How to talk an elderly patient off the road

Many seniors are reluctant to give up the wheel, despite deteriorating driving skills. Here's how to reach them.

By Susan Harrington Preston

Just over a decade ago, an 86-year-old woman in a Rolls-Royce ran down a young medical student as he crossed an intersection, throwing him into the air. "It was her chauffeur's day off," says the former student, Robert M. Kleinhaus, who's now an internist in Syracuse. "The woman apparently stepped on the accelerator instead of the brake, giving me added lift."

When Kleinhaus regained consciousness on the pavement, the driver was kicking him in the buttocks, screaming that he had dented her car. In a subsequent deposition, the woman stated that she knew his injuries weren't serious because he was still breathing when the ambulance took him away.

In fact, the injuries were so severe that rehabilitation took four years of Kleinhaus' life. He suffered two broken arms, two broken legs, and three fractures in his back. He had to endure a whole-body cast for several weeks.

Most 86-year-olds don't wreak such vehicular havoc. But many are capable of it. Ophthalmologist John C. Hagan sees plenty of elderly patients who won't surrender the wheel—but should.

"One man came to me after failing his vision test at the DMV," says Hagan, who practices in North Kansas City, MO. "His vision was something like 20-400. I told him he shouldn't be driving, and he said, 'Go to hell.' But then he couldn't find his way out of the parking lot. He drove around in a circle until one of my staffers knocked on his car window and showed him the exit."

It's no surprise that patients balk when they're told they shouldn't drive. "We're taking away their independence," says Charles Aronberg, a Beverly Hills ophthalmologist. "They get very angry, especially the men."

Gastroenterologist James W. Brown of Wenatchee, WA, agrees. "Most men consider driving a hallowed right, regardless of age," he says.

Surrendering the car keys may also make an elderly person feel isolated and depressed—or worse, notes nephrologist Bayard Paul Quinn of Texarkana, TX. Further, trying to board a bus with grocery bags, say, may be more than an elderly patient can handle. "I can't bring myself to take away their licenses if they have no real alternatives for transportation," says FP Bernd A. Wollschlaeger, who practices in North Miami Beach, FL.

Still, when patients endanger themselves and others, trying to talk them off the road is your ethical—and sometimes legal—responsibility (see "What's your responsibility?"). Here's how some of your colleagues are meeting it.

Use the facts and the family to make your point

Elderly drivers may not see that their driving skills are failing—and neither may the spouses who depend upon them for transportation.

Prove it. "You have to make it really plain that they're going to kill themselves or somebody else," says Warren Wolfe, an FP based in Cherry Hill, NJ. "You have to prove it to them—get them to try to walk in a straight line or hold their hand steady."

ENT specialist Wallace Rubin of Metairie, LA, uses a dynamic posturography test. "When patients realize they would have fallen if they hadn't been wearing a harness, they're usually persuaded that they shouldn't drive," he says.

You can also send patients to a driver-training school or rehabilitation clinic experienced with elderly and disabled drivers for a private assessment of driving skills, with a road test. "I've done this quite often, and it really does help," says Jeffry C. Hatcher, an FP in Paris, IL. "Patients seem to accept it as fair and impartial."

Work with the family. Often, children come to the doctor at wits' end about Dad's driving. "Almost always, the children tell harrowing tales of near misses," says FP Scott R. Helmers of Sibley, IA. "At the next visit, I usually ask the elderly driver if there have been any problems. If he or she will admit to mishaps, or if accompanying children remind them, then we can focus on the problem. Most times I simply state that it's unsafe for them to drive. At that point, the children usually take away the keys."

Often, the family wants someone to catch the flak. Internist John S. Saia of Rockville, MD, cheerfully accepts that role: "I tell the family, 'Blame it on me!' "

You can also help families by referring them to such resources as the New York State Office for the Aging's When You Are Concerned, a 56-page handbook available at aging.state.ny.us/caring/concerned.

Fortunately, doctors may have an impact where family members don't. One worried daughter in Cincinnati reported that her father gave up the keys after a doctor "prescribed" that he not drive by writing a note on a prescription pad.

Give them the statistics. You can also try reminding patients how vulnerable they are to injury. In side-impact accidents—the ones to which the elderly are most prone—drivers 60 or older are up to 20 times as likely as those aged 20 to 29 to wind up with multiple broken ribs. One study of Michigan motorists found that in accidents in which drivers stopped at intersections and then pulled into oncoming traffic, nearly 70 percent of those who violated the right of way were over 60. And, about half of fatal crashes involving drivers 80 and older occur at intersections and affect more than one vehicle, according to the Insurance Institute of Highway Safety, based in Arlington, VA.

Let the patient save face

Beyond the transportation problems and loss of independence, elderly patients may be just plain embarrassed to be told they aren't capable of driving anymore. Helping them save face can go a long way toward winning their cooperation.

Beware blunt words. Elderly patients may interpret "you shouldn't be driving" or "it's time to quit" as a threat to their well-being, even their identity. But being straightforward doesn't mean being tactless. For instance, you could talk with them about "graduating" or "retiring" from driving.

"I tell them it's time for a chauffeur," says Saia, who also provides a handy answer to a common protest: "If they say 'I've never had an accident,' I tell them, 'We want to keep your record unblemished.' "

Shift the blame. "I sometimes tell patients to 'take a break' from driving until the side effects of a new medication are apparent. That way, it's the medication's fault," says cardiologist David Schaefer of Rochester Hills, MI. "Later, if they still can't drive safely, I tell them they could hurt someone near and dear to me—me!"

Use Schaefer's strategy with care, though, because it could spur noncompliance. Says Warren Wolfe: "I have a lot of macho 80-year-old patients who say, 'Doc, I'm not taking this blood pressure medicine because it ruins my sex life, it's expensive, and it makes me tired. If I die, I die. I'm going to live the way I want to live.' To them, living includes driving."

Wolfe uses a different tactic. "I say, 'What if you don't die? What happens if you lose a leg or have a concussion and you can't walk or talk or eat? That's a living death, and you become a burden to the family.' All of a sudden, a light goes on and they say, 'Hey, maybe you're right.' "

Let money do the talking. Many of today's elderly patients, who remember the Great Depression, harken to suggestions for thrift.

Saia asked one woman, "How much are you paying in insurance—$500 a year, plus gas and maintenance? You could take a cab lots of times for that!" She took that very well, Saia says.

Then there's fear of lawsuits. "I try to help patients understand that if they have an accident, they will probably get the blame," says GP John Tyrrell of Manchester, IA. "If they're sued, it will be a miserable, and possibly costly, experience."

Ultimately, however, if a patient drives despite a revoked license, you can't take away the keys. "We're not marshals," notes John Hagan.

Internist Roger G. Smith of Hillsboro, OR, had one such patient, an 85-year-old woman. "Three other doctors had told her she couldn't drive, and that she had to go live in a nursing home," he said. "All three had sent in DMV reports, but the cops didn't do a thing.

"Thankfully, she died in her sleep," he says, "Not on the road."

The author is a former Senior Editor of Medical Economics.

What's your responsibility?

You have an ethical obligation to report unsafe drivers, according to the American Medical Association. If the driver poses a clear risk to himself and the community but refuses to give up the wheel, it's the doctor's ethical responsibility to notify the Department of Motor Vehicles, the association maintains.

In at least six states—California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania—physicians also have a legal duty to report unsafe drivers of any age to licensing authorities. California says doctors must report dementia; three states (Delaware, Nevada, and New Jersey) mandate reporting epilepsy.

Even where the law doesn't require it, doctors may still have an avenue for reporting patients whose driving has deteriorated. All states have a medical advisory board that makes decisions about whether a person reported to the board can continue to drive. "The Maryland Motor Vehicle Administration has a health form with a question on it about driving skills," says internist John S. Saia, who practices in Rockville, MD. "I tell the patient I can't fill out a form saying you're fit to drive."

If you don't report an impaired driver and the person goes out and hurts someone, the victim or his family may sue you for damages or wrongful death or for failure to report. If you do notify the motor vehicle department and your state doesn't have a law protecting doctors from lawsuits for good-faith reports, you can be sued for breach of patient confidentiality.

And in any state, you risk a breach-of-privacy lawsuit if you disclose information to the patient's family members without his permission. If you can't secure permission—and you should whenever feasible—you may be comforted in knowing that such suits against physicians are very rare.

Your report-don't report decision-making must also include the fact that you may be the only person in a position to identify a driver as unsafe. Just five states impose age limits on license renewals online or by mail, according to the Insurance Institute for Highway Safety. And only six states require aging drivers to appear in person and pass a vision or road test.

 

Sue Preston. How to talk an elderly patient off the road. Medical Economics 2002;10:45.