Legal, ethical quandaries muddle debate over vision of elderly drivers
As long as there have been elderly, visually impaired drivers, optometrists have wrestled over the balance between protecting themselves from legal action and protecting the well-being of their patients and of those with whom their patients share the road.
The reporting debate
Laws obligating optometrists to report vary by state and are based on the views of the state legislatures and the driving needs of their citizens.
In California, for instance, there is no legal obligation for an optometrist to report to the department of motor vehicles (DMV) a visually impaired driver who may not be suitable for the road. That said, there is still considerable debate over what optometrists’ obligations should be.
“In today’s society, driving a motor vehicle plays a major role in an individual’s lifestyle, and when a driving license is revoked for medical reasons, it can lead to social isolation and depression,” William L. Park, OD, FAAO, told Primary Care Optometry News in an interview. “The ability to drive is the ultimate form of independence in today’s society, and in the U.S., a driver’s license is intrinsically tied to quality of life.”
“The argument I favor is that optometrists shouldn’t be obliged to report the presence of vision loss or disease to the department of motor vehicles,” Ian L. Bailey, OD, MS, DSc(hc), FCOptom, FAAO, a professor of optometry and vision science at the University of California, Berkeley, School of Optometry, said in an interview.
Bailey argued that if optometrists were obligated to report a visually impaired patient as being unsuitable for driving to the DMV, it would breach doctor-patient confidentiality and would make the clinician vulnerable to lawsuits.
Image: Bailey IL
Optometrists in California are vulnerable to lawsuits as it is, he said. “If one of your patients was to get in an accident, and the other people involved, correctly or incorrectly, said that it was because of the person’s vision, then they could say that the optometrist should have told them not to drive, and then that brings you into court,” he said.
The best defense against this kind of lawsuit is to clearly record that the recommendation to cease driving was given and the reasons why it was given and to record it each time that point is reiterated, according to Bailey.
“It could be that you did actually tell them not to drive, but if you’re in court and there’s not a record, it could go badly for you. You need something tangible to help defend yourself in court,” he said.
Bailey argued further that obligating optometrists to report these patients might cause those who are worried about losing their license to avoid coming in for eye examinations.
“And so it could be that the glaucoma patient who needs to come back for regular checks and to have their medications modified as needed would give up attending for eye care because they’d be worried about having their driver’s license pulled,” he said. “I would prefer that not happen.”
Visual requirements for driving
Just as legal obligations vary by state, so do visual requirements. California’s requirements are built around the detection of poor visual acuity, insofar as poor visual acuity will be the first indicator of a visual impairment that can cause enough of a risk when driving, Bailey said.
According to an article Bailey wrote for the California Optometric Association’s magazine, when California drivers are issued their initial license or their renewal, they undergo a visual acuity test and must be measured to have at least 20/40 vision. If the test is failed, but passed with the refractive correction of spectacles or contact lenses, then a license will be issued with the provision that the driver must wear corrective lenses when driving.
If the test is failed even with refractive correction, a second vision test is conducted by the DMV to measure the acuity in each eye, whereupon if the applicant obtains 20/40 or better in one eye and 20/70 or better in the other eye, he or she is considered to have met the minimum visual standards for licensure. Once an applicant fails to meet this minimum standard, he or she is given a form for their optometrist or ophthalmologist to fill out, which is where the other visual functions such as visual field come into play, Bailey wrote.
Florida works a little differently.
According to Florida resident Katie Gilbert Spear, OD, MPH, an applicant must have, along with a minimum visual acuity, a minimum visual field.
“But even if you don’t have a minimum visual field standard in your state,” Spear said, “it’s still important to assess visual field, because if you’ve lost half your field of vision, obviously it can impair your driving.
“What I do in my office with a patient who is visually impaired,” she said, “is I always check their acuity and their visual field to see if they have any limitations. I also check other factors like cognitive ability, reaction time, decision-making ability by interviewing the patient and the family.”
Spear said her occupational therapist, who sees all her low vision patients, also evaluates the patient.
“If she notices any problems, we refer the patient to a local rehabilitation center that has a driving course,” she said.
Park said, “First and foremost, it’s important to ensure that visually impaired individuals have obtained maximal correction for refractive errors and that best corrected visual acuity has been achieved.”
“Other important tests include contrast sensitivity, glare sensitivity, color perception, binocularity, depth perception, overall health and range of motion assessment,” Park said. “Systemic disease should also be scrutinized.”
“Some people will be really disadvantaged by having lighting that’s too bright,” Bailey said. “And there will be many people whose vision will be substantially worse when the light’s not so bright. So some might be fine driving in nice, bright, sunny conditions, but if it becomes overcast, or if gets toward the end of the day and things are getting a little bit darker, their vision might be substantially affected, and they will become substantially less well-equipped for driving.”
“Practitioners who ignore cognitive, visual or systemic implications on ability to drive, as a result of their work-up and assessment of all modalities, put themselves at risk for lawsuits,” Park said. “Practitioners should also either initiate a road evaluation for the patient and/or evaluate telescopic systems to establish safe driving skills.”
Improving acuity with devices
Some visually impaired patients who fail to meet standards of vision for driving licensure can be prescribed a device, such as the bioptic telescope, that reduces their impairment, Bailey said.
However, clinicians should be cautious in prescribing the bioptic telescope. “If people have significant visual field loss, it would worry me. If people have significant contrast sensitivity loss, it bothers me,” he said.
He would also avoid prescribing a telescope to a patient who does not have reasonable vision in the second eye.
“At our clinic, we only fit the bioptic telescope before one of the eyes, because it creates some blind area in the eye that uses it,” he said. “There could be important activity — a truck driving into the intersection, or a kid on a skateboard zipping across the road — that’s in that blind area at a critical time, and you fail to see them. If you have the second eye that’s reasonably functional, with good visual fields and contrast sensitivity, and you’ve got both eyes open, then when you’re looking through the bioptic telescope you’ll be able to pick up information from the second eye that will alert you to activity within the field ahead,” he said.
Another device to help these patients keep their licenses, according to Park, is a filter. The filters enhance contrast, figure-ground perception and traffic light recognition. These filters are primarily yellow and brown amber, he said.
These patients can also benefit from the use of a GPS, according to Bailey.
“We tell them that it might be a good idea to get one for the speech output function, so that they don’t have to be quite so reliant on reading the sign for getting the information; they can have something that tells them that their turn is coming up in 500 yards,” he said.
Recommendation to cease driving
“When I tell a patient that they’re not legal to drive, or if I’m concerned about their driving, I always do it in front of a family member too,” Spear told PCON. ”
Spear added that it is also a good idea to gather more information from an accompanying family member.
“I ask, ‘How’s your dad been driving recently?’ And they usually tell me ‘We don’t let him drive.’ That’s what I find a lot. Many families have already taken the keys away from the patients because they’re concerned for the patient’s safety and for everyone else’s safety too,” she said.
It is also a good idea, according to Spear, to give the patients a little bit of perspective.
“I tell them that I understand they’re giving up their freedom to drive, but I ask them how they would feel if their grandchild was in the driveway and they ran them over. Or I ask how they would feel if they hit the neighbor’s child because they ran out and they couldn’t see them,” she said.
“It’s very individualistic,” Bailey said. “Sometimes you’ll express yourself strongly in your recommendation; other times you’ll be calm,” he said. “It really depends on the patient. With some patients, as soon as you start to talk about it, you see barriers come down and you get the strong impression that they’re not going to listen, that they don’t want to hear it.
“How you should approach it is very much influenced by the magnitude of the driving impairment as you see it,” Bailey continued, “and the person’s ability to listen to the arguments, understand them and respond appropriately to the information you’ve given.”
“Optometrists are essential to determining if patients have the ability to drive safely,” Spear said, “and they’re well positioned to deliver the news that a patient can no longer drive safely, because we have such a personal relationship, especially if you’re their low vision provider. You see them multiple times, you train them on different devices — so you usually have created a personal relationship with them, and their family too.
“You always run the risk of making them angry,” she conceded. “But if you do it correctly and if you’re concerned about their safety and the safety of others, then you’ll be fine.” – by Daniel R. Morgan