Cancer Knowledge network CASES

1. Cancer Knowledge network CASES Esther Chan, Michelle Hanna Alex Louie, MD and David D’Souza, MD

2. List of Cases • Generalized seizures • Reporting and reinstating a revoked license • Moderate neurosensory deficits secondary to low grade glioma • Medical, ethical, and legal implications associated with license revocation in brain cancer patients

3. Case 1 – Seizures

4. Case 1 - Seizures • 26 year old male comes to your office following a generalized seizure with complete loss of consciousness. • Isolated event; no history of epilepsy, no alcohol or drug involvement, no history of trauma. • Seizure did not occur while driving, but as the treating physician, is it necessary to report the patient’s condition to the ministry of transportation?

5. According to CMA Guidelines… • …YES! “Any seizure is grounds for immediate cessation of all driving activities.”

6. CMA Guidelines • Resumption of driving will depend on neurologic assessment of the patient and the nature of the driving activity that is involved. • Driving after a seizure caused by use of a substance depends on complete abstinence from use of that substance. • Lack of compliance, including forgotten doses of medications, is grounds for immediate cessation of all driving activities.

7. CMA recommendations for drivers who have experienced seizures

10. Medication Withdrawal or Change

12. Seizures and Driving – Summary • Seizure activity is grounds for immediate cessation of all driving activities • Multiple factors play a role in duration of license cessation, including: • Nature of driving (private vs commercial) • Nature of seizure (generalized vs simple) • Diagnosis of epilepsy? • Presence of seizure triggers (drugs, alcohol, trauma) • Medical control of seizures (drug withdrawal/changes)

13. Back to the case… • Given that this seizure was not drug or alcohol related, it would be treated as a single, unprovoked seizure before a diagnosis. • This patient would therefore be advised against driving for at least 3 months, and would be given a neurologic assessment, EEG, and appropriate imaging.

14. References • Canadian Medical Association. Determining medical fitness to operate motor vehicles. CMA driver’s guide. 7th ed. Ottawa (ON): The Association; 2006.

15. CASE 2How to report a medically unfit driver

16. Let us return to our patient in Case 1… • A 26 year old male comes to your office following a generalized seizure with complete loss of consciousness. • Isolated event; no history of epilepsy, no alcohol or drug involvement, no history of trauma Seizure did not occur while driving but as we know from Case 1, seizures are a reportable medical condition.

17. Report After deciding a patient may be unfit to drive (see tools for determining medical fitness in Case 3), a formal report must be made to the driving authorities in each respective jurisdiction. In Canada, each province has a driving authority who manages driving related matters. In the United States, most states operate independently and have a state-wide driving authority.

18. Back to the patient in Case 1 Let us imaging the patient in Case 1 was an Ontario citizen… The Ontario Highway Traffic Act states: “Every legally qualified medical practitioner shall report to the Registrar the name, address, and clinical condition of every person sixteen years of age or over attending upon the medical practitioner for medical services, who in the opinion of the medical practitioner is suffering from a condition that may make it dangerous for that person to operate a motor vehicle.” - Section 203,Ontario Highway Traffic Act

19. Reporting In Ontario, the Ministry of Transportation, Ministry of Health and Long Term Care and Ontario Medical Association Joint Forms Committee have developed a Medical Reporting Form for medically unfit drivers.

20. Reporting Continued… Although it is not necessary to use the Medical Reporting Form general information to include in a report are: • Patient Identifiers (Name, Address, DOB, Driver Licence # if available) • Medical condition resulting in driving impairment (list all if more than one) • Date of examination for which report is based • If patient is aware of report • Physician Identifiers (Name, Address, Discipline)

21. Optional Information It is optional to include relevant information contributing to the decision. • results of investigations • current functional status, medications, treatment, prognosis • whether the condition is in the physicians’ opinion a serious risk to road safety or if the threat to road safety is unknown • duration of expected threat (days/weeks/months)

22. Commercial Drivers For commercial drivers it may be pertinent to include an average idea of types of duties involved. • Activity summary – distance, fueling, performing maintenance, securing the load, etc. • Driving schedule – maximum duration allowed to drive continuously, time off to sleep, etc. • Physical duties involved with operation of the vehicle – handling landing gears/trailers, etc.

23. Do not forget… To always warn the patient not to drive until further notice and DOCUMENT the report in the medical chart. Things to include in the medical chart: • Whether the report was discussed with patient. • If the patient was advised not to drive until further notice. • Patients response to report.

24. Without documentation of a discussion with patients to refrain from driving, physicians may be held liable if patients are involved in a motor vehicle accident as a result of their medical condition during the period of time in which their case is under review. In a Ontario study examining actual reporting practices of physicians caring for brain tumour patients, researchers found that only 41% of brain tumour patients were advised not to drive. In the same study, of patients with documented seizures it was found that only 68% had documentation of a discussion about driving and only 56% had formal documentation of a report to the Ministry of Transportation.

25. Medical Reporting Form A copy of the Ontario Medical reporting form can be found at: http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/023-SR-LC-097~1/$File/SR-LC-097.pdf For more information about procedural reporting in other provinces, please refer to provincial driving authority.

26. Provincial Driving Authorities

27. Reinstating a Driver’s License If the patients’ condition has sufficiently changed to believe they are no longer medically unfit to drive, a physician may send a letter to the same driving authority documenting the change in condition and recommendation for reinstatement.

28. Determining medical fitness to drive Licensing authorities and the general public grossly overestimate a physicians’ ability to predict whether a patient will be involved in a MVC. This is because: • Abilities may fluctuate and symptoms observed in a physician office may not reflect true driving ability. • Medical events that alter function may occur after an office visit and difficult to predict. • Standard physical exams detect presence or absence of disease and do not assess function. • It is difficult for a physician to predict a patients’ judgement and defensive driving strategies.

29. Tools to determine medical fitness to drive Currently there are is no evidence-based approaches for assessing medical fitness to drive in primary care. In a review of 1500 articles related to health and medical fitness to drive only level III evidence (ie. expert opinion or consensus statements) were found. Available resources? The CMA Driver’s Guide – Determining medical fitness to drive CanDRIVE Allied health care professionals

30. The CMA Driver’s Guide Is a publication provided by the Canadian Medical Association. Is a resource for all medically reportable conditions. Does not instruct on how to assess driving ability. Can be found at: http://www.cma.ca/determining-fitness-to-drive

31. CanDRIVE Acronym Cognition: dementia, delirium, depression; executive function, memory, judgement, psychomotor speed, attention, reaction time, visuospatial function. Acute or fluctuating illness. Neuromusculoskeletal disease or neurologic effects: Speed of movement, speed of mentation, LOC, Parkinson’s disease, syncope, arthritis, hypo/hyperglycemia. Drugs: drugs that affect cognition or speed of mentation.ie. Benzodiazepines Record: Patient/family describe accidentsor near-accidents. In-Car Experiences: ie. lost or forgetful while driving. Vision: Acuity, contrast sensitivity, diplopia. Ethanol use www.candrive.ca

32. Allied Health care professionals Physicians may refer to occupational therapists or other health care providers that may perform in-office or on-road driving tests. Is an appropriate method of testing for medical conditions that are present all the time. ie. Cannot assess driving ability in patients with seizures. On-road testing may best reflect driving ability but are expensive ($300 to $600) and usually paid for by patients themselves. Specialized driver assessment by occupational therapists or on-road testing is resource intensive and does not replace physicians’ screening and assessment. ie. Parkwood Hospital Driver Assessment and Rehabilitation Program - http://www.sjhc.london.on.ca/darp

33. Other resources… • SAFE DRIVE checklist • Ottawa Driving and Dementia Toolkit

34. References Canadian Medical Association. Determining medical fitness to operate motor vehicles. CMA driver’s guide. 7th ed. Ottawa (ON): The Association; 2006. Government of Ontario (1990) Highway Traffic Act. http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_90h08_e.htm. Accessed 8 Jun 2012. Molnar FJ, Byszewski AM, Marshall SC, Man-Son-Hing M. In-office evaluation of medical fitness to drive: practical approaches for assessing older people. Can Fam Physician. Mar 2005;51:372-379. Winkelaar P. Reporting patients with medical conditions affecting their fitness to drive. CMPA Perspective 2010;2(4):3-5.

35. Case 3 – Intracranial tumours

36. Case 3 – Brain Tumour • 54 year old male recently diagnosed with low grade glioma • Mild neurosensory deficits • Vision intact, no seizures, no weakness • Unilateral numbness and tingling, headaches • Condition stable for one year, likely to remain stable for another 2-3 years. • Patient lives in a rural community begs you to let him keep driving on small rural roads

37. Brain Tumours – CMA Guidelines Intracranial tumours: “A patient who wishes to resume private or commercial driving after removal of an intracranial tumour must be evaluated regularly for recovery of neurologic function and the absence of seizure activity.”

38. Benign Tumours – CMA Guidelines “If a patient’s cognitive function, judgement, coordination, visual fields, sense of balance, motor power and reflexes are all found to be normal after the removal of a benign intracranial tumour, there is usually no reason to recommend any permanent driving restrictions. If a seizure occurred either before or after the removal of a tumour, the patient should be seizure free for at least 12 months, with or without medication, before resuming driving.”

39. Malignant Tumours – CMA Guidelines “No general recommendation can be made about driving after the removal of a malignant or metastatic brain tumour. The opinions of the consulting neurologist and the surgeon who removed the tumour should always be sought and each case evaluated individually.”

40. Next Steps? • Are you legally obliged to report this patient? • Which doctors are most responsible for reporting impaired patients to the MoT? • What are the guidelines regarding reporting patients with intracranial tumours to the MoT?

41. CMA Drivers Guide • Canadian Medical Association published: Determining medical fitness to operate motor vehicles. CMA driver’s guide. • Limited and require further validation. • Variability in symptoms caused by brain tumours = difficult to establish a basis on when to revoke patient’s license.

42. The Importance of MoT Reporting • Sunnybrook study  40% of injured drivers were found to have a reportable condition. • Accidents resulted in: • 53 deaths • 551 surgeries • $3 million in hospital costs Therefore, medical conditions DO impact driving ability, and may increase risk of motor vehicle accidents.

43. Barriers to Reporting Despite these facts, many physicians do not report their patients. • Only 3% of patients with reportable conditions were brought to the MOT’s attention(Sunnybrook study). Many patients with reportable conditions continue to drive.

44. Barriers to Reporting Majority of family physicians feel that doctors should be legally responsible for reporting unsafe drivers, however, over 45% feel that they are not confident in their ability to do so.

45. Barriers to Reporting • Require further education and screening guidelines for assessing patients. • 25% of physicians are not aware of the CMA guide. • Limited information on how to assess driving fitness in patients prior to definitive treatment.

46. Barriers to Reporting • Negative impact on physician-patient relationship • 60% of Saskatchewan doctors feel that physician-patient relations would be negatively affected if they were responsible for the removal of their patient’s driving privileges.

47. Barriers to Reporting • Physicians may not report because they are unaware of local legislation. For example, • 30% of Australian physicians • 73% of American physicians unaware of reporting guidelines in their countries.

48. Back to Case 3… • To report or not to report??? No concrete guidelines exist. At this time, it is up to the consulting physician to determine if the patient poses a risk to themselves and others when driving. • In Case 4 we will discuss the medical, ethical, and legal implications associated with license revocation in brain cancer patients.

49. References • Canadian Medical Association. Determining medical fitness to operate motor vehicles. CMA driver’s guide. 7th ed. Ottawa (ON): The Association; 2006. • Molnar F, Byszewski A, Marshall S, Man-Son-Hing M. In-office evaluation of medical fitness to drive: practical approaches for assessing older people. Can Fam Physician. 2005; 51:372-379. • Marshall SC, Gilbert N. Saskatchewan physicians’ attitudes and knowledge regarding assessment of medical fitness to drive. CMAJ.1999; 160(12):1701-1704. • Winkelaar P. Reporting patients with medical conditions affecting their fitness to drive. CMPA Perspective 2010;2(4):3-5. • Redelmeier DA, Venkatesh V, Stanbrook MB. Mandatory reporting by physicians of patients potentially unfit to drive. OpenMedicine 2008;2(1):4–13. • Chin YS, Jayamohan J, Clouston P, Gebski V, Cakir B. Driving and patients with brain tumours: a postal survey of neurosurgeons, neurologists and radiation oncologists. J ClinNeurosci. 2004; 11(5):471-474.

50. CASE 4 Physicians have a medical, ethical and often a legal duty to report patients that are medically unfit to drive.