Clinical dilemma - Driving against medical advice

You recently see Mrs Smith, a newly diagnosed epileptic patient, driving her children to school. You distinctly remember your consultation with her two weeks earlier, during which you advised her to inform the DVLA about her diagnosis and that she should not drive. She does not see you, but you feel very uneasy about knowing that she is still driving against your advice. What should you do?

Photograph: istock

A GP's opinion
Dr Alison Glenesk is a GP trainer in Aberdeen

It can be very difficult to decide to breach a patient's right to confidentiality; however, in this case it is essential to get this woman off the road before she endangers herself or her family.

The GMC agrees; paragraph 22 of 'Duties of a Doctor' states that a patient's right to confidentiality can be breached if it is in the public interest to do so.

I have a lot of sympathy for this patient, who is obviously going to find life without a driving licence very trying.

I could, of course, simply inform the DVLA. I would, however, contact the patient first, to see if she misunderstood my advice, and confirm that she must stop driving forthwith, and reapply for her licence only after she has been fit-free for one year. I would encourage her to discuss the situation with her family if she has not already done so.

It is possible that she will not go on to inform the DVLA, but it will be difficult to know if she has followed my guidance.

The best course of action is to offer to inform the DVLA, with her knowledge and consent. This way, I will know that the appropriate course of action has been taken, while maintaining my relationship with the patient. If she does not agree, I will question her motives and may well end up informing the DVLA with her knowledge, but without express consent.

It is essential to keep accurate records of all face-to-face and telephone encounters, as this is the sort of situation that could lead to a complaint.

A medico-legal response
Dr Marika Davies, Medical Protection Society, medico-legal adviser

Patients have a legal duty to inform the DVLA about medical conditions that may affect their safety as a driver. Mrs Smith has been advised not to drive and to inform the DVLA, but has failed to do so and is putting not only herself, but also her children and others at risk by continuing to drive.

You may wish to ask Mrs Smith to come in to see you, in order to ensure that she understands that her condition may impair her ability to drive, and you should do your best to persuade her to stop. Your discussions and advice should be carefully documented in her medical records, and ideally followed up with a letter to the patient.

If she disagrees, then she should be offered a second opinion, but should still be advised not to drive until the second opinion has been obtained.

The GMC states: 'If you do not manage to persuade patients to stop driving, or you are given or find evidence that a patient is continuing to drive contrary to advice, you should disclose relevant medical information immediately, in confidence, to the medical adviser at the DVLA.'

If you decide that it is necessary to inform the DVLA, you should let Mrs Smith know of this and also inform her once the disclosure has been made.

A patient's view
Elizabeth Brain is a member of the RCGP patient partnership group

You should make contact with the patient as soon as possible and arrange to meet her, preferably in an informal environment. A home visit would be ideal. The approach should be friendly and non-judgmental, at least to start with, as there could be several innocent reasons for her action and there is always the possibility that you saw someone else.

Mrs Smith's mind was probably in a whirl after receiving your diagnosis and she could have been preoccupied with trying to come to terms with it. She may not have absorbed what you said and, under the circumstances, simply misunderstood your advice that she should not drive. Her agreement to advise the DVLA might, similarly, have been made without realising what she said or she could have forgotten as she left the surgery.

You should begin by checking that it was definitely her who was driving and then repeat the advice that you have previously given. You should emphasise the acute dangers involved both to her, and to any passengers, other drivers and pedestrians.

Cessation of driving may present her with an extreme hardship. This should be explored and possible solutions discussed. You could finish by suggesting that you contact her in a couple of weeks to see how she is coming to terms with her diagnosis, as well as to see how life is progressing without the availability of her car.

If all fails, and then only as a last resort, should you advise her that you will be obliged to report her to the authorities.

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