Cases & Commentaries

Carpe Diem (Seize the Day)

Commentary By Allan Krumholz, MD

The Case

A 53-year-old man presented for a new patient
visit at a local medical clinic. He had several chronic medical
conditions including hypertension, hyperlipidemia, depression,
osteoarthritis, and a seizure disorder. His medications included
phenytoin for his seizure disorder. Two months prior to this
presentation, the patient called the on-call physician worried that
he had suffered a seizure. The patient requested a "handicapped"
license plate because of increasing difficulty walking long
distances due to his osteoarthritis. To his surprise, the physician
informed him of the need to alert the Department of Motor Vehicles
(DMV) about his seizure disorder. The patient reported that his
neurologist allowed him to drive "only to and from work" because
his seizures were "nocturnal." Despite the patient receiving
treatment from several physicians over the years, this was the
first time a physician explained the need to report his condition
to the DMV. The patient was very upset with the treating physician,
but the physician felt he was complying with the law.

The Commentary

By reporting a recent seizure to his new
physician, this man suddenly confronts his doctor with the
difficult and complex legal and medical problem of managing and
advising the driver with seizures or epilepsy.(1,2) My first step when caring for a patient who reports
loss or alteration of consciousness is to try to determine the
cause. This is done with a careful history and physical, followed
by appropriate clinical or diagnostic tests, which may include
screening blood work, an EKG, an EEG, or a brain imaging study.
Establishing a likely cause will help determine whether it presents
a real risk for driving.(3)

In the United States, all states have laws and
rules prohibiting licensing drivers with medical conditions that
may pose safety risks, like loss of consciousness or seizures. But
what is the duty of the physician? To me, the key point is this:
it is the responsibility of the state, not the physician, to
determine who should or should not drive an automobile. The
physician or other health care provider has a duty to serve as a
consultant or advisor to the state and the patient and to comply
with the law. Although the state makes the final decision, many
states rely very strongly on a physician's findings and
recommendations. Unfortunately, not all states give physicians
legal immunity when they supply this type of information.(4)

One critical issue is who should report the
driver with epilepsy. In every state, potential drivers must report
that they have seizures to the state licensing authority.
Physicians are mandated to report drivers with seizures or epilepsy
in only six states: California, Delaware, Nevada, New Jersey,
Oregon, and Pennsylvania.(1,2,4,5) The rules vary somewhat, but in general, health
care professionals in the mandatory reporting states are required
to report drivers with epilepsy or seizures to state authorities,
under threat of both legal and monetary penalties (including
significant liability for damages should a patient
crash).(4)

Even in states without mandatory physician
reporting of drivers with seizures, the physician still has legal
obligations and risks.(6)
First, it is generally accepted that the physician should inform a
patient with epilepsy or seizures of the rules for driving in that
state. This discussion with the patient should be documented in the
chart. For example, I usually write something brief such as, "State
law regarding driving and seizures was discussed with the patient."
As my legal colleagues remind me, "If it is not written in the
chart, it never happened." I separate my discussion with the
patient into two broad categories: legal rules and driving risks
for the individual. The risks of driving with epilepsy and crashing
vary depending on such factors as the nature and frequency of the
seizures.(3)

Even in states without mandatory reporting, it
may be appropriate for a physician to report a patient to state
authorities. For example, a patient whose uncontrolled seizures
have already caused a crash is at greater risk for subsequent
crashes. In such a situation, if a patient refuses to self-report,
I strongly consider and usually report the patient myself. In
addition, I specifically inform the patient and document in the
chart that I advised him to stop driving immediately. The letter
doing so is sent to the state motor vehicle administration and can
be brief and factual—stating simply, for example, that this
is my patient, the patient has seizures, and he was advised by me
not to drive. I usually send a copy of that same letter to the
patient.

Although driving was generally prohibited for
patients with seizures in the early years of the automobile, by the
early 1970s the precedent was established that an individual with
well-controlled seizures should be eligible for a driving license.
The determination of seizure control was based largely on an
adequate seizure-free interval and was a factual judgment by a
medical specialist. Based on generally favorable safety experiences
with this standard and the growing importance of the automobile in
society, the trend since then has been one of further
liberalization of driving restrictions for seizures and shortening
of required seizure-free intervals.(2,5,7)

Is there an optimal seizure-free interval? A
single standard probably would not satisfy all because of varied
culture, social and environmental factors, and risk tolerances. For
example, in many European or American cities with excellent public
transportation, a prohibition from driving may not have adverse
social, cultural, or psychological consequences. However, in many
suburban, rural, or remote regions of the United States and other
countries, inability to drive an automobile is a severe
handicap.

In the United States, the duration of the
required seizure-free interval varies among states from 3 to 12
months (Figure). (Information on specific states is available
at: [ go to related site ] AND [ go to related site ]). This wide range reflects
limited scientific data on the risks for driving with epilepsy.
Many states have adopted 3-month seizure-free restrictions, and
this interval is consistent with the consensus statement from the
American Academy of Neurology (AAN), American Epilepsy Society
(AES), and the Epilepsy Foundation (EF).(6) Scientific research on this is limited, but one study
found that, among patients with epilepsy who drive, 6- to 12-month
seizure-free intervals significantly reduced the odds of crashing
during a seizure compared with shorter intervals.(3) However, longer seizure-free intervals appear to
discourage compliance with rules for regulating drivers with
epilepsy, while shorter seizure-free intervals encourage
compliance.(8-11)

Noncompliance with legal restrictions on driving
with seizures is a major problem, and the 3 month interval is an
attempt to balance compliance with risk-reduction. Most individuals
with seizures who drive never reveal their disorder to
authorities.(3,8-10,12) The magnitude of noncompliance may, in part,
explain why harsh legal restrictions on driving with seizures have
not been very successful in preventing collisions. More permissive
restrictions (ie, a 3-month seizure-free interval), although
potentially increasing the individual's risk of a crash, may
actually reduce the cumulative risks by promoting better compliance
with existing legal driving limitations.(11,13)

One of the primary system strategies to improve
reporting and compliance is to educate both patients with seizure
disorders and providers caring for them. First, doctors caring for
these patients should familiarize themselves with local state
regulations and relate these clearly. These change frequently so it
is important to be up to date. The local state affiliate of the
Epilepsy Foundation provides this information online at [ go to related site ]. In Maryland, our
affiliate of the Epilepsy Foundation released a pamphlet for
patients and health care professionals, which explains the rules
and regulations for potential drivers with epilepsy. I find it
useful to hand out to my patients to help them understand our local
rules and their responsibilities regarding seizures and driving. I
encourage other states or localities to consider developing
something similar. Finally, in my opinion, one thing that does not
receive adequate emphasis is the need to develop viable
alternatives to driving for patients with seizures and other
disabilities. If these were available, more seizure patients might
comply with reporting requirements and driving restrictions.

Take-Home Points

  • It is the responsibility of the
    state, not the physician, to determine who should or should not
    drive an automobile.
  • As a
    physician or health care provider, your duty is to comply with the
    law and to serve as a consultant or advisor to the state and the
    patient. The state makes the final decision.
  • People with seizures
    that are uncontrolled are prohibited from
    driving.
  • People with controlled seizures may be permitted
    to drive.
  • Control is typically determined by the period of
    time a person has been seizure-free because this is predictive of
    the risks of recurrence. Most states require that seizures be
    controlled from 3 to 12 months.
  • Although longer seizure-free intervals may
    decrease the risk of seizure-related crashes, this additional
    safety must be balanced against a parallel increase in
    non-compliance with reporting requirements seen with more
    restrictive policies.

Allan Krumholz,
MD
Professor of Neurology, University of Maryland Medical School
Director, University of Maryland Epilepsy Center

References

1. Krumholz A, Fisher
RS, Lesser RP, Hauser WA. Driving and epilepsy. A review and
reappraisal. JAMA. 1991;265:622-6.[ go to PubMed ]

2. Barrow RL, Fabing
HD. Epilepsy and the law. New York, NY: Hoeber Medical Division of
Harper and Row; 1966.

3. Krauss GL,
Krumholz A, Carter RC, Li G, Kaplan P. Risk factors for
seizure-related motor vehicle crashes in patients with epilepsy.
Neurology. 1999;52:1324-9.[ go to PubMed ]

4. Krauss GL, Ampaw
L, Krumholz A. Individual state driving restrictions for people
with epilepsy in the US. Neurology. 2001;57:1780-5.[ go to PubMed ]

5. Krumholz A.
Driving and epilepsy: a historical perspective and review of
current regulations. Epilepsia. 1994;35:668-74.[ go to PubMed ]

6. Consensus
statements, sample statutory provisions, and model regulations
regarding driver licensing and epilepsy. American Academy of
Neurology, American Epilepsy Society, and Epilepsy Foundation of
America. Epilepsia. 1994;35:696-705.[ go to PubMed ]

7. Ooi WW, Gutrecht
JA. International regulations for automobile driving and epilepsy.
J Travel Med. 2000;7:1-4.[ go to PubMed ]

8. Dalrymple J,
Appleby J. Cross sectional study of reporting of epileptic seizures
to general practitioners. BMJ. 2000;320:94-7.[ go to PubMed ]

9. McLachlan RS,
Jones MW. Epilepsy and driving: a survey of Canadian neurologists.
Can J Neurol Sci. 1997;24:345-9.[ go to PubMed ]

10. Gastaut H, Zifkin
BG. The risk of automobile accidents with seizures occurring while
driving: relation to seizure type. Neurology. 1987;37:1613-6.[ go to PubMed ]

11. Sonnen AE.
Epilepsy and driving: a European view. International Bureau for
Epilepsy. Paswerk Bedrijven,
Haarlem;1997:11-32.

12. Berg AT, Vickrey
BG, Sperling MR, et al. Driving in adults with refractory
localization-related epilepsy. Multi-Center Study of Epilepsy
Surgery. Neurology. 2000;54:625-30.[ go to PubMed ]

13. Krumholz A. To
drive or not to drive: the 3-month seizure-free interval for people
with epilepsy. Mayo Clin Proc. 2003;78:817-8.[ go to PubMed ]

Figure

Figure.
Seizure-free restrictions for non-commercial driving: U.S.
states

Image removed.