CANCER KNOWLEDGE
NETWORK CASES
Esther Chan, Michelle Hanna
Alex Louie, MD and David D’Souza, MD
List of Cases
1.
Generalized seizures
2.
Reporting and reinstating a revoked license
3.
4.
Moderate neurosensory deficits secondary to low
grade glioma
Medical, ethical, and legal implications associated
with license revocation in brain cancer patients
CASE 1 – SEIZURES
Case 1 - Seizures



26 year old male comes to your office following a
generalized seizure with complete loss of consciousness.
Isolated event; no history of epilepsy, no alcohol or drug
involvement, no history of trauma.
Seizure did not occur while driving, but as the treating
physician, is it necessary to report the patient’s condition to the
ministry of transportation?
According to CMA Guidelines…

…YES!
“Any seizure is grounds for
immediate cessation of all
driving activities.”
CMA Guidelines
1.
2.
3.
Resumption of driving will depend on neurologic
assessment of the patient and the nature of the
driving activity that is involved.
Driving after a seizure caused by use of a substance
depends on complete abstinence from use of that
substance.
Lack of compliance, including forgotten doses of
medications, is grounds for immediate cessation of
all driving activities.
CMA recommendations for drivers who have
experienced seizures
Type of Seizure
Private Drivers
•
Single, unprovoked
seizure before a diagnosis or posttraumatic seizure
•
No driving for at least 3 months
and:
Neurologic assessment,
preferably including EEG
(awake and asleep) and
appropriate imaging
Commercial Drivers
•
•
•
After diagnosis of epilepsy
Drive if:
•6 months seizure free* on
medication
•Physician has insight into patient
compliance
•Physician cautions against fatigue,
alcohol
•
•
No driving private vehicles for
at least 3 months
Neurologic assessment,
including EEG (awake and
asleep) and appropriate
imaging
If no epilepsy diagnosis,
resume professional driving if
seizure free for 12 months
Resume driving if 5 years
seizure free
Recommendations for
individual patients may differ
on an exceptional basis.
Type of Seizure
Private Drivers
•
After surgery to prevent
epileptic seizures
Seizures only in asleep or
immediately on wakening
•
•
Commercial Drivers
Resume driving if 12 months
seizure free after surgery with
therapeutic drug levels
Recommendations for
individual patients may differ
on an exceptional basis.
•
Drive after 1 year from initial
seizure if drug levels are
therapeutic
•
•
Resume driving if 5 years
seizure free
(Recommendations for
individual patients may differ
on an exceptional basis.)
No driving commercial
vehicles for at least 5 years
Medication Withdrawal or Change
Type of Seizure
Private Driver
•
No driving for 3 months from
the time medication is
discontinued or changed
•
No driving for 6 months from
the time medication is
discontinued or changed
•
Resume driving if seizure
free for 3 months
•
Resume driving if seizure
free for 6 months
•
Drive any vehicle if seizure
free off medication for 5
years with no epileptiform
activity within previous 6
months on waking and sleep
EEG
•
Same as private drivers
Initial withdrawal or change
If seizures recur after
withdrawal or change
Long-term withdrawal and
discontinuation of a medication
Commercial Driver
Type of Seizure
Auras (simple partial
seizures)
Alcohol-withdrawal induced
seizures
Juvenile myoclonic
epilepsy (Janz syndrome)
Private Driver
Commercial Driver
Drive if:
•Seizures are unchanged for at
least 12 months
•No generalized seizures
•Neurologist approves
•No impairment in level of
consciousness or cognition
•No head or eye deviation with
seizures
Drive if:
•Seizures remain benign for at
least 3 years
•No generalized seizures
•Neurologist approves
•No impairment in level of
consciousness or cognition
•No head or eye deviation with
seizures
Drive if:
•Remain alcohol free and seizure
free for 6 months
•Complete a recognized
rehabilitation program for
substance dependence
•Compliant with treatment
•
•No driving of any class of
vehicle unless taking appropriate
anti-seizure medication
Same as private drivers
Seizures and Driving – Summary


Seizure activity is grounds for immediate cessation
of all driving activities
Multiple factors play a role in duration of license
cessation, including:
 Nature
of driving (private vs commercial)
 Nature of seizure (generalized vs simple)
 Diagnosis of epilepsy?
 Presence of seizure triggers (drugs, alcohol, trauma)
 Medical control of seizures (drug withdrawal/changes)
Back to the case…


Given that this seizure was not drug or alcohol
related, it would be treated as a single, unprovoked
seizure before a diagnosis.
This patient would therefore be advised against
driving for at least 3 months, and would be given a
neurologic assessment, EEG, and appropriate
imaging.
References

Canadian Medical Association. Determining medical
fitness to operate motor vehicles. CMA driver’s
guide. 7th ed. Ottawa (ON): The Association; 2006.
CASE 2
HOW TO REPORT A MEDICALLY
UNFIT DRIVER
Let us return to our patient in Case 1…


A 26 year old male comes to your office following
a generalized seizure with complete loss of
consciousness.
Isolated event; no history of epilepsy, no alcohol or
drug involvement, no history of trauma
Seizure did not occur while driving but as we know
from Case 1, seizures are a reportable medical
condition.
Report
After deciding a patient may be unfit to drive (see
tools for determining medical fitness in Case 3), a
formal report must be made to the driving authorities
in each respective jurisdiction.
In Canada, each province has a driving authority who
manages driving related matters. In the United States,
most states operate independently and have a statewide driving authority.
Back to the patient in Case 1
Let us imaging the patient in Case 1 was an Ontario
citizen…
The Ontario Highway Traffic Act states:
“Every legally qualified medical practitioner shall report to
the Registrar the name, address, and clinical condition of
every person sixteen years of age or over attending upon
the medical practitioner for medical services, who in the
opinion of the medical practitioner is suffering from a
condition that may make it dangerous for that person to
operate a motor vehicle.”
- Section 203, Ontario Highway Traffic
Act
Reporting
In Ontario, the Ministry of Transportation, Ministry of
Health and Long Term Care and Ontario Medical
Association Joint Forms Committee have developed a
Medical Reporting Form for medically unfit drivers.
Reporting Continued…
Although it is not necessary to use the Medical Reporting
Form general information to include in a report are:
•
•
•
•
•
Patient Identifiers (Name, Address, DOB, Driver Licence # if
available)
Medical condition resulting in driving impairment (list all if
more than one)
Date of examination for which report is based
If patient is aware of report
Physician Identifiers (Name, Address, Discipline)
Optional Information
It is optional to include relevant information
contributing to the decision.
•
•
•
•
results of investigations
current functional status, medications, treatment, prognosis
whether the condition is in the physicians’ opinion a serious
risk to road safety or if the threat to road safety is
unknown
duration of expected threat (days/weeks/months)
Commercial Drivers
For commercial drivers it may be pertinent to include
an average idea of types of duties involved.
•
•
•
Activity summary – distance, fueling, performing
maintenance, securing the load, etc.
Driving schedule – maximum duration allowed to drive
continuously, time off to sleep, etc.
Physical duties involved with operation of the vehicle –
handling landing gears/trailers, etc.
Do not forget…
To always warn the patient not to drive until further
notice and DOCUMENT the report in the medical
chart.
Things to include in the medical chart:
•
•
•
Whether the report was discussed with patient.
If the patient was advised not to drive until further notice.
Patients response to report.
Without documentation of a discussion with patients to
refrain from driving, physicians may be held liable if
patients are involved in a motor vehicle accident as a
result of their medical condition during the period of
time in which their case is under review.
In a Ontario study examining actual reporting practices of physicians caring for
brain tumour patients, researchers found that only 41% of brain tumour
patients were advised not to drive.
In the same study, of patients with documented seizures it was found that only
68% had documentation of a discussion about driving and only 56% had formal
documentation of a report to the Ministry of Transportation.
Medical Reporting Form
A copy of the Ontario Medical reporting form can be
found at:
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttac
h/023-SR-LC-097~1/$File/SR-LC-097.pdf
For more information about procedural reporting in
other provinces, please refer to provincial driving
authority.
Provincial Driving Authorities
Province
Driving Authority
Newfoundland & Labrador
Service NL – Motor Vehicle Registration Division
Prince Edward Island
Department of Transportation and Infrastructure Renewal
Nova Scotia
Services NS - Registry of Motor Vehicles
New Brunswick
Department of Public Safety – Motor Vehicle Branch
Quebec
Société de l’assurance automobile (SAAQ)
Ontario
Ministry of Transportation
Manitoba
Manitoba Public Insurance – Driver Licensing
Saskatchewan
Saskatchewan Government Insurance (SGI) – Saskatchewan
Auto Fund
Alberta
Alberta Transport - Driver Fitness and Monitoring
British Columbia
Insurance Corporation of British Columbia (ICBC)
Nunavut
Department of Economic Development & Transportation
Northwest Territories
Department of Transportation
Yukon
Department of Highways and Public Works – Motor Vehicles
Branch
Reinstating a Driver’s License
If the patients’ condition has sufficiently changed to
believe they are no longer medically unfit to drive, a
physician may send a letter to the same driving
authority documenting the change in condition and
recommendation for reinstatement.
Determining medical fitness to drive
Licensing authorities and the general public grossly
overestimate a physicians’ ability to predict whether a
patient will be involved in a MVC.
This is because:
•
•
•
•
Abilities may fluctuate and symptoms observed in a physician office may
not reflect true driving ability.
Medical events that alter function may occur after an office visit and
difficult to predict.
Standard physical exams detect presence or absence of disease and do not
assess function.
It is difficult for a physician to predict a patients’ judgement and defensive
driving strategies.
Tools to determine medical fitness to
drive
Currently there are is no evidence-based approaches
for assessing medical fitness to drive in primary care.
In a review of 1500 articles related to health and medical
fitness to drive only level III evidence (ie. expert opinion or
consensus statements) were found.
Available resources?
The CMA Driver’s Guide – Determining medical
fitness to drive
CanDRIVE
Allied health care professionals
The CMA Driver’s Guide
Is a publication provided by the Canadian Medical
Association.
Is a resource for all medically reportable conditions.
Does not instruct on how to assess driving ability.
Can be found at: http://www.cma.ca/determining-fitness-to-drive
CanDRIVE Acronym
Cognition: dementia, delirium, depression; executive function, memory, judgement, psychomotor speed,
attention, reaction time, visuospatial function.
Acute or fluctuating illness.
Neuromusculoskeletal disease or neurologic effects:
Speed of
movement, speed of mentation, LOC, Parkinson’s disease, syncope, arthritis, hypo/hyperglycemia.
Drugs: drugs that affect cognition or speed of mentation. ie. Benzodiazepines
Record: Patient/family describe accidents or near-accidents.
In-Car Experiences: ie. lost or forgetful while driving.
Vision: Acuity, contrast sensitivity, diplopia.
Ethanol use
www.candrive.ca
Allied Health care professionals
Physicians may refer to occupational therapists or other health care
providers that may perform in-office or on-road driving tests.
Is an appropriate method of testing for medical conditions that are present
all the time. ie. Cannot assess driving ability in patients with seizures.
On-road testing may best reflect driving ability but are expensive ($300
to $600) and usually paid for by patients themselves.
Specialized driver assessment by occupational therapists or on-road
testing is resource intensive and does not replace physicians’ screening and
assessment.
ie. Parkwood Hospital Driver Assessment and Rehabilitation Program - http://www.sjhc.london.on.ca/darp
Other resources…


SAFE DRIVE checklist
Ottawa Driving and Dementia Toolkit
References
Canadian Medical Association. Determining medical fitness to operate motor vehicles.
CMA driver’s guide. 7th ed. Ottawa (ON): The Association; 2006.
Government of Ontario (1990) Highway Traffic Act.
http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_90h08_e.htm.
Accessed 8 Jun 2012.
Molnar FJ, Byszewski AM, Marshall SC, Man-Son-Hing M. In-office evaluation of
medical fitness to drive: practical approaches for assessing older people. Can Fam
Physician. Mar 2005;51:372-379.
Winkelaar P. Reporting patients with medical conditions affecting their fitness to drive.
CMPA Perspective 2010;2(4):3-5.
CASE 3 – INTRACRANIAL
TUMOURS
Case 3 – Brain Tumour


54 year old male recently diagnosed with low
grade glioma
Mild neurosensory deficits
Vision intact, no seizures, no weakness
 Unilateral numbness and tingling, headaches
 Condition stable for one year, likely to remain stable for
another 2-3 years.


Patient lives in a rural community begs you to let
him keep driving on small rural roads
Brain Tumours – CMA Guidelines
Intracranial tumours:
“A patient who wishes to resume private or commercial
driving after removal of an intracranial tumour must
be evaluated regularly for recovery of neurologic
function and the absence of seizure activity.”
Benign Tumours – CMA Guidelines
“If a patient’s cognitive function, judgement,
coordination, visual fields, sense of balance, motor
power and reflexes are all found to be normal after the
removal of a benign intracranial tumour, there is usually
no reason to recommend any permanent driving
restrictions. If a seizure occurred either before or after
the removal of a tumour, the patient should be seizure
free for at least 12 months, with or without medication,
before resuming driving.”
Malignant Tumours – CMA Guidelines
“No general recommendation can be made about
driving after the removal of a malignant or
metastatic brain tumour. The opinions of the
consulting neurologist and the surgeon who
removed the tumour should always be sought and
each case evaluated individually.”
Next Steps?



Are you legally obliged to report this patient?
Which doctors are most responsible for reporting
impaired patients to the MoT?
What are the guidelines regarding reporting
patients with intracranial tumours to the MoT?
CMA Drivers Guide



Canadian Medical Association published:
Determining medical fitness to operate motor vehicles.
CMA driver’s guide.
Limited and require further validation.
Variability in symptoms caused by brain tumours =
difficult to establish a basis on when to revoke
patient’s license.
The Importance of MoT Reporting


Sunnybrook study  40% of injured drivers were
found to have a reportable condition.
Accidents resulted in:
 53
deaths
 551 surgeries
 $3 million in hospital costs
Therefore, medical conditions DO impact driving ability,
and may increase risk of motor vehicle accidents.
Barriers to Reporting
Despite these facts, many physicians do not report
their patients.

Only 3% of patients with reportable conditions were
brought to the MOT’s attention (Sunnybrook study).
Many patients with reportable conditions continue
to drive.
Barriers to Reporting
Majority of family
physicians feel that
doctors should be legally
responsible for reporting
unsafe drivers, however,
over 45% feel that they
are not confident in their
ability to do so.
Barriers to Reporting



Require further education and screening guidelines
for assessing patients.
25% of physicians are not aware of the CMA
guide.
Limited information on how to assess driving fitness
in patients prior to definitive treatment.
Barriers to Reporting


Negative impact on
physician-patient relationship
60% of Saskatchewan
doctors feel that physicianpatient relations would be
negatively affected if they
were responsible for the
removal of their patient’s
driving privileges.
Barriers to Reporting

Physicians may not report because they are
unaware of local legislation.
For example,
 30%
of Australian physicians
 73% of American physicians
unaware of reporting guidelines in their countries.
Back to Case 3…

To report or not to report???
No concrete guidelines exist. At this time, it is up to the
consulting physician to determine if the patient
poses a risk to themselves and others when driving.

In Case 4 we will discuss the medical, ethical, and
legal implications associated with license revocation
in brain cancer patients.
References






Canadian Medical Association. Determining medical fitness to operate motor
vehicles. CMA driver’s guide. 7th ed. Ottawa (ON): The Association; 2006.
Molnar F, Byszewski A, Marshall S, Man-Son-Hing M. In-office evaluation of medical
fitness to drive: practical approaches for assessing older people. Can Fam
Physician. 2005; 51:372-379.
Marshall SC, Gilbert N. Saskatchewan physicians’ attitudes and knowledge
regarding assessment of medical fitness to drive. CMAJ.1999; 160(12):1701-1704.
Winkelaar P. Reporting patients with medical conditions affecting their fitness to
drive. CMPA Perspective 2010;2(4):3-5.
Redelmeier DA, Venkatesh V, Stanbrook MB. Mandatory reporting by physicians of
patients potentially unfit to drive. OpenMedicine 2008;2(1):4–13.
Chin YS, Jayamohan J, Clouston P, Gebski V, Cakir B. Driving and patients with brain
tumours: a postal survey of neurosurgeons, neurologists and radiation oncologists. J
Clin Neurosci. 2004; 11(5):471-474.
CASE 4
Physicians have a medical,
ethical and often a legal duty
to report patients that are
medically unfit to drive.
Medical
•
•
2,800 new cases of primary brain tumours were
diagnosed in Canada in 2012.
It is estimated that 20–40% of intracranial tumours are
metastatic.
Many brain tumours cause some degree of physical or
neurocognitive deficit (i.e. weakness, blurred vision) which
may impair the ability to perform highly sophisticated
tasks such as driving.
Medical
Medically unfit drivers kill more than 5,000
pedestrians worldwide every year.
Both patient and society are at risk of physical harm
from impaired drivers.
Due to their medical expertise and clinical experience,
physicians are delegated the responsible for early
recognition and reporting of symptoms that may
potentially impair driving.
MEDICAL
The physicians’ duty to report unfit drivers supersedes
physician duty of confidentiality.
“disclose your patients’ personal health information to third parties only with their
consent, or as provided for by law, such as when the maintenance of
confidentiality would result in a significant risk of substantial harm to others or, in
the case of incompetent patients, to the patients themselves.”
- Section 35, CMA Code of Ethic
In a review by the CMPA of all driving-related cases involving physicians, patient
complaints of a report being filed was the most common charge brought against
doctors. Inaccurate diagnosis, diagnosis non-relevant to driving, and breach of
confidentiality were often cited as the reason for complaints.
In the majority of cases, the Colleges have been supportive of physicians’ decision
to report.
Ethical
Patients often depend on driving privileges to earn
income, socialize and live autonomously.
Although a physician does not make the ultimate
decision to revoke, their report is an important factor
in determining the motor vehicle licensing authority’s
subsequent action.
Ethical
Thus, while physicians do not make the ultimate decisions
to revoke driving privileges, reporting a patient as
potentially medically unfit to drive is NOT a benign
action.
A physicians’ driving report may severely disable patients
from participating independently in society.
i.e. In Ontario, the Highway Traffic Act requires reports be followed-up on within
one month during which time patients must immediate locate alternative
transportation after being notified they cannot drive even if they are found fit to
drive later on.
Reason’s commonly cited by physicians
for not reporting
•
•
•
•
•
•
Lack of tools for determining driving fitness.
Negative impact on patient quality of life.
Negative impact on patient-physician relationship.
Time restraints.
Long delay between report and license suspension.
Delays for patients trying to reinstate their license.
Legal
In 9 of 12 Canadian provinces, mandatory reporting
legislation exists for physicians to report medically
unfit drivers.
“Every legally qualified medical practitioner shall report to the Registrar
the name, address, and clinical condition of every person sixteen years of
age or over attending upon the medical practitioner for medical services,
who in the opinion of the medical practitioner is suffering from a condition
that may make it dangerous for that person to operate a motor vehicle.”
- Section 233, Ontario Highway Traffic Act
Cases brought against Physicians
Injured Patients:
Legal action was often brought against physicians
following motor vehicle accidents in which a person
was injured or killed.
Physicians were charged with failure to warn or
failure to report.
Cases continued…
Non-patient Injured Parties:
Legal action has been brought against physicians (and
successfully won) in cases where non-patient parties
were injured in a motor vehicle crash caused in part
by medical disability.
The CMPA has reported that in cases in which only
patient-drivers have been charged, patients or their
insurers have sued the patient’s physician in turn.
Legal
In all jurisdictions, if a report is made in accordance
with the legislation and in good faith reporting
legislation protects the physician from legal action
brought against the physician for making the report.
But don’t forget…
The CMPA suggests that before the report, physicians inform their patients of
the nature and intent of the report.
Remind patients that physicians only inform driving authorities of possible
impairment. Decisions to restrict driving privileges are made by the licensing
authority.
Warn patients that until a decision is made that they should not drive.
Document in the medical record that you have warned the patient not to
drive and a report has been made.
Note: the legislation on reporting protects physicians against legal action but
does not prevent complaints to the College.
Jurisdiction
Reporting
MD protection for
reporting
Admissibility of reports as evidence in legal proceedings
Alberta
Not directly addressed, but
interpreted as
discretionary.
Protected
Reports confidential.
British Columbia
Mandatory for MD if the
unfit driver has been
warned of the danger and
still continues to drive.
Protected unless the
physician acts falsely or
maliciously.
Not addressed.
Subject to the provisions of access to information legislation.
Manitoba
Mandatory
Protected
Privileged
Not admissible as evidence except to prove compliance with reporting obligations.
New Brunswick
Mandatory
Protected
Not addressed.
Newfoundland and
Labrador
Mandatory
Protected
Privileged
Not admissible in evidence in trial except to prove compliance with reporting obligations.
Northwest Territories
Mandatory
Protected unless physician
acts maliciously or without
reasonable grounds.
Not admissible in evidence or open to public inspection except to prove compliance with the
reporting provision and in a prosecutions of a section 330.
The person who is the subject of the report is entitled to a copy of the report upon payment of a
prescribed fee.
Nova Scotia
Discretionary
Protected
Not addressed
Subject to access to information legislation.
Nunavut
Mandatory
Protected unless physician
acts maliciously or without
reasonable grounds.
Not admissible in evidence or open to public inspection except to prove compliance with the
reporting provision and in a prosecutions of a section 330.
The person who is the subject of the report is entitled to a copy of the report upon payment of a
prescribed fee.
Ontario
Mandatory
Protected
Privileged
Not admissible in evidence except to prove compliance with reporting obligations.
Prince Edward Island
Mandatory
Protected
Privileged
Not admissible in evidence except to prove compliance with reporting obligations.
Quebec
Discretionary
Protected
Not admissible in evidence except in cases of judicial review of certain decisions of the motor
vehicle licensing authority.
Saskatchewan
Mandatory
Protected as long as the
physician acts in good
faith.
Privileged
Not admissible in evidence except to show that the report was made in good faith in accordance
with reporting obligation.
Yukon
Mandatory
Protected
Not addressed.
Adapted from the 7th edition of the CMA Driver’s Guide
References
Canadian Cancer Society’s Steering Committee on Cancer Statistics. Canadian Cancer Statistics
2012. Toronto, ON: Canadian Cancer Society; 2012.

Canadian Medical Association. Determining medical fitness to operate motor vehicles. CMA
driver’s guide. 7th ed. Ottawa (ON): The Association; 2006.

CMA Policy Statements. CMA Code of Ethics 2004. Ottawa, ON: Canadian Medical Association.

Government of Ontario (1990) Highway Traffic Act.
http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_90h08_e.htm

Jang R, Man-Son-Hing M, Molnar F, Hogan DB, Marshall SC, Auger J, et al. Family Physicians'
attitudes and practices regarding assessments of medical fitness to drive in older persons. J Gen
Intern Med. 2007; 22(4):531-542.

Marshall SC, Gilbert N. Saskatchewan physicians’ attitudes and knowledge regarding assessment
of medical fitness to drive. CMAJ. 1999; 160(12):1701-1704.

Redelmeier DA, Venkatesh V, Stanbrook MB. Mandatory reporting by physicians of patients
potentially unfit to drive. Open Medicine 2008;2(1):4–13.

Winkelaar P. Reporting patients with medical conditions affecting their fitness to drive. CMPA
Perspective 2010;2(4):3-5.

Simpson CS, Hoffmaster B, Mitchell LB, Klein GL. Mandatory physician reporting of drivers with
cardiac disease: Ethical and practical considerations. Can J Cardiol. 2004; 20(13):1329-1334.
