A common reason for doctors seeking medico-legal advice from the MDU are concerns around patients' fitness to drive, particularly when weighing up whether to make a disclosure to the authorities.

Most patients are happy to follow medical advice about their fitness to drive and willing to notify the relevant authorities. But there are times this doesn't happen. Here we look at what you can do to make sure you're giving patients the latest advice, and how to avoid a complaint further down the line.

Review the latest guidance

The starting point in making clinical judgments about a patient's ability to drive safely is being familiar with the guidance produced jointly by the Road Safety Agency and the National Office for Traffic Medicine. Updated each year, and now in its 11^th edition, the Medical Fitness to Drive Guidelines outline what busy doctors need to know when assessing fitness to drive.

One of the significant changes in the 2022 edition is increasing the expiry age for Group 1 drivers from age 70 to 75 (Group 1 drivers can drive cars, motorcycles and work vehicles, such as tractors). Once over 75, patients will be required to reapply for a driving licence every three years (or annually in some cases).

It's important to remind those under 75 that they still have an obligation to tell the National Driver Licence Service (NDLS) if they develop a condition that could impair their ability to drive safely.

Know which conditions to notify

There are also some limited changes to certain neurological conditions (chapter 2), psychiatric disorders (chapter 5) and cardiovascular disorders (chapter 3).

One notable change is in relation to the definition of alcohol misuse (chapter 6) which now includes binge-drinking behaviour. The guidelines now say that "clinicians should consider binge-drinking as an important aspect of alcohol misuse" and be aware of its potential impact on road safety and the need to be vigilant for it.

The HSE and World Health Organisation define binge drinking as the consumption of six or more 'standard' drinks (defined as 10g alcohol per drink) in one sitting, usually over a short space of time.

Consider disclosing information

Most patients will accept the advice of their doctor when told to stop driving and notify the NDLS of their medical condition. Sometimes patients are unable or unwilling to accept their doctor's advice to stop driving and the difficult question is what your ethical obligations are, as a registered medical practitioner.

Normally, you should not disclose information to a third party about a patient unless he or she expressly gives permission for that to happen. Consequently, when disclosure of confidential information is contemplated without the patient's agreement, doctors would need to justify that decision on the grounds that it was necessary in the public interest to do so.

The guidelines provide detail on the circumstances where it may be necessary to breach confidentiality and make a disclosure to the NDLS (section 2.3.1). These include:

the patient is unable or unwilling to appreciate the impact of their condition on their fitness to drive (for example, because of dementia)
the patient is unable or unwilling to take notice of the doctor's recommendations and advice
the patient continued to drive, against medical advice, and is likely to present a danger to others.

Keep the patient informed

Where the doctor decides that a disclosure should be made to the NDLS this should be confined to providing information that is directly relevant and, where possible, with the patient's agreement.

It is good practice to confirm to the patient in writing when the disclosure has been made, and summarising (or providing a copy) of the information that was disclosed to the NDLS.

This approach to disclosure is consistent with the Medical Council's Guide to Professional Conduct and Ethics. It states that there can be a public interest in disclosing information where the benefits to another individual or society outweigh the duty of confidentiality.

This may occur in exceptional circumstances to protect individuals or society from risks of serious harm. Doctors must carry out "a balancing exercise" of individuals' rights and the public interest. You should disclose the information to an appropriate person or authority and include only the information needed to meet the purpose.

Get training and advice

Questions about fitness to drive, and in particular concerns about patients continuing to drive against medical advice, can be difficult and contentious. Educational resources, including formal training courses along with research and publications, are available from the National Office for Traffic Medicine and will be helpful to those who wish to expand or refresh their knowledge. For individual cases which may have medico-legal consequences, it's a good idea to have a low threshold for getting advice from your medical defence organisation at an early stage this may help prevent a complaint further down the line.

Case scenario

"My patient has type 2 diabetes and has started on tablets which are known to carry a risk of inducing hypoglycaemia. He is a lorry driver and I have completed a Driving Licence Medical Report Form (DLMRF) for him, so I know he needs to inform the NDLS. But he has admitted to me today that he hasn't yet done so. What should I do?"

While you have a duty of confidentiality to your patient, there are circumstances where it may be necessary to breach confidentiality to protect patients or the community from harm in the public interest.

First, try to persuade the patient to inform the NDLS without delay, and confirm to you that he has done so. If this doesn't work you may have to inform the NDLS, but you should still do so with the patient's agreement, if possible.

Only pass on necessary information, such as the patient's name, contact details, copy of the DLMRF and details of the medical condition which prevents them driving. Inform the patient in writing that you have done this and make a note in the records setting out your actions and reasons for disclosing information. This will help if you are asked to justify your actions at a later date.

MDU membership

MDU membership is open to consultants and hospital doctors not currently in training posts working in public hospitals. To find out more, see themdu.com/ireland

A version of this article first appeared in the June 2022 edition of Irish Medical Independent.

Advising patients on fitness to drive in the Republic of Ireland

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