I find one of the more difficult conversations with patients about their cardiac disease is when we have to advise them to stop driving. This enforced change in lifestyle markedly affects everyone, especially the elderly. In my practice in a rural city, the impact is that bit greater as there are fewer avenues to maintain individual mobility. Even a cursory look at my children’s grandparents shows many potential limitations to their lives if they weren’t allowed to drive, and to ours, if we have no child-sitting for evenings out!
Last week one of my EP colleagues told me he’d just seen a patient with an SVT who was syncopal during episodes and he advised them not to drive until further therapeutic action had been done. He shared that although there appeared to be an understanding and acceptance of the advice it seemed clear to him they were still going to drive home.
Doctors disclosing to the DVLA that they’re aware patients were still driving after being advised not to, remains an ethically challenging discussion. GMC advice has been debated, but I think most agree that in the interests of the greater good a compromise in patient confidentiality can at times be appropriate. I’ve never had to consider doing it, but I can recall more than one patient I’ve had a concern about. I wonder how many times this happens, and how the relationship and ongoing care was afterwards if the reporting, or suspected reporting, practitioner was still involved?
My feeling is we are correctly more diligent in the contemporary age in passing on the DVLA’s advice to patients on their fitness to drive. I usually spread the responsibility of the blow by making it clear the DVLA’s authority, usually adding I agree with them. Not unreasonably patients often see a path of negotiation with you and their disappointment is clear as mostly the position has limited leeway of interpretation. As the driving restriction takes prominence in the consultation, I do often wonder how much of the other bits of key information are missed or not absorbed.
100 Year Old Driving School
A few days after my corridor conversation my wife shouted me to join her watching the TV programme ” 100 Year Old Driving School“. If you haven’t seen it (I don’t watch much television either) the show follows the RSPoA helping octogenarians, nonagenarians and centurions (!) consider whether they are safe in continuing to drive. It was impressive to see senior citizens with lovely life stories still enjoying it, but it was at times very scary seeing the near misses of these apparently healthy individuals.
The elderly patients in my general cardiology clinic where the driving question is most relevant tend to be those with aortic stenosis (AS). The DVLA’s guidance for AS is clear that the exclusion is when patients are symptomatic. Although we know there can be a slight disconnect between patients self-volunteered symptoms and the objective evidence, I think most are comfortable using ETTs to help define that now.
Symptoms at rest
“Why is it that they shouldn’t drive if their symptoms only occur on exertion,” asked my registrar at the end of a clinic. “Well, you can get symptoms at rest including sudden cardiac death …although I have to say, I don’t know the exact figures on how likely it is.” He looked a little sceptical, so I continued: “I can picture man in room 6 in CCU who I looked after as registrar who had severe AS and recurrent syncope and an EMD arrest at rest, who we had to resuscitate with CPR and adrenaline, somewhere I have a paper from the 60s which describes it, I’ll dig it out.”
We know the circumstances of SCD in severe AS is almost always closely associated with physical activity. But one imagines that in the setting of a concurrent illness with a small lowering of BP from being intravascularly deplete only very minimal activity may lead to hypotension, syncope and possibly then SCD.
Avoidable external influences that cause vasodilatation are important too. At times I get slightly odd looks on a ward round when I stress that AS patients should only have a lukewarm shower and sitting down to minimise its potential effects. And let’s not forget the importance of taking away GTN spray, which I do regularly in clinics from patients who’ve been given it for their breathlessness of unknown cause?!
Interestingly in the study I was referencing, nine patients with severe aortic stenosis and a history of recurrent syncopal attacks were studied with a physician constantly in attendance for 72 hours (diligent clinical research from another era!). They found that if syncopal attacks lasted from 20 to 40 seconds, the ECGs showed sinus but with changes in the ST segments. But if the attacks were longer than 40 seconds then either ventricular standstill or ventricular fibrillation were the cardiac mechanisms responsible. The time difference is probably that to cause sufficient myocardial ischaemia in the hypertrophied LV.
Overall I find the DVLA cardiac advice clear and justifiable. They are obviously done with expertise and diligence and have been broadly responsive to changing evidence and the times. The progressive modification in the advice around ICDs reflects this quite well and was the near last conversation on this topic I had prior to penning this blog.
In the cardiomyopathy clinic, a young man with DCM and symptomatic VT with an ICD had just got his driving license back after a period of stability. We were debating the pros and cons of reducing his potent anti-arrhythmic cocktail, which had been giving him some modest side-effects. One of his key considerations was that if there was a change in his anti-arrhythmics he would need to have a 3 month period off driving and in the setting of having had to stop doing it for 6 months and only just got back, he wanted to stay in status quo.
Is the paradigm in this area going to shift and soon? A friend was extolling the virtue of driverless cars, which seem the ideal solution for the elderly generally, and certainly the lovely grandparents in ” 100 Year Old Driving School“. It could also be the answer for cardiac patients who are restricted from driving. Although our discussion followed to if and how the car could assess if the occupant was unwell and then what could be done to help them? Nonetheless, driverless cars do seem ever closer to being a reality, may be fully ready and equipped for when I’m a hundred?!
Meantime, it remains important to have the difficult conversation and be supportive of our patients. Helping them, but also all of us, stay safe from the potentially threatening consequences of cardiac diseases whilst on the road remains essential.