Epilepsy, driving and confidentiality

1. Epilepsy, driving and confidentiality Extra case 2

2. Presentation • 22 year old male university student admitted to hospital • PC: prolonged grand mal seizure • HPC • Longstanding epilepsy  well-controlled for past 5 years (no seizures) • No identifiable reason for this seizure • Neurology review: recommends change in anti-epileptic drug Rx; should not drive for > 3 months (until medication stabilises)

3. A few weeks later • Mother contacts GP  son has started driving again • Makes appointment for her son to discuss situation with GP later that day

4. Discuss possible causes of Josh’s grand mal seizure • Epilepsy  aberrant neuronal activity • Can be genetic (eg. defective ion channel genes) • Brain repair following trauma/stroke • Drugs/alcohol (including withdrawal) • Dehydration • Metabolic disorders (hypoglycaemia, hypoxia, liver/kidney) • Infection (eg. meningitis) • Psychogenic seizure • Tumour • Syncope (but unlikely)

5. What are the guidelines in Queensland regarding fitness to drive for people who have epilepsy?Why may Josh continue to drive despite advice not to do so?

6. Public safety Vs right to privacy • In relation to public safety there is, on the one hand, the community's right to be protected from persons driving on a public road who suffer from designated medical conditions such as epilepsy, to themselves, their passengers and all other users of the roadway. • On the other hand there is the patient's right to privacy but perhaps more importantly, the real likelihood that if a doctor is mandated to report then any patient may choose not to consult a doctor at all for fear of losing their driver's licence, thus posing, in my view, a greater risk or danger to not only themselves but their fellow passengers and to all other road users.

7. Why does a patient have a right to privacy • Part of a doctor’s duty of care to their patients is to maintain confidentiality. • If there is a breach of confidentiality and the patient can prove damages then the doctor can be sued for negligence. • The question then is: can a doctor be sued for negligence for losses incurred by a patient because they informed the transport department that their patient is unfit to drive?

8. What are Dr Smith’s ethical and legal obligations regarding Josh’s driving?Comment on Dr Smith’s obligation to respect patient confidentiality.

9. Are doctors required to report patients who are medically unfit to drive? • Health professionals in Qld are not compelled to report medically unfit drivers to the department. • Reporting, however, is mandatory in NT and SA

10. Can a health professional be sued for a breach of confidentiality? • Health professionals are afforded protection from liability for providing information in good faith about a person's medical fitness to hold, or continue to hold, a Queensland driver licence.

11. Jet’s Law • On the 1st of March 2006 and named "Jet's Law" in recognition of Jet Rowland, a little 22 month old boy who was killed in 2004 when a driver with epilepsy crashed into the car in which he was a passenger. • Under the relevant law, Queensland driver licence holders must promptly report to the Department of Transport and Main Roads any mental or physical incapacity (a medical Condition) that is likely to adversely affect their ability to drive.

13. History • Has ever been found unfit to drive a motor vehicle in the past, and the reasons; • Whether there is any history of epilepsy, syncope or other conditions of impaired consciousness including sleep disorders; neurological conditions; psychiatric disorders; problems arising from alcohol and/or drugs; diabetes; • hypertension and other cardiovascular conditions, especially ischaemic heart disease; locomotor disorders; • hearing or visual problems; • Whether the person has a history of motor vehicle incidents; • Whether they are taking medications which might affect driving ability; • The existence of other medical conditions which, when combined, might exacerbate any road safety risks • The nature of their current driving patterns and needs, for example, how frequently they drive, for what purposes, over what distances, whether they travel at night, etc. • Perform and examination

14. Examination • Cardiovascular • Lung sounds • Liver size • Neurological (Upper & lower limbs, vision and hearing) • Neuropsychological assessment (do an MMS if indicated) • Urinalysis (protein, glucose)

15. Doctor determines the patient is unfit to drive... What do you tell the patient? • Initial or isolated seizure (not necessarily a diagnosis of epilepsy) – 6 months seizure free period before driving again • Recurrent seizure following seizure free period • With precipitating cause (sleep deprivation or other temporary illness) – 1 month • Unknown cause – 3 months • Anticonvulsant withdrawal trial under consultant supervision – 3 months following completion of withdrawal • “Safe seizures” – those that occur at specific times of the day (eg upon waking) – a restricted licence can be applied for

16. If epilepsy has been diagnosed • New diagnosis – 6 months seizure free but can be reduced to 3 months if recommended fit to drive by an experienced consultant neurologist • History of uncontrolled seizures – 2 years seizure free • Seizures only whilst asleep – 12 months daytime seizure free period • Following surgery to prevent seizures – 12 months