraindication to Older age not a contraindication to

drivingdriving• Driving may be critical to maintaining Driving may be critical to maintaining

independenceindependence• Due to increased prevalence of Due to increased prevalence of

chronic diseases which may impair chronic diseases which may impair driving, increase frequency of medical driving, increase frequency of medical exam for fitness to drive needed as exam for fitness to drive needed as patient ages (eg. yearly after age 80)patient ages (eg. yearly after age 80)

Back to Case 3Back to Case 3You are scheduled to see the following You are scheduled to see the following patients in clinic today. Assuming patients in clinic today. Assuming investigations have not been completed, who investigations have not been completed, who would you consider safe to drive?would you consider safe to drive?aa)) 62 yo with TIA 2 days ago 62 yo with TIA 2 days ago b) 80 yo with visual impairmentb) 80 yo with visual impairmentc)c) 50 yo truck driver with diabetes mellitus,50 yo truck driver with diabetes mellitus,

starting on insulinstarting on insulind) 65 yo with syncope 1 week agod) 65 yo with syncope 1 week agoe) 55 yo taxi driver with dyspnea at rest from e) 55 yo taxi driver with dyspnea at rest from

COPDCOPD

Bottom lineBottom line• If you aren’t sure, advise the patient If you aren’t sure, advise the patient

not to drive and inform the ministry not to drive and inform the ministry of transportation of transportation

• Public safety has priority over Public safety has priority over individual driverindividual driver

ReferencesReferences

• Determining Medical Fitness to Determining Medical Fitness to Operate Motor Vehicles: CMA Operate Motor Vehicles: CMA Driver’s Guide 7Driver’s Guide 7thth edition, 2006 edition, 2006

• CCS consensus conference 2003: CCS consensus conference 2003: Assessment of the Cardiac Patient for Assessment of the Cardiac Patient for Fitness to Drive and Fly – executive Fitness to Drive and Fly – executive summarysummary

• Ontario Ministry of Transportation Ontario Ministry of Transportation “Medical Condition Report” “Medical Condition Report” http://www.mto.gov.on.ca/english/dandv/driver/medreport/medreport.pdf