CANCER KNOWLEDGE NETWORK CASES Esther Chan, Michelle Hanna Alex Louie, MD and David DSouza, MD.

CANCER KNOWLEDGE NETWORK CASES

Esther Chan, Michelle HannaAlex Louie, MD and David D’Souza,

MD

List of Cases

1. Generalized seizures

2. Reporting and reinstating a revoked license

3. Moderate neurosensory deficits secondary to low grade glioma

4. Medical, ethical, and legal implications associated with license revocation in brain cancer patients

CASE 1 – SEIZURES

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?

According to CMA Guidelines… …YES!

“Any seizure is grounds for immediate cessation of all driving activities.”

CMA Guidelines

1. Resumption of driving will depend on neurologic assessment of the patient and the nature of the driving activity that is involved.

2. Driving after a seizure caused by use of a substance depends on complete abstinence from use of that substance.

3. Lack of compliance, including forgotten doses of medications, is grounds for immediate cessation of all driving activities.

CMA recommendations for drivers who have experienced seizures

Type of Seizure Private Drivers Commercial Drivers

Single, unprovoked

seizure before a diagnosis or post-traumatic seizure

• No driving for at least 3 months and:

• Neurologic assessment, preferably including EEG (awake and asleep) and appropriate imaging

• No driving private vehicles for at least 3 months

• Neurologic assessment, including EEG (awake and asleep) and appropriate imaging

• If no epilepsy diagnosis, resume professional driving if seizure free for 12 months

After diagnosis of epilepsy

Drive if:•6 months seizure free* on medication•Physician has insight into patient compliance•Physician cautions against fatigue, alcohol

• Resume driving if 5 years seizure free

• Recommendations for individual patients may differ on an exceptional basis.

Type of Seizure Private Drivers Commercial Drivers

After surgery to prevent

epileptic seizures

• Resume driving if 12 months seizure free after surgery with therapeutic drug levels

• Recommendations for individual patients may differ on an exceptional basis.

• Resume driving if 5 years seizure free

• (Recommendations for individual patients may differ on an exceptional basis.)

Seizures only in asleep or

immediately on wakening

• Drive after 1 year from initial seizure if drug levels are therapeutic

• No driving commercial vehicles for at least 5 years

Type of Seizure Private Driver Commercial Driver

Initial withdrawal or change

• No driving for 3 months from the time medication is discontinued or changed

• No driving for 6 months from the time medication is discontinued or changed

If seizures recur after

withdrawal or change

• Resume driving if seizure free for 3 months

• Resume driving if seizure free for 6 months

Long-term withdrawal and

discontinuation of a medication

• Drive any vehicle if seizure free off medication for 5 years with no epileptiform activity within previous 6 months on waking and sleep EEG

• Same as private drivers

Medication Withdrawal or Change

Type of Seizure Private Driver Commercial Driver

Auras (simple partial

seizures)

Drive if:•Seizures are unchanged for at least 12 months•No generalized seizures•Neurologist approves•No impairment in level of consciousness or cognition•No head or eye deviation with seizures

Drive if:•Seizures remain benign for at least 3 years•No generalized seizures•Neurologist approves•No impairment in level of consciousness or cognition•No head or eye deviation with seizures

Alcohol-withdrawal induced

seizures

Drive if:•Remain alcohol free and seizure free for 6 months•Complete a recognized rehabilitation program for substance dependence•Compliant with treatment

• Same as private drivers

Juvenile myoclonic

epilepsy (Janz syndrome)

•No driving of any class of vehicle unless taking appropriate anti-seizure medication

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)

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.

References

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

CASE 2HOW TO REPORT A

MEDICALLY UNFIT DRIVER

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.

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.

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

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.

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)

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)

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.

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.

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.

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.

Provincial Driving Authorities

Province Driving AuthorityNewfoundland & Labrador Service NL – Motor Vehicle Registration Division

Prince Edward Island Department of Transportation and Infrastructure Renewal

Nova Scotia Services NS - Registry of Motor Vehicles

New Brunswick Department of Public Safety – Motor Vehicle Branch

Quebec Société de l’assurance automobile (SAAQ)

Ontario Ministry of Transportation

Manitoba Manitoba Public Insurance – Driver Licensing

Saskatchewan Saskatchewan Government Insurance (SGI) – Saskatchewan Auto Fund

Alberta Alberta Transport - Driver Fitness and Monitoring

British Columbia Insurance Corporation of British Columbia (ICBC)

Nunavut Department of Economic Development & Transportation

Northwest Territories Department of Transportation

Yukon Department of Highways and Public Works – Motor Vehicles Branch

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.

Determining medical fitness to driveLicensing 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.

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 driveCanDRIVEAllied health care professionals

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

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 accidents or near-accidents.

In-Car Experiences: ie. lost or forgetful while driving.

Vision: Acuity, contrast sensitivity, diplopia.

Ethanol use

www.candrive.ca

Allied Health care professionalsPhysicians 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

Other resources…

SAFE DRIVE checklist Ottawa Driving and Dementia Toolkit

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.

CASE 3 – INTRACRANIAL TUMOURS

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

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.”

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.”

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.”

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?

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.

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.

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.

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.

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.

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.

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.

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.

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 Clin Neurosci. 2004; 11(5):471-474.

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

Medical

• 2,800 new cases of primary brain tumours were diagnosed in Canada in 2012.

• It is estimated that 20–40% of intracranial tumours are metastatic.

Many brain tumours cause some degree of physical or neurocognitive deficit (i.e. weakness, blurred vision) which may impair the ability to perform highly sophisticated tasks such as driving.

Medical

Medically unfit drivers kill more than 5,000 pedestrians worldwide every year.

Both patient and society are at risk of physical harm from impaired drivers.

Due to their medical expertise and clinical experience, physicians are delegated the responsible for early recognition and reporting of symptoms that may potentially impair driving.

MEDICAL

“disclose your patients’ personal health information to third parties only with their consent, or as provided for by law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm to others or, in the case of incompetent patients, to the patients themselves.”

- Section 35, CMA Code of Ethic

In a review by the CMPA of all driving-related cases involving physicians, patient complaints of a report being filed was the most common charge brought against doctors. Inaccurate diagnosis, diagnosis non-relevant to driving, and breach of confidentiality were often cited as the reason for complaints.In the majority of cases, the Colleges have been supportive of physicians’ decision to report.

The physicians’ duty to report unfit drivers supersedes physician duty of confidentiality.

Ethical

Patients often depend on driving privileges to earn income, socialize and live autonomously.

Although a physician does not make the ultimate decision to revoke, their report is an important factor in determining the motor vehicle licensing authority’s subsequent action.

Ethical

Thus, while physicians do not make the ultimate decisions to revoke driving privileges, reporting a patient as potentially medically unfit to drive is NOT a benign action.

A physicians’ driving report may severely disable patients from participating independently in society.

i.e. In Ontario, the Highway Traffic Act requires reports be followed-up on within one month during which time patients must immediate locate alternative transportation after being notified they cannot drive even if they are found fit to drive later on.

Reason’s commonly cited by physicians for not reporting

• Lack of tools for determining driving fitness.• Negative impact on patient quality of life.• Negative impact on patient-physician

relationship.• Time restraints.• Long delay between report and license

suspension.• Delays for patients trying to reinstate their

license.

Legal

In 9 of 12 Canadian provinces, mandatory reporting legislation exists for physicians to report medically unfit drivers.

“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 233, Ontario Highway Traffic Act

Cases brought against PhysiciansInjured Patients:Legal action was often brought against physicians following motor vehicle accidents in which a person was injured or killed.

Physicians were charged with failure to warn or failure to report.

Cases continued…

Non-patient Injured Parties:Legal action has been brought against physicians (and successfully won) in cases where non-patient parties were injured in a motor vehicle crash caused in part by medical disability.

The CMPA has reported that in cases in which only patient-drivers have been charged, patients or their insurers have sued the patient’s physician in turn.

Legal

In all jurisdictions, if a report is made in accordance with the legislation and in good faith reporting legislation protects the physician from legal action brought against the physician for making the report.

But don’t forget…

The CMPA suggests that before the report, physicians inform their patients of the nature and intent of the report.

Remind patients that physicians only inform driving authorities of possible impairment. Decisions to restrict driving privileges are made by the licensing authority.

Warn patients that until a decision is made that they should not drive.

Document in the medical record that you have warned the patient not to drive and a report has been made.

Note: the legislation on reporting protects physicians against legal action but does not prevent complaints to the College.

Jurisdiction Reporting MD protection for reporting

Admissibility of reports as evidence in legal proceedings

Alberta Not directly addressed, but interpreted as discretionary.

Protected Reports confidential.

British Columbia Mandatory for MD if the unfit driver has been warned of the danger and still continues to drive.

Protected unless the physician acts falsely or maliciously.

Not addressed.Subject to the provisions of access to information legislation.

Manitoba Mandatory Protected PrivilegedNot admissible as evidence except to prove compliance with reporting obligations.

New Brunswick Mandatory Protected Not addressed.

Newfoundland and Labrador

Mandatory Protected PrivilegedNot admissible in evidence in trial except to prove compliance with reporting obligations.

Northwest Territories Mandatory Protected unless physician acts maliciously or without reasonable grounds.

Not admissible in evidence or open to public inspection except to prove compliance with the reporting provision and in a prosecutions of a section 330. The person who is the subject of the report is entitled to a copy of the report upon payment of a prescribed fee.

Nova Scotia Discretionary Protected Not addressedSubject to access to information legislation.

Nunavut Mandatory Protected unless physician acts maliciously or without reasonable grounds.

Not admissible in evidence or open to public inspection except to prove compliance with the reporting provision and in a prosecutions of a section 330. The person who is the subject of the report is entitled to a copy of the report upon payment of a prescribed fee.

Ontario Mandatory Protected PrivilegedNot admissible in evidence except to prove compliance with reporting obligations.

Prince Edward Island Mandatory Protected PrivilegedNot admissible in evidence except to prove compliance with reporting obligations.

Quebec Discretionary Protected Not admissible in evidence except in cases of judicial review of certain decisions of the motor vehicle licensing authority.

Saskatchewan Mandatory Protected as long as the physician acts in good faith.

PrivilegedNot admissible in evidence except to show that the report was made in good faith in accordance with reporting obligation.

Yukon Mandatory Protected Not addressed.

Adapted from the 7th edition of the CMA Driver’s Guide

References

Canadian Cancer Society’s Steering Committee on Cancer Statistics. Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer Society; 2012.Canadian Medical Association. Determining medical fitness to operate motor vehicles. CMA driver’s guide. 7th ed. Ottawa (ON): The Association; 2006.CMA Policy Statements. CMA Code of Ethics 2004. Ottawa, ON: Canadian Medical Association.Government of Ontario (1990) Highway Traffic Act. http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_90h08_e.htmJang R, Man-Son-Hing M, Molnar F, Hogan DB, Marshall SC, Auger J, et al. Family Physicians' attitudes and practices regarding assessments of medical fitness to drive in older persons. J Gen Intern Med. 2007; 22(4):531-542.Marshall SC, Gilbert N. Saskatchewan physicians’ attitudes and knowledge regarding assessment of medical fitness to drive. CMAJ. 1999; 160(12):1701-1704.Redelmeier DA, Venkatesh V, Stanbrook MB. Mandatory reporting by physicians of patients potentially unfit to drive. Open Medicine 2008;2(1):4–13.Winkelaar P. Reporting patients with medical conditions affecting their fitness to drive. CMPA Perspective 2010;2(4):3-5.Simpson CS, Hoffmaster B, Mitchell LB, Klein GL. Mandatory physician reporting of drivers with cardiac disease: Ethical and practical considerations. Can J Cardiol. 2004; 20(13):1329-1334.