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. (Information on specific states is available at: [ 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 ]