IT’S CLEAR from the calls we receive on our advice line that matters related to medical confidentiality continue to be a source of concern and challenge to members. Confidentiality lies at the heart of the trusted doctor-patient relationship and it is rightly taken very seriously by doctors but cannot be absolute. Information may have to be disclosed in order to protect the public interest, even when consent has been refused by the patient.
This is seen clearly in cases where patients present with medical conditions that may impair their fitness to drive. The ability to drive can be of huge importance to patients, tied in with their occupation, independence, social interaction, family life and identity.
Though some patients will immediately understand and be happy to follow their doctor’s advice to stop driving when faced with a disqualifying medical condition or treatment, others may find it more difficult to accept. They may disagree with the advice and consider that they are still competent to drive, or they may seek to cope with the condition by offering to restrict driving in some way.
Clearly, whilst patients may be willing to accept any risk to themselves in driving, the risk inevitably extends to other members of the public. Doctors who are accustomed to acting as patient advocates may find themselves in the uncomfortable position of having to act against their patient’s wishes and to breach their confidentiality in such circumstances.
The decision on whether or not a patient may drive with a temporary or permanent medical condition or treatment is a matter of clinical judgment, bearing in mind the detailed guidance provided by the DVLA. Some conditions, such as a clearly documented loss of visual acuity, may be relatively straightforward, but others such as alcohol misuse or fainting episodes may be more difficult to assess. It is therefore important to record as precisely as possible the history provided and any examination findings, together with the reasons for the decision on fitness to drive. In some areas of the UK it is possible to refer patients to a specialist centre for a formal driving assessment to help decide on matters in borderline cases.
Under the provisions of the Road Traffic Act 1998, a person who has a medical condition or treatment that may impair his fitness to drive has a legal obligation to notify the matter to the DVLA. Failure to do so is an offence that may attract a fine of up to £1,000, and in the event of an accident a driver may face prosecution. The first step for doctors is therefore to explain clearly the nature of the medical condition or treatment and how this may affect driving. The patient should then be advised to stop driving and of their legal obligation to self-report to the DVLA.
In May 2016 the DVLA published a revised edition of its Assessing fitness to drive – a guide for medical professionals. This document is available online and can be accessed to demonstrate the regulations to the patient if need be. This conversation should then be recorded in detail in the medical records.
Doctors accustomed to acting as advocates may find themselves in the uncomfortable position of having to act against their patient’s wishes.
Refusal to comply
The situation becomes challenging when, despite the doctor’s best attempts, the patient refuses to agree to self-reporting and signals an intention to continue driving. In these circumstances, the GMC provides specific and helpful supplementary guidance. It may be that the patient will welcome referral for a second opinion on fitness to drive if this is suggested, and the doctor may wish to raise this and to offer to arrange it. However, it is important that the patient agrees and accepts that driving is prohibited in the meantime whilst awaiting the second opinion.
If a patient continues to drive when they may not be fit to do so, then every reasonable effort should be made to persuade them to stop. Discussing the matter with relatives, friends or carers could be helpful but only if the patient consents to this approach.
Should all attempts fail to persuade the patient to stop driving, or the doctor discovers that the patient is continuing to drive against advice, then this should be disclosed to a medical adviser at the DVLA. This should be done in confidence and include all relevant medical information which relates to the patient’s fitness to drive.
Before taking this step, however, it is important that the doctor tries to inform the patient of the decision to disclose personal information to the DVLA and perhaps further discuss the matter. Having made the disclosure, the doctor should then, in addition, write to the patient confirming that this has been done.
Each step of this process advised by the GMC should be documented carefully in the patient’s records, so that there is clear evidence of the measures that have been taken to persuade the patient to stop driving, and to protect the patient and the public interest.
The situation is somewhat different when a patient who may be unfit to drive presents with a condition such as dementia which is associated with cognitive decline. In this case, an additional assessment must be made as to whether the patient understands fully the advice they are being given in relation to driving, and has the mental capacity to remember to self-report to the DVLA and follow the advice given.
The GMC advises that if the patient is incapable of understanding the advice, for example because of dementia, then the doctor should inform the DVLA immediately. Again the reasons for deciding to disclose in this way should be recorded.
The GMC last produced guidance on confidentiality and DVLA disclosures in 2009, and revised guidance is due to be released in 2017, a consultation process having been completed through 2015 and 2016. It is likely, however, that the new guidance will simply build on the current guidance, emphasising the key ethical duties and obligations of doctors in relation to fitness to drive issues.
Should members have any specific queries in regard to fitness to drive and making disclosures to the DVLA, please phone an adviser at MDDUS.
Barry Parker is a medical adviser at MDDUS and editor of Summons