Reporting LOC to DMV

[lockian]

Wondering what you'd do in this kind of situation.

I have a patient with a history of multiple episodes of loss of consciousness, likely syncope due to physical and psychological stress. They were seen for this among other issues by pcp, neuro, and then myself. No one except myself and a triage nurse told them not to drive per the chart.

My state is not a mandatory physician reporting state, but patients are required to report to the DMV within 30 days about any episodes of "loss of voluntary control." Physicians may report but nothing compels them to report or not-report. I don't see any documentation that anyone has told the patient to do this, or that anyone helped them complete a form for the DMV - the form has a physician attestation section. I also saw them a couple times before realizing that a patient is supposed to report this to the DMV (I'm new-ish to the state). It's definitely been 30+ days since the first episode but less than 30 days since the last episode. I don't think the patient would've reported anything on their own, knowing them overall.

I feel bad and like I'm going to get in trouble for not getting on this sooner. And how should I even go about getting on this issue? I told them not to drive but not what they should do with regard to the DMV. Yes, other doctors did not seem to address it, but is they provided subpar care doesn't mean I won't be held to whatever is standard of care in this situation.

---

Members don't see this ad.

 

[wolfvgang22]

This is a public safety issue. You need to have the conversation with the patient and let them know you recommend they do not drive and why. Tell the patient what your reporting requirements are and that you will be reporting. Tell them it is not your decision on whether they are allowed to drive or not, but the DMV's decision, you are only reporting the condition. Tell them what the conditions need to be in order for your recommendation to change. I find this goes best if the patient has family or a close friend involved in the patient's care as they usually agree about safety and can help the patient with transportation. Document the encounter.

If you work in the VA, it is different. Federal VA directives claim to supersede state law and the directive to VA employees since a few years ago is to not report. They claim veteran privacy as the reason. I strongly disagree with this, given the danger to public safety. I still make my recommendation not to drive and document but do not fill out the state reporting form. I document the VA directive as well. If I am greatly concerned I will urgently consult the Ethics committee. I have not had to do this so far as the patient's I've told not to drive have all had family or close friend who also told them not to drive and chauffeur the patient, or the patient is in long term care. If not a VA patient I will always report.

As an aside, if a patient is going to leave my office or the ER or hospital impaired I ask them not to drive and offer to help them get transportation. I advise if they refuse I will call the campus or city police, and I do if they refuse. I have seen police allow a clearly impaired patient leave clinic parking lot in a vehicle before, sadly.

 

[comp1]

Concur, VA privacy directives supersede any state law and are generally much more restrictive than HIPAA. This can be to your benefit if you are ever subpoenaed as the VA can just say "no." It sounds like you aren't a mandatory reporter, so a delay isn't a clear problem other than if you did genuinely believe the public was endangered. If you aren't in the VA and this is a discretionary breech of confidentiality in your state, it's really up to you. Since you're posting in the psychiatry forum...these episodes are likely a bit different than epilepsy which is kind of the DMV's focus. Is it possible they could occur while driving? Are they actual losses of consciousness? Ultimately this is information the DMV is going to want from you to make their decisions. If you just send them a form saying investigate this patient, they're going to send the patient back with another form asking you to explain what the exact condition is and how it might relate to driving ability. To the best of my understanding, the DMVs of most states do not employ their own physicians to make determinations about medical conditions, they rely on the person's own physician reports. If you really wanted to some how both report this and absolve yourself of any other decision making, you could say that you can't assess driving ability and recommend the DMV perform their own exam. This would likely be a behind the wheel driving test, which may or may not relate to the condition you're describing.

 

[lockian]

Concur, VA privacy directives supersede any state law and are generally much more restrictive than HIPAA. This can be to your benefit if you are ever subpoenaed as the VA can just say "no." It sounds like you aren't a mandatory reporter, so a delay isn't a clear problem other than if you did genuinely believe the public was endangered. If you aren't in the VA and this is a discretionary breech of confidentiality in your state, it's really up to you. Since you're posting in the psychiatry forum...these episodes are likely a bit different than epilepsy which is kind of the DMV's focus. Is it possible they could occur while driving? Are they actual losses of consciousness? Ultimately this is information the DMV is going to want from you to make their decisions. If you just send them a form saying investigate this patient, they're going to send the patient back with another form asking you to explain what the exact condition is and how it might relate to driving ability. To the best of my understanding, the DMVs of most states do not employ their own physicians to make determinations about medical conditions, they rely on the person's own physician reports. If you really wanted to some how both report this and absolve yourself of any other decision making, you could say that you can't assess driving ability and recommend the DMV perform their own exam. This would likely be a behind the wheel driving test, which may or may not relate to the condition you're describing.

So, to be honest, the tricky part is I don't know how these episodes may affect driving. The workup is not complete but neuro has low suspicion for seizures. Based on the story, the episodes sound like good old fashioned vasovagal syncopes triggered by physical and emotional stress. There is some shaking described by bystanders, but that can happen even if it's not a bonafide seizure. Are these events likely to occur while driving? Well, if the patient is mindful of not driving when emotionally or physically overextended, then no. But do they meet the state's vague definition of "loss of voluntary control?" Yes.

Yes, if the patient fills out the DMV report form there's a doctor section on it right off the bat. I'm supposed to put prognosis and cause, and I'm not even sure how to answer those questions. But my answers to those questions would help the DMV determine if they should suspend the person's driver's license or not.

 

[Stagg737]

Follow your state law (or VA if working there), inform the patient of your recommendations regarding driving, and document everything. I look at this similarly as someone with severe panic attacks that physically disable them. Would you contact the DMV if a patient has panic attacks that impair their driving? I'm not aware of mandated reporting regarding panic attacks, but it really comes down to what is legally required and what you can control (your recommendations). Even if you report to the state, the patient is still the one who will make the decision regarding their driving.

Yes, if the patient fills out the DMV report form there's a doctor section on it right off the bat. I'm supposed to put prognosis and cause, and I'm not even sure how to answer those questions. But my answers to those questions would help the DMV determine if they should suspend the person's driver's license or not.

You don't know either of those, so put "undetermined" and add something like (work-up incomplete). If the work-up is completed and a concerning cause is found, follow-up with the DMV then. Your job is to provide your medical opinion, not interpret the law. Don't get too hung up on it.