1. ARE THEY SAFE TO DRIVE? Jennifer Mason OT Reg. (NS) Tobi Flewwelling OT Reg. (NS)

2. Faculty/Presenter Disclosure CFPC CoI Templates: Slide 1

3. Disclosure of Commercial Support CFPC CoI Templates: Slide 2

4. Presentation Objectives To review and clarify:  The Family Physicians’ responsibilities in identifying and reporting patients deemed unsafe to drive  The criteria considered when making the assessment  Guidelines on imposing permanent vs temporary driving restrictions  When to report an unsafe driver and if advising the patient not to drive is adequate  What to do when patients are discovered to be non-compliant

5. Driving - Provincially Regulated  Driving is provincially regulated  The regulatory body for Nova Scotia is the Registry of Motor Vehicles (RMV)  RMV has 2 divisions  The Medical Division  Driver Compliance  Key features of the Medical Division are the Medical Fitness Coordinator and Medical Advisory Council (MAC)

6. Duty to Report “ All provinces and territories impose a statutory duty on physicians relating to the reporting of patients deemed unfit to drive. This duty may be mandatory or discretionary, depending on the jurisdiction. The duty to report prevails over a physician’s duty of confidentiality.” CMA Driver’s Guide

7. Provincial Regulations regarding Reporting by Physicians  Nova Scotia, Quebec, – Discretionary  Alberta – Not directly addressed – interpreted as discretionary  BC – Mandatory if the unfit driver has been warned of the danger and continues to drive  All other provinces and Territories – Mandatory

8. Physician Responsibility in NS  Discretionary not Mandatory  Common Law dictates that the physician can still be held responsible if someone is driving when it was reasonable to think they would be unsafe  Legislation protects physicians from legal action brought against them for making a report

9. Suspension  The duty is to report a change in medical status that is likely to effect driving  Can specifically request a suspension  Medical details are not required if requesting suspension  The suspension is made by the Registry and the patient receives a letter from them  License is suspended, not revoked

10. Registry of Motor Vehicles (RMV)  Will suspend if it is recommended by physician  May go to MAC if there are conflicting medical opinions  May require a Comprehensive Driver Evaluation through the Nova Scotia Rehabilitation Centre

11. Medical Examination Report A Physician will receive a request to complete the medical examination report:  If the letter sent to the RMV did not clearly recommend suspension  If patient is flagged by Access NS when renewing their license  If patient has a condition that may progress and they are being monitored by the RMV

12. Permanent or Temporary Restrictions  Suspended license – may be temporary or permanent i.e. suspension can be lifted  Revoked license (license taken away)  Temporary/defined time driving restrictions - usually unnecessary to inform the RMV : e.g. For post surgery/illness restrictions that are for a defined length of time

13. Reporting vs. Advising Not to Drive  The Registry of Motor Vehicles would like all patients reported (except for temporary cases)  Many physicians choose not to formally report but advise the patient to stop driving  Considerations:  Competency  Compliance  Family involvement  Physician responsibility

14. Reporting vs. Advising Not to Drive Advising the patient not to drive may be enough if:  The driving restriction is temporary (e.g. post surgery, new medication trial)  There is confidence that the patient will be compliant and/or family is able to assist in enforcing Note: the majority of patients we see do not remember being told not to drive  Needs to be clearly stated  May help to write it (prescription)  Inform patients of insurance issue

15. When Patients are Non-Compliant  If they haven’t been reported – report them to the RMV  If they are suspended and you have reason to believe that they are driving:  Contact the police – the police in their community will be asked to watch for the individual  The RMV can suspend the vehicle plates but that eliminates anyone else from using the car

16. Requirements for Driving  Physical Function  Strength and Range of Motion  Reaction Time  Visual-Perceptual Function  Vision – acuity, visual field, contrast sensitivity, glare, night vision  Visual-spatial neglect, spatial relations, figure ground, visual scanning

17. Requirements for Driving  Cognitive Function  Attention, processing speed, problem solving, judgment, memory, multi-tasking  Considerations  Driving is contraindicated for frontal/Lewy Body dementias  Paper/pencil tests are poor predictors of on-road performance  There are no “cut-off” scores for driving  There is some evidence that decline in IADL’s is more correlated to on-road performance

18. Multidisciplinary Approach to Driver Evaluation Driver Evaluation Program (902) 473-1299 If you have questions contact Tobi Flewwelling OT tobi.flewwelling@nshealth.catobi.flewwelling@nshealth.ca or Jennifer Mason OT jennifer.mason@nshealth.cajennifer.mason@nshealth.ca Initial Assessment Client identifies driving as a valued occupation YES NO Physician explains potential need for driver evaluation Team completes usual assessments/interventions No further intervention related to driving Further assessment Needed? YESNO Referral to Comprehensive Driver Evaluation Program Discussion re: driver cessation Team explores alternate forms of transportation with client Physicians letter to Registry of Motor Vehicles Impairment identified in one or more of the following areas: IADL: Meal preparation, money management, medication management Physical functioning that could translate to difficulty operating a vehicle Perception Cognition

19. NSHA Comprehensive Driver Evaluation Program  Only program of its kind in Nova Scotia  Based at the Nova Scotia Rehab Centre  Established 1978  Fee for service model: $440.00  Physician referral required  Evaluation requested/accepted by RMV

20. Evaluators  The evaluation is completed by an occupational therapist who has successfully met the requirements for a Certified Driver Rehabilitation Specialist (CDRS)  On-roads are carried out with a certified driving instructor in a dual-brake vehicle  Vehicle is equipped with hand controls and steering aids or left foot gas if needed  The final recommendation is made by the occupational therapist

21. Evaluation Clinical Assessment (family member encouraged to attend, especially for client’s with memory concerns)  Driving history  Physical assessment  Cognitive/perceptual screen  Reaction time

22. Evaluation On Road Assessment  40 minutes  Dual brake vehicle  Vehicle equipped with adaptations (hand controls, left foot gas, steering aids)  Standard routes – one for city drivers, one for those who don’t typically drive in the city  Can individualize if appropriate  All patients are taken on-road

23. Adaptations- Simple Mechanical  Hand controls

24.  Left foot accelerator-

25.  Steering device- Spinner knob/tri pin

26. Transfer/lift seats

27. Ramps/Lifts

28. Transfer of Mobility Equipment

29. Results  Assessment results are reviewed with client and family  Recommendations and Final Report- sent to referring physician and family physician  Only sent to RMV with client’s consent  Client requires final decision from physician unless already suspended  Client is provided with equipment prescription if appropriate and instructions on purchase, installation and regulations

30. Resources  NSHealth Website: Driver Evaluation Program http://www.cdha.nshealth.ca/rehabilitation-supportive-care- services/assistive-technology/driver-evaluation-program  Medical Fitness to Drive CMA guide https://www.cma.ca/EN/Pages/drivers-guide.aspx  Driving Brochures: Driving safely as you age http://www.olderdriversafety.ca/consumer/resources/index.html  Driving and Dementia https://www.candrive.ca/en/resources/physician-resources/19-driving- toolkit.html

31. Contact Information  Driver Evaluation Program (902) 473-1299.  Jennifer Mason OT jennifer.mason@nshealth.cajennifer.mason@nshealth.ca  Tobi Flewwelling OT tobi.flewwelling@nshealth.catobi.flewwelling@nshealth.ca