The older individual is confronted with multiple losses, such as declining health or the death of loved ones, a deterioration in personal health, and loss of prestige and participation in society. Losing the ability to drive because of declining health is a symbolic and concrete representation that a person is no longer capable of performing as he or she once did; it is a clear evidence of the decline. The purpose of this article is to explore the impact of this loss.
The ability to drive or to possess a legal driver's license is a very important part of our mobile American society. It reflects status and independence. There is an excitement to being mobile and attending to one's own needs. To be mobile is a symbol of autonomy - just observe the enthusiasm of a toddler taking his first steps or the adolescent gaining his first driver's license or the keys to the family car. Possession of a driver's license means choice, freedom, and identity. In our culture, it reflects a rite of passage into adulthood.
In our society, the reliance on the automobile for autonomy, independence, and survival is considered the norm. Despite other efficient forms of transportation, the automobile remains the most satisfying and first choice of travel. For an older person, possessing a driver's license may provide the means to go shopping, visit a friend, keep medical appointments, or just take little rides as a diversion from being housebound.1
For the older individual, shifting from one's personal automobile to public transportation may require the mastery of new knowledge. Accommodating the schedules of public transportation can pose physical hardships and, in some cases, may be impossible. Some older people are concerned about their personal safety and fear harassment when taking public transportation. There is also the psychological loss and embarrassment in giving up one's sense of independence and power that is linked to personal mobility.
Berg described a correlation between the lack of an automobile for transportation and isolation and loneliness.2 In a study of 418 rural Americans, Kivet found that the most important factors related to loneliness were adequacy of transportation, widowhood, availability of organized social activity, and frequency of phone calls.3 In Kivet's rural sample, the lack of adequate transportation was the most significant correlation to loneliness.
The clinical issues faced by a nurse working with the older person are twofold. First is the issue of driving competence and assessment of the person's physical, emotional, and cognitive abilities to manipulate an automobile safely. Second is the person's response to losing a driver's license or the ability to drive.
It is generally accepted that older drivers may experience special problems not consistently seen in younger drivers, such as declining motor skills, loss in hearing acuity, and failing sight.4 These problems may be compounded by physical illnesses, such as arthritis, neuralgia, or strokes. Medication can also affect a person's perception and ability to react to stimuli. Investigators have concluded that older drivers demonstrated more caution to compensate for deteriorating sensorimotor skills.5 Fisher compared an older driver group (ages 65 to 83) to a younger group (ages 19 to 35) and noted that the older group drove slower and failed to make designated exits.6 Older drivers were more often involved in certain types of accidents and traffic violations, such as failure to yield and inattention to road signs and traffic lights. They also seemed to be unaware of traffic around them, making fewer speed changes.
Additionally, older people may experience a lessening of neuromuscular efficiency because of illnesses such as respiratory problems, cardiac disease, or cardiovascular insufficiency. Some states have special requirements for reissuing a driver's license to those over 70. Some states require physicians to inform motor vehicle departments if a person is in danger of losing consciousness or is unable to safely manipulate an automobile because of physical, emotional, or cognitive reasons. Although statutes do not specifically address the role of nurses, it would be helpful for nurses, especially those practicing in extended or independent roles, to know the law in their states.
Patients rarely ask questions about their ability to drive safely. More often, family members are the first to express concern about the older person's ability to drive. Raising questions directly is very difficult. The family may be worried about safety and yet reluctant to take something away that is valued, or they may want to avoid a confrontation.
Driving competence becomes even more difficult to address when the impairment is cognitive. In a longitudinal study of Alzheimer-type dementia, Friedland noted that motor vehicle crashes occurred in early and middle stages of the illness and were not related to the disease duration or severity.7 Thus, there was no safe driving period in the illness. The researchers additionally stated that neither a Mini Mental Status Exam nor the spouse or other family member can be relied on to predict the safety of continued driving.
Relatives of drivers who are impaired due to memory loss, poor judgment, or other cognitive functions have described in great detail their fears in being driven by someone who increasingly makes traffic errors. Spouses and other family members will develop an array of elaborate excuses for trying to reduce their relative's time behind the wheel. Persons closest to the impaired driver are often the most fearful and yet most immobilized to ask for help in assessing safety or establishing driving restrictions. Their own sadness and anger in seeing the decline of their loved one may interfere with the ability to address the issue: they want to protect their relative and they may not feel that they have the power or authority to take the driving privilege away. Consequently, the impaired driver, who has an unrealistic perception of his abilities, and the family, who is hesitant to confront him, may come to the attention of health-care providers or the legal system.
As nurses, we must be aware of how subtly fears may be expressed and give permission to acknowledge the concern and conflict directly. As resources to the family, we have a responsibility to aid the family in evaluating the driving ability and safety of the affected driver. Driving assessment clinics are available that will objectively test the individual's ability to interpret and respond to written and verbal stimuli, to use good judgment, and to manipulate the car safely. Family members have enough to cope with as the older person declines and should not have to serve as the judge in assessing the ability to drive and as the enforcer in setting driving limits. It may assist the family to know that the decision to suspend a license actually rests with an authority outside the family system. Spouses of demented drivers find it easier to say, "the doctor, nurse, or state say you shouldn't be driving," rather than, "I don't think you should drive." Individuals may also be more apt to accept the loss of driving if they are informed that their ability can be retested at a future date.
When the decision has been made that the older person is no longer able to drive, the nurse needs to assess the impact and meaning of this decision for the person and the family. Several theories of loss and grieving can be used to develop a conceptual framework for understanding the dynamics in a person's response to the loss.
Kubler-Ross defined five stages of an individual's grieving process as denial, anger, bargaining, depression, and acceptance.8 Grieving the loss of the ability to drive is complex in that driving is associated with so many interactions and experiences. The person may quickly resolve the financial burden, but may never come to accept the burden of always having to ask another for transportation. The person who is able to acknowledge why he is no longer considered safe will work through the five stages more successfully than the person who does not. For example, the person who experienced a left side field of vision loss secondary to a cerebral vascular accident and who can say, "I don't see anything on the left so I won't be safe to drive," is more successful at mastering the grieving process than the person who does not acknowledge his cognitive or judgment deficits and says, "those doctors and my wife don't know what they are talking about. I've been driving for 40 years just fine. ' '
Nurses have further developed the conceptual framework of loss and grieving. Benoliel9 and Kowalsky10 suggest that some losses are not totally resolved to acceptance. Similar episodes can stimulate previous stages of grieving and can remind the individual that the loss is permanent as the grieving continues. This is reflected in a statement by a patient who voluntarily gave up driving after a cerebral vascular accident: "Sometimes I just want to get behind the wheel again. I miss driving."
Losing part of one's ability to function due to aging adds a special aspect to grieving. The grieving is for a part of oneself that no longer exists. Pollack stated there is a "mourning process for oneself as one gets older and must come to terms with change resulting from this unavoidable progression. One might describe the process as a mourning for former states of the self, as if these states represented lost objects."11
Losing the ability to drive is often concurrent with other losses. The emotional crisis imposed by numerous losses and changes can result in further deterioration and withdrawal. There may be anger and helplessness as the person feels he has lost yet another meaningful piece of himself. As with other losses, factors that influence how the individual responds to the loss of the ability to drive include age, number of losses encountered within a short time, past experiences with loss, availability and use of support systems, ability to maintain a sense of control, and esteem. 12
There is a range of responses in how the person may comply with limiting or relinquishing the ability to drive. The responses may range from acknowledgment of the deficit and acceptance of not driving to struggling and denying. Voluntarily giving up driving or restricting driving to low traffic areas may demonstrate a means to maintain some degree of self-esteem. The person may have a sense of pride in actively giving up a dangerous or humiliating experience. In contrast, being forced to relinquish the car keys or driver's license may stimulate feelings of shame and doubt. For someone with a cognitive impairment, the response may be very difficult if the person is unable to appreciate the loss and cannot remember from day to day that he cannot drive. Family members may find themselves continually informing the person of the driving loss.
Not only is assessment of the patient's emotional response important, but also the family's response to the change. Role changes within the family are inevitable when elderly adults can no longer drive. This can be a very disruptive experience for all concerned. Shifting from well-established patterns to new patterns can stimulate great reluctance and misgivings.13 Control, sense of power, and boundaries within the family shift to accommodate the changes. For the family, the role shifts require a delicate balance of taking over and performing former functions for the elderly while not shutting them out or taking away all independence. When the elderly express fear that their transportation needs are a burden to others, they need to be given permission to communicate their fears directly.
The loss of spontaneity may be very difficult. The person must have the right change to ride a bus, or may have to adapt to a bus schedule or arrange trips according to someone else's ability to drive. Gone are the impulsive drives on a beautiful day or a drive to break boredom. In our busy society, family members may have ambivalent feelings about serving as chauffeurs. The nurse needs to ask how decreased mobility will affect the opportunity for social interaction and explore ways to maintain existing or initiate new social interactions.
Support and Problem Solving
Both the patient and his family may benefit from having an understanding of how the decision to take away driving privileges was made and of the expected responses to loss and grief. Nurses should encourage both the family and patient to talk about their feelings and anticipated problems. They should help patients identify what they will miss most about driving, such as being behind the steering wheel, freedom, or pleasure. Reminiscing in a supportive relationship about pleasant memories may be healing.
The individual needs some form of control over the immediate environment. For example, although a grandson had a comfortable income, his elderly grandfather insisted he accept a few dollars when he drove his grandfather to an appointment. This gesture allowed the grandfather to express appreciation and maintain a degree of independence and self-esteem.
The individual may be able to maintain some independence by discovering community resources that can be used in keeping medical appointments or doing necessary shopping. The individual could learn new skills, such as mastering mass transit, with the aid of a companion.
There are, of course, families where problem solving is difficult. When the family has not resolved long-standing conflicting relationships, the reversal in dependence may not be tolerated and the older person may need to consider special public assistance programs or other alternatives. Solutions can be difficult when resources within the family are strained.
Cognitively impaired patients may not remember that they are no longer able to drive or they may refuse to accept the decision, causing their families to fear for their safety as well as the safety of the general public. In such cases, creative and firm interventions are needed to help families keep the cognitively impaired patient from getting behind the wheel. Spouses of the impaired driver may have to insist that they drive. Families have altered ignition keys, drained gasoline tanks, removed distributor caps, or permanently lent the vehicle to someone else.
Neugarten said that the elderly are prepared to accept and adapt to life changes that are expected as appropriate for their age.14 Adapting may assist in maintaining self-esteem.
Nurses should recognize and support the patient's attempts to maintain selfesteem in accepting the loss. A statement such as, "I am no longer safe to drive," may reflect sadness as well as control, judgment, and self-esteem.
Patients who have come to accept the loss may note financial savings when not maintaining an automobile, or may come to appreciate the pleasure of watching the scenery instead of focusing on the responsibility of driving.
Loss of the ability to drive due to declining health can affect an individual's identity and autonomy and can also symbolize the deterioration of an individual's functioning. Grief is an expected response to die loss. Losing the ability to drive is complicated when an individual does not perceive the deterioration and does not appreciate the decision. Giving up die ability to drive can disrupt a family at a time when resources or coping abilities are already strained. How the individual family resolves the loss depends on a number of factors, such as ability to work through the grieving process, concurrent losses, cognitive abilities, and the availability of resources and abilities.
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