Medical practice--like life, come to think of it--sometimes feels like a series of difficult conversations. One of the most difficult, for me anyway, is discussing with an older person the possibility that he or she may no longer be fit to drive safely.
Tragedies such as the recent incident in Concord, MA, in which an elderly woman driving to a dialysis appointment rammed into a mom walking with her two small children--all survived, though the toddler was badly injured--might make the issue seem clear: older people's driving skills should be re-tested periodically (there's actually a Facebook page devoted to this cause) or, perhaps there's an age beyond which people should not drive at all. Regulations vary by state--in Massachusetts the only restriction on older drivers is that people over 75 must appear in person to renew their licenses.
Though incidents like the one in Concord, as well as one in Stoughton in 2009 in which a 4 year old girl was killed, highlight the dangers of "driving while old," statistics on older drivers are mixed. This graph, from the Insurance Institute for Highway Safety, shows that the total number of car accidents (as of 2009) peaked among young drivers and did not increase appreciably with age:
Which gets me back to those difficult conversations. They usually go something like this: a husband, wife, or adult child of a patient will call in advance of their visit and say, "Could you tell them they need to stop driving? They'll listen to you."
When the patient comes in, I tell him or her that a family member has raised concerns about their driving; usually their vision or reflexes, but sometimes their sense of direction. Often the patient acknowledges that his or her driving skills aren't what they once were, but insists that it doesn't matter because they never drive at night anymore, or on the highway. When I point out (see second graph above) that it's those small local trips in which accidents are likely to occur, the patient takes a different tack. Do I want them to lose their independence? How will they get to the grocery store, the hairdresser, a friend's house? Do I realize what a huge change this will be for them?
Older men, especially, who are likely to have been the primary drivers in their households for decades, find the loss of the wheel very hard to face.
So how do we balance an older person's right to (and need for) autonomy with the public's safety?
In practice, when this concern comes up, I suggest a driving assessment. AAA lists resources for these voluntary assessments. Spaulding Rehabilitation Hospital offers assessments for drivers potentially impaired by age, illness or injury.
Sometimes, I admit, I've encouraged an older person to stop driving even when they've passed the assessment--based on reports of their driving behavior by family. I understand their sense of loss, I tell them, but there are ways to recover from it--even if that involves moving, using public transportation, or getting rides.
But there's no recovering from being killed by an impaired driver--or from killing someone with a car, for that matter.
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