My father is dead and I'm angry. No, this has nothing to do with the stages of grief. It's certainly not directed at the trauma ICU team that kept him alive for ten days after he drove off the road and rolled over in his car a number of times. The State Trooper called to the scene wasn't sure how many times, but the fact that he had head injuries, even with the air bags deploying, signals more than once. Or so says my uncle, my dad's older brother, a retired aerospace engineer who knows such things.
I'm angry because this simply didn't have to happen. My eighty year old father shouldn't have been driving in general and certainly not that Sunday three weeks ago. He had been in the ER for disorientation five days earlier and for acute kidney failure the week before that. My stepmother always did the driving and had done so every day of that fateful week. But when she left him for a few hours to check in on her ninety-three year old mother in failing health, he decided to go out. My father never listened to advice. Not from his doctors, not from his wife, not from me. He always knew better.
I'm angry because, as the editor of Parentgiving.com, I've spent the last four years giving seniors, their grown children and other caregivers information on how to live better and stay healthy, on how to face the changes that often accompany advancing age, especially when managing chronic health conditions (of which stubbornness should be one) and on how to broach sensitive topics, and it's frustrated when attempts fall on (literally and figuratively) deaf ears. I had "the talk" with my father about the car keys, about advance directives, about a special needs trust for a family member. Some things did get done in the nick of time as it turned out, but the relinquishing the car did not.
"It's very hard in this country to stop someone from driving," the trauma ICU attending surgeon told me on the afternoon of the accident. "Americans equate independence with their cars." As she gave me the rundown of my father's injuries, each one felt like a slap. I could feel my body recoil. Fifteen broken ribs, a broken sternum, shoulder and humerus, a handful of fractured vertebrae. Deep lacerations across each upper eyelid and the top of his head, where I could make out a long row of staples now encrusted with blood. Widespread bruises across his torso marking the outline of his seatbelt. Internal bleeding was the as-yet unanswered question.
He was still conscious then and able to recognize me, but he had no memory of what happened, and tests found no signs of a heart attack or stroke. His many chronic conditions included diabetes, heart failure and the beginnings of dementia—he could have blacked out or simply fallen asleep at the wheel. We won't ever know.
Three days later he had a heart "event" and was put on a ventilator. He never spoke again. For the next week, we waited to see if all the machinery could handle the heavy lifting while his body tried to heal. But there was too much physical stress for his heart to handle and we invoked the do-not-resuscitate when it was clear that extreme measures couldn't change the inevitable outcome.
If there is any solace, it's that my father had a one-car accident. He was driving alone, no one else was hurt. But the next time someone who shouldn't be driving gets into a car, will everyone else on the road be as lucky? Most importantly, what else could we have done to prevent this and what can everyone do to be spared the pain of losing a loved one? I turned to Dr. Robert Murden, of Geriatric Medicine at the Ohio State University Wexner Medical Center in Columbus who has spoken and published on the topic extensively, and Dr. Douglas Scharre, Director of the Division of Cognitive Neurology at the Ohio State Wexner Medical Center. Both are leaders in their respective fields and respected members of the Parentgiving "Question An Expert" panel.
Dr. Murden, who recently gave a workshop on the topic at the national meeting of the Society of General Internal Medicine, says the issue of driving among individuals with dementia is perhaps the most difficult in medicine. "Driving is key for independence in this country and most people are very resistant to taking away their independence. It is clear that some people with early dementia are safe to drive, which makes it even harder for families and physicians to decide who has reached that point of not being safe. There are several articles and algorithms published on how to make that determination, and the National Highway Transportation and Safety Administration (NHTSA) has an excellent monograph for families and for physicians on this area," Dr. Murden points out.
At the NHTSA's website, families can find a wealth of information and actionable steps to take. As a starting point, your answers to these suggested questions will let you know if it's time to be concerned about a senior's driving:
- Is the senior getting lost on routes that should be familiar?
- Do you see new dents or scratches on the car?
- Has he or she gotten a recent ticket for a driving violation?
- Was there a recent near-miss or crash?
- Has the senior been advised to limit or stop driving due to a health reason?
- Does the senior get overwhelmed by road signs and markings while driving?
- Is he or she taking any medication that might affect the ability to drive safely?
- Does he or she speed up or drive too slowly for no reason?
- Does your loved one have an illness that may affect driving skills?
You'll also find videos to watch and an in-depth, downloadable pamphlet called the "Drive Well Toolkit: Promoting Older Driver Safety and Mobility in Your Community". Taking action isn't easy. "Families often are afraid to be the bad guys and take the verbal complaints if they make driving impossible, even though this is the only truly safe option," says Dr. Murden. Fortunately, you have an influential ally in your loved one's primary care physician as well as other specialists on his or her medical team.
"There are office tests the primary care physician can do that have cutoffs--those scoring below the cutoff are clearly unsafe to drive, and there are centers devoted to testing elderly drivers to see if they are safe," says Dr. Murden. "The NHTSA monograph includes a chapter on how physicians should talk to patients about this--try to get the patient to agree it is unsafe for others on the road and if they want to avoid hurting others they should voluntarily stop; if they won’t, try to get the family to make driving impossible by hiding keys, disabling the car or selling the car; and if the family won’t or can’t do this, send a letter to the state motor vehicles bureau informing them the patient is unsafe."
Unfortunately, the system in place isn't without complexities, and you can't rely solely on your local DMV. "If a physician decides to write a letter to the motor vehicles bureau he/she needs to ask permission of the driver," explains Dr. Murden. "If the driver says no, ethically the physician still is required to send the letter, but can be sued by the patient for a HIPPA violation of revealing privileged information if the letter is sent and can be sued by any people injured by this person who has been identified as an unsafe driver if the letter is not sent, a dilemma that limits physician willingness to deal with this issue at times. A few states have laws mandating such reporting, which eliminates the HIPPA worry, but most do not.
"If motor vehicles receives such a letter they can ignore it or they can call the person in for a test," continues Dr. Murden. "Some people subsequently pass such a test as motor vehicles tests cover more rules of the road, which people with dementia usually are good at, rather than judgment in risky situations such as making left turns with oncoming traffic, which people with dementia are poor at and which are tested by the driving centers mentioned above. If they test someone who fails, all the DMV can do is take away the driver's license, and if a car is still available, people with dementia will often still drive without the license. If a person fails a driving test by one of the centers referred to above, that only provides evidence for the family to act or the physician to act, but there is no legal or other action toward the driver."
Putting A Plan Into Action
Once you are aware of the alternative approaches you can take, you need to take action.' According to Dr. Scharre, there are steps you can implement on a regular basis to stay on top of the situation. And be sure to realize it's a fluid situation. Case in point: A friend's mother with mid-stage Parkinson's disease was able to pass a driving test last year; however, in the last few months, she's put three dings in her car, and her son's anxiety level was ratcheted up on the scale. Here's what Dr. Scharre suggests.
How to Assess Driving Skills:
- Have a family member ride with or follow the senior at least once a month to evaluate him or her for impaired driving judgment issues.
- Monitor the mileage on the car. If mileage is longer than the short trips they are taking, it could mean they are getting lost.
- Monitor the car for new dents or scrapes.
- Schedule a driving assessment or evaluation by a hospital or university or the Bureau of Motor Vehicles as noted by Dr. Murden.
- Have the senior take the "4-Turn Test." This is a brief assessment tool that can be done in a physician's office and is designed to assist in the determination of driving abilities in dementia patients. See details and information about the test, which was developed at the Ohio State University, at: neurology.osu.edu/cognitive/4turn.html
How to get a loved one to stop driving:
- His or her physician can write a prescription that tells the senior to "temporarily stop driving." She or she can explain that while a work-up is in progress or while a new medication is being tested, it is best to hold off temporarily on driving. The doctor can reassess at the next visit. Patients often do not like to be told that they should never drive again.
- Remove the car from the home. Excuses could be that a child or grandchild needs to borrow the car temporarily or the car may need repairs.
- Remove the car keys.
- Make the car inoperable.
Yes, it's tough love time, but I can assure you that the alternative is a lot worse.