Driving (or not) after critical illness

The national public health burden attributable to impaired recovery from critical illness is substantial. ¹ Over recent years, there has been an increasing recognition of and commitment to address the physical, psychological and social aspects of post-intensive care recovery. Hence, the provision of multi-modal rehabilitation after critical illness, which is now enshrined in the NICE Guideline 83 published in 2009, and the first edition of the Core Standards for Intensive Care Units published in 2013. The General Provision of Intensive Care Services document, which relates to the entire nature and scope of an intensive care medicine service, due for publication in 2015, will further formalise the need for intensive care follow-up services.

One crucially important milestone along the recovery and rehabilitation pathway from critical illness is the return to driving one’s vehicle. The number of drivers continues to increase, with 32 million people in Great Britain holding a full driving licence in 2013. Of particular note is the proportion of older (>70 years) people holding a full driving licence which has increased from 29% to a striking 62% in the last eight years. ² Driving is an advanced task which signifies a step-wise reacquisition of independence. Many patients, therefore, regard their return to driving as a valuable recovery goal. Clinicians might also use a patient’s return to driving as an objective marker of recovery, since it requires both physical and mental complex functioning.

For some patients, the return to driving will represent the chance to return to work, either by enabling commuting or for employment duties. There are over 300,000 large goods vehicle drivers and 300,000 taxi and private hire vehicle drivers in England and Wales, not to mention many other professionals who drive as part of their job (e.g. emergency services, delivery services, pilots, boat captains, train and bus drivers) and workers who operate other motorised machinery. Thus, the economic consequences of driving ineligibility decisions are substantial.

However, there is very little insight and guidance available about when and how patients recovering from critical illness should return to driving. The DVLA medical standards of fitness-to-drive document states that “In the interests of road safety, those who suffer from a medical condition likely to cause a sudden disabling event at the wheel or who are unable to safely control their vehicle from any other cause, should not drive.” ³ The document gives detailed legally-binding guidance about driving ineligibility and duration of ineligibility for a number of medical disorders. The standards differ for group 1 (ordinary driving licence) and group 2 (vocational/passenger carrying vehicle) entitlement, the latter being justifiably more stringent.

A recent analysis shows that many of these DVLA-specified disorders are commonly diagnosed during the course of a critical care admission. In a six-month audit of 440 sequential admissions at a UK university hospital's general adult intensive care unit, 70 (16%) of patients acquired a new DVLA-relevant diagnosis, and the range of these diagnoses was diverse (Table 1). In addition, a discharge notes review revealed that evidence of identification and communication of these diagnoses to receiving teams in the hospital was almost universally absent. Mention of driving eligibility was present in only 2 (3%) of these 70 affected patients’ ICU discharge summaries. This might equate to approximately 136 “care omissions” per year in our hospital. Driving eligibility is therefore a common issue for ICU patients, and perhaps not one about which ICU staff are actively communicating about with other healthcare professionals nor patients.

Table 1.

Showing the classification and frequency of DVLA-relevant diagnoses occurring in an audit of 440 sequential critically ill adult patients.

Diagnosis	n (%)
Total number of patients	440
Patients acquiring DVLA-relevant  diagnosis during ICU	70 (16%)
Traumatic brain injury	13 (19%)
Myocardial infarction	12 (17%)
Seizure	10 (14%)
Suicidal depression	9 (13%)
Stroke syndrome	7 (10%)
Persistent alcohol misuse	6 (9%)
Unexplained syncope	5 (7%)
Arrhythmia	2 (3%)
Hypoglycaemia on insulin	1 (1%)
New diagnosis insulin dependent   diabetes mellitus	1 (1%)
Sub-arachnoid haemorrhage	1 (1%)
Internal cardiac defibrillator insertion	1 (1%)
Meningitis	1 (1%)
Drug dependence	1 (1%)

ICU, intensive care unit.

One significant limitation of the DVLA medical standards document is that it only addresses the “diagnosis-based” aspect of driving eligibility. Although necessary, this diagnosis-based strategy is certainly not sufficient, because it does not account for the wide range of physical, cognitive and pharmacological impairments that are common consequences of critical illness and that might overtly or covertly affect one’s ability to operate a vehicle. That said, in a preliminary paragraph entitled “driving after surgery”, the DVLA document states:

Any decision regarding returning to driving must take into account several issues. These include recovery from the surgical procedure, recovery from anaesthesia, the distracting effect of pain, impairment due to analgesia (sedation and cognitive impairment), as well as any physical restrictions due to the surgery, underlying condition, or other co-morbid conditions. ³

This statement captures the notion of a “multi-modal” approach to driving assessment, acknowledging the need for an alternative approach to fitness-to-drive assessment for surgical patients. Perhaps, such an approach ought also to be applicable to ICU patients.

Aside from the overall philosophy of fitness-to-drive decisions, there is the question of with whom the responsibility for fitness-to-drive decisions might lie. Some patients may look to clinicians for guidance about when to drive; others may simply assume it is safe to do so. The ultimate responsibility for ensuring that licence holders are fit to drive lies with the Secretary of State for Transport acting through the DVLA. From our personal experience in the Rehabilitation After Critical Illness Clinic in Reading, the guidance given to patients seems to be inconsistent. For instance, one patient with severe short-term memory problems following an out of hospital cardiac arrest was considered fit to drive by the DVLA two months after the event, whereas, those patients having routine procedures such as bypass surgery and insertion of a pacemaker had their licence withheld for longer periods.

A survey of 50 driving licence holders recovering from severe head injury suggested the presence of significant social pressure to return to drive after injury. Many reported difficulties in driving; only one received written information about driving. Whether patients routinely check their insurance policy before returning to drive is not known. ⁴

According to its existing guidance, the GMC believes that doctors have a role to play in advising patients about driving cessation. It tells doctors:

The driver is legally responsible for informing the DVLA about such a condition or treatment. However, if a patient has such a condition, you should explain to the patient: (a) that the condition may affect their ability to drive, and (b) that they have a legal duty to inform the DVLA about the condition. ⁵

Exactly which clinician should do this, and when it should happen, is open to debate; perhaps, ICU clinicians are well placed to take the lead on this important matter.

In conclusion, critical illness and subsequent driving ineligibility frequently coexist. Decisions about driving after ICU are complex, current guidance is poorly suited to the recovering ICU patient, and clinical responsibility is unclear. Even when impairments have been identified, the implications for driving are uncertain. A decision to return to driving carries several important implications for road safety, public health and medical liability not to mention the safety of the patient recovering from critical illness. The question of “how patients and their families can best be supported as they start living at home again” has now been identified as one of the top three research priorities by the James Lind Alliance Priority Setting Partnership, for which research funding has been allocated. ⁶ The purpose of this editorial is to raise awareness of an important gap in post-ICU care, promote best practice across the UK, and prompt a national conversation within the intensive care community about how to evaluate and manage our patients’ fitness-to-drive.