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Complex Situations (SLO7)
A 23 year old woman presents to the Emergency Department after collapsing at work. Her colleagues describe 3 minutes of twitching followed by a 15 minute period of confusion. She has bitten her tongue. The patient denies previous similar episodes. You suspect a first seizure and plan to discharge the patient with follow up arranged. What, if any, advice regarding driving do you need to give before discharge from the Emergency Department?
Answer:
Advise the person to stop driving while waiting to see the specialist for confirmation of the diagnosis, to avoid potentially dangerous work or leisure activities (for example working with heavy machinery or at heights, or swimming), and to be mindful of safety in the home (for example showering rather than taking baths), and at school.Assessing Fitness to Drive
Complex Situations (SLO7)
Last Updated: 9th January 2024
Doctors’ and patients’ responsibilities
The Driver and Vehicle Licensing Agency (DVLA) in England, Scotland and Wales and the Driver and Vehicle Agency (DVA) in Northern Ireland are legally responsible for deciding if a person is medically unfit to drive. This means they need to know if a person holding a driving licence has a condition or is undergoing treatment that may now, or in the future, affect their safety as a driver.
The driver is legally responsible for telling the DVLA or DVA about any such condition or treatment. Doctors should therefore alert patients to conditions and treatments that might affect their ability to drive and remind them of their duty to tell the appropriate agency. Doctors may, however, need to make a decision about whether to disclose relevant information without consent to the DVLA or DVA in the public interest if a patient is unfit to drive but continues to do so.
Assessing a patient's fitness to drive
When diagnosing a patient’s condition, or providing or arranging treatment, you should consider whether the condition or treatment may affect their ability to drive safely. You should:
- refer to the DVLA’s guidance Assessing fitness to drive – a guide for medical professionals, which includes information about disorders and conditions that can impair a patient’s fitness to drive
- seek the advice of an experienced colleague or the DVLA’s or DVA’s medical adviser if you are not sure whether a condition or treatment might affect a patient’s fitness to drive.
Key conditions:
| Condition | Group 1 (cars and motorcycles) | Group 2 (lorries and buses) |
|---|---|---|
| Epilepsy or multiple unprovoked seizures | Must not drive and must notify DVLA. Driving must cease for 12 months from the date of the most recent seizure, unless the seizure meets legal criteria to be considered as a permitted seizure | Must not drive and must notify DVLA. The person with epilepsy must remain seizure-free for 10 years (without epilepsy medication) before licensing may be considered. |
| First unprovoked epileptic seizure/ isolated seizure | Must not drive and must notify DVLA. Driving must cease 6 months from the date of the seizure, or for 12 months if there is an underlying causative factor that may increase risk. | Must not drive and must notify DVLA. Driving must cease 5 years from the date of the seizure. If, after 5 years, a neurologist has made a recent assessment and clinical factors or investigation results indicate no annual risk greater than 2% of a further seizure, the licence may be restored. |
| Provoked seizures (except related to use of alcohol or illicit drugs) |
Must not drive and must notify DVLA. In most cases driving must cease for 6 months after the provoked seizure. | Must not drive and must notify DVLA. Driving must cease for up to 5 years after the provoked seizure. |
| Stroke and cerebral venous thrombosis | Must not drive but may not need to notify DVLA. Driving may resume after 1 month if there has been satisfactory clinical recovery. DVLA does not need to be notified unless there is residual neurological deficit 1 month after the episode. | Must not drive and must notify DVLA. A licence will be refused or revoked for 1 year following a stroke or TIA. Relicensing after 1 year may be considered if there is no debarring residual impairment likely to affect safe driving and there are no other significant risk factors. |
| Single transient ischaemic attack | Must not drive for 1 month but need not notify DVLA. | Must not drive and must notify DVLA. A licence will be refused or revoked for 1 year following a stroke or TIA. Relicensing after 1 year may be considered if there is no debarring residual impairment likely to affect safe driving and there are no other significant risk factors. |
| Multiple transient ischaemic attack | Must not drive and must notify DVLA. Multiple TIAs over a short period will require no driving for 3 months. Driving may resume after 3 months if there have been no further TIAs. | Must not drive and must notify DVLA. A licence will be refused or revoked for 1 year following a stroke or TIA. Relicensing after 1 year may be considered if there is no debarring residual impairment likely to affect safe driving and there are no other significant risk factors. |
| Typical vasovagal syncope (solitary episode) | While standing: May drive and need not notify DVLA.
While sitting: May drive and need not notify DVLA if there is an avoidable trigger which will not occur whilst driving. Otherwise must not drive until annual risk of recurrence is assessed as below 20%. |
While standing: Must not drive and must notify DVLA.
While sitting: Must not drive for 3 months and must notify DVLA. Will require investigation for identifiable and/or treatable cause. |
| Cardiovascular, excluding typical syncope (solitary episode) | Must not drive and must notify DVLA. Driving may be allowed to resume after 4 weeks if the cause has been identified and treated. If no cause has been identified, the licence will be refused or revoked for 6 months. | Must not drive and must notify DVLA. Driving may be allowed to resume after 3 months if the cause has been identified and treated. If no cause has been identified, the licence will be refused or revoked for 12 months. |
Reporting concerns to the DVLA or DVA
Doctors owe a duty of confidentiality to their patients, but they also have a wider duty to protect and promote the health of patients and the public. The guidance below sets out the steps doctors should take if a patient’s failure or refusal to stop driving exposes others to a risk of death or serious harm.
If a patient has a condition or is undergoing treatment that could impair their fitness to drive, you should:
- explain this to the patient and tell them that they have a legal duty to inform the DVLA or DVA
- tell the patient that you may be obliged to disclose relevant medical information about them, in confidence, to the DVLA or DVA if they continue to drive when they are not fit to do so
- make a note of any advice you have given to a patient about their fitness to drive in their medical record.
If a patient is incapable of understanding this advice – for example, because of dementia – you should inform the DVLA or DVA as soon as practicable.
If a patient refuses to accept the diagnosis, or the effect of the condition or treatment on their ability to drive, you can suggest that they seek a second opinion, and help arrange for them to do so. You should advise the patient not to drive in the meantime. As long as the patient agrees, you may discuss your concerns with their relatives, friends or carers.
If you become aware that a patient is continuing to drive when they may not be fit to do so, you should make every reasonable effort to persuade them to stop. If you do not manage to persuade the patient to stop driving, or you discover that they are continuing to drive against your advice, you should consider whether the patient’s refusal to stop driving leaves others exposed to a risk of death or serious harm. If you believe that it does, you should contact the DVLA or DVA promptly and disclose any relevant medical information, in confidence, to the medical adviser.
Before contacting the DVLA or DVA, you should try to inform the patient of your intention to disclose personal information. If the patient objects to the disclosure, you should consider any reasons they give for objecting. If you decide to contact the DVLA or DVA, you should tell your patient in writing once you have done so, and make a note on the patient’s record.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
