Assessing Fitness to Drive

In this section

3.3.1. Confidentiality, privacy and reporting to the driver licensing authority

3.3.2. Patient–health professional relationship

3.3.3. Patient hostility towards the health professional

3.3.4. Dealing with individuals who are not regular patients

3.3.5. Role of medical specialists

3.3.6. Role of driver assessors and trainers

3.3.7. Role of independent experts/ panels

3.3.8. Documentation

Patients rely on health professionals to advise them if a permanent or long-term illness, disability, medical condition or injury, or the effects of the treatment for any of those things may affect their safe driving ability and whether it should be reported to the driver licensing authority. The health professional has an ethical obligation, and potentially a legal one, to give clear advice to the patient in cases where a long-term illness, disability, medical condition or injury, or the effects of the treatment for any of those things, may affect safe driving ability. Health professionals are advised to note in the patient’s medical record the nature of the advice given.

Health professionals have both an ethical and legal duty to maintain patient confidentiality. The ethical duty is generally expressed through codes issued by professional bodies. The legal duty is expressed through legislative and administrative means and includes measures to protect personal information about a specific individual. The duty to protect confidentiality also applies to driver licensing authorities.

The patient–professional relationship is built on a foundation of trust. Patients disclose highly personal and sensitive information to health professionals because they trust that the information will remain confidential. If such trust is broken, patients could forgo examination/treatment or modify the information they give to their health professional, potentially placing their health at risk.

Although confidentiality is an essential component of the patient–professional relationship, there are, on rare occasions, ethically or legally justifiable reasons for breaching confidentiality. With respect to assessing and reporting fitness to drive, the duty to maintain confidentiality is legally qualified in certain circumstances in order to protect public safety. Health professionals should consider reporting directly to the driver licensing authority in situations where a patient is either:

• unable to appreciate the impact of their condition
• unable to take notice of the health professional’s recommendations due to cognitive impairment
• provides unreliable information on their condition, or
• continues driving despite appropriate advice and is likely to endanger the public.

In the Australian Capital Territory, New South Wales, Queensland, Tasmania, Victoria and Western Australia, statute provides that health professionals who make such reports to driver licensing authorities without the patient’s consent but in good faith that a patient is unfit to drive are protected from civil and criminal liability. The Northern Territory does not currently provide this protection (refer to Appendix 3. Legislation relating to reporting).

In South Australia and the Northern Territory current legislation imposes mandatory reporting. A positive duty is imposed on health professionals to notify the relevant authority in writing of a belief that a driver is physically or mentally unfit to drive (refer to Appendix 3. Legislation relating to reporting).

It is preferable that any action taken in the interests of public safety should be taken with the consent of the patient wherever possible and should certainly be undertaken with the patient’s knowledge of the intended action.

The patient should be fully informed as to why the information needs to be disclosed to the driver licensing authority and be given the opportunity to consider this information. Failure to inform the patient will only exacerbate the patient’s (and others’) mistrust in the patient– professional relationship. It is recognised that there might be an occasion where the health professional feels that informing the patient of the disclosure may place the health professional or others at risk of violence. Under such circumstances the health professional must consider how to appropriately manage such a situation (refer to section 3.3.3. Patient hostility towards the health professional).

In making a decision to report directly to the driver licensing authority, it may be useful for the health professional to consider:

• the seriousness of the situation (i.e. the immediate risks to public safely or others both from the patient’s attitude and the degree of risk their condition poses)
• the risks associated with disclosure without the individual’s consent or knowledge, balanced against the implications of non- disclosure
• the health professional’s ethical and professional obligations
• whether the circumstances indicate a serious and imminent threat to the health, life or safety of any person.

Considerations involving cases where there is an immediate threat to public safety may require the health professional to exercise their duty of care in line with relevant professional standards and report the driver to the driver licensing authority or the police. This may be appropriate in instances where there is a high risk – for example, drivers with a history of reckless driving, crashes or intentions to cause harm involving motor vehicles.

Examinations requested by a driver licensing authority

When a patient presents for a medical examination at the request of a driver licensing authority the situation is different with respect to confidentiality. The patient may present with a form or letter from the driver licensing authority requesting an examination for the purposes of licence application or renewal, or as a stipulation of a conditional licence. The completed form should be sent directly to the driver licensing authority, rather than returned to the driver. In the case where an electronic medical report form is completed, these reports will be returned directly to the driver licensing authority.

Privacy legislation

All health professionals and driver licensing authorities should be aware of the National Privacy Principles, the Health Privacy Principles and other privacy legislation applicable in their jurisdiction (e.g. health records legislation) when collecting and managing patient information and when forwarding such information to third parties.

It is expected that health professionals will be able to act objectively in assessing a patient’s fitness to drive. If this cannot be achieved – for example, where there may be the possibility of the patient ceasing contact or avoiding all medical management of their condition – health professionals should be prepared to disqualify themselves and refer their patient to another practitioner.

A difficult ethical situation arises in the event that the health professional has reason to doubt the veracity of the information provided by a patient regarding their health, and their capacity to drive safely. In this case health professionals could consider the following strategies:

• contacting their professional indemnity insurer, discussing the problem and documenting the advice
• discussing the problem with colleagues
• referring the person for a second or specialist opinion
• contacting the relevant driver licensing authority and, without identifying the patient, discussing the problem and documenting the advice.

With these additional inputs it may be possible to carefully discuss and reassess the situation with the patient, taking care to document the proceedings.

Sometimes patients feel affronted by the possibility of restrictions to their driving or withdrawal of their licence and may be hostile towards their treating health professional. In such circumstances the health professional may elect to refer the driver to another practitioner or may refer them directly to the driver licensing authority without a recommendation regarding fitness to drive. Driver licensing authorities recognise that it is their role to enforce the laws on driver licensing and road safety and will not place pressure on health professionals that might needlessly expose them to risk of harassment or intimidation.

The health professional may refer the patient to the standards in this publication when dealing with such situations. They may point out that the standards are developed by the National Transport Commission in cooperation with professional medical, allied health associations and road safety experts based on current evidence and are enforced by driver licensing authorities.

More information about managing patient– professional hostility is available from the Royal Australian College of General Practitioners website at www.racgp.org.au/your-practice/business/tools/safetyprivacy/gpsafeplace/

Care should be taken when health professionals are dealing with drivers who are not regular patients. Some drivers may seek to deceive health professionals about their medical history and health status and may ‘doctor shop’ for a desirable opinion. If a health professional has doubts about a person’s reason for seeking a consultation, they should consider:

• asking permission from the person to request their medical file from their regular health professional
• conducting a more thorough examination of the person than would usually be undertaken
• noting on the medical report returned to the driver licensing authority the length of time the patient has been known to them and whether the health professional had access to the full medical record/history.

In most circumstances medical assessments of drivers of either commercial or private vehicles can be conducted by a general practitioner. However, if doubt exists about a patient’s fitness to drive or if the patient’s particular condition or circumstances are not covered specifically by the standards, review by a specialist experienced in managing the particular condition is warranted and the general practitioner should refer the patient to such a specialist.

It is important that treating specialists share their fitness-to-drive assessment outcomes with the patient’s general practitioner. This is in recognition of the important role general practitioners have in healthcare coordination and monitoring of long-term health conditions as well as potential road safety and public health implications.

In the case of commercial vehicle drivers, the opinion of a medical specialist is generally required for an initial recommendation and periodic review of a conditional licence; the main exceptions to this are set out here and in section 4.4.7. What if there is a delay before a specialist can be seen?.

This requirement reflects the higher safety risk for commercial vehicle drivers and the consequent importance of expert opinion. In circumstances where access to specialists is limited, once the initial recommendation is made, alternative arrangements for subsequent reviews by the general practitioner may be made with the approval of the driver licensing authority and with the agreement of the specialist and the treating general practitioner.

Note: The opinion of a specialist is relevant only to their specialty. General practitioners are in a good position to integrate reports from various specialists in the case of multiple disabilities to help the driver licensing authority make a licensing decision. An occupational physician or an authorised health professional may provide a similar role for drivers of commercial vehicles and their employers. For the purposes of this publication, the term ‘specialist’ refers to a medical or surgical specialist other than a general practitioner, acknowledging that Fellows of the Royal Australian College of General Practitioners and Fellows of the Australian College of Rural and Remote Medicine have specialist status under current medical registration arrangements (refer to www.medicalboard.gov.au).

As previously described, a practical driver assessment (including on- or off-road components) may be required to assess the impact of injury, illness, disability or the ageing process on driving skills including judgement, decision-making skills, observation and vehicle handling. Such assessments are particularly useful in borderline cases where vehicle modifications or adaptations are required and/ or where the impact of injury, illness, disability or the ageing process on functionality is not clear. They should be conducted by suitably qualified occupational therapy driving assessors. Advice regarding the availability and access to driver assessors is available from the local driver licensing authority and Occupational Therapy Australia (refer also to Appendix 10. Specialist driver assessors).

Recommendations following assessment may relate to licence status, the need for vehicle modifications, rehabilitation or retraining (refer to section 2.3.2. Driver rehabilitation), licence conditions or restrictions (refer to section 4.4. Conditional licences) and reassessment.

Driver training and rehabilitation providers have a role in supporting drivers to retain and regain skills as a result of injury, disability or illness, and to adapt to using vehicle modifications. Training may be conducted on-road and may be supplemented by simulator- or computer- based training.

Recognising that not all medical and driving circumstances can be specifically or fully covered in these standards, driver licensing authorities may draw on independent expert medical advice to inform borderline or otherwise difficult licensing decisions.

Clear documentation of the assessment results and communication with the patient and driver licensing authority is important. Refer to section 5.2. Which forms to use.