If a driver experiences a generalized tonic-clonic seizure while driving – with minimal to no warning aura, the likelihood of a serious accident is not insignificant. Such an accident could injure the driver and passengers of that car, pedestrians, people in other vehicles, and property. Bad things could happen.
Three professional societies (the American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America) just published a Position Statement entitled “Seizures, Driver Licensure, and Medical Reporting Update.” Its prior Position Statement was last published in 2007.
The rationale for providing guidance is based on the following conclusions from studies:
- There is a modest but real increased risk of motor vehicle accidents (MVAs) associated with epileptic seizures,1,2 and increased seizure frequency is associated with higher risk of MVAs.5
- Risk of fatal MVAs associated with epileptic seizures is not higher than in the general population of drivers and is significantly lower than the risk of fatal MVAs associated with alcohol use disorder or young drivers.3,4,5
- Risk of recurrent seizures and MVAs for individuals declines with longer seizure-free intervals, with progressively reduced risk of recurrent seizures and MVAs after 6 and 12 months of seizure freedom.6,7,8
- At a population level, universal legal requirements for seizure-free intervals longer than 3 months do not seem to reduce MVAs or fatalities, although individualized restrictions longer than 3 months may be appropriate based on individual clinical factors (e.g., adherence and treatment resistance).9
- Many drivers with seizures disregard legal restrictions on driving, and regulatory compliance may be increased by prescribing individualized and less onerous seizure-free intervals.
- Mandatory reporting by health care practitioners does not decrease MVAs but does increase likelihood of unlicensed driving and withholding information from practitioners.10,11
Driving is regulated by the states. There are exceptions – such as commercial driving where drivers must meet specific requirements set by the Department of Transportation (DOT) and the Federal Motor Carrier Safety Administration (FMCSA), including passing a DOT physical and completing necessary training. For most people in most situations, the states set the rules.
The Position Statement argued the states should continue to set the rules.
In the absence of national driving standards, states should enact enabling legislation allowing the Departments of Motor Vehicles (DMVs), medical advisory boards, and consultants to establish driver-licensing and appeals processes that include individualized assessments by medical advisory boards and adhere to evidence-based recommendations. Such legislation should protect practitioners involved in the licensing process who are acting in good faith from liability…
Licensing criteria for each medical condition should appear in regulations and guidelines rather than being prescribed by statute.
The treating practitioner should be responsible for reporting the pertinent medical facts on forms provided by the DMV. These forms should be detailed and precise and should offer an opportunity for the treating practitioner to make a recommendation about whether the patient should be licensed and to give narrative commentary. However, the practitioner should not be required to offer any recommendation or commentary. When treating practitioners do submit a recommendation, the ultimate responsibility and final decision should still reside with the medical advisory board
In other words, healthcare professionals should be allowed to participate. But such professionals will not replace the DMV.
What About Seizure-Free Intervals?
States vary in terms of seizure free intervals for resumption of driving.
Montana has no fixed interval of time. Kentucky requires 90 days (or longer). Massachusetts requires 6 months (with exceptions). New Hampshire requires 1 year (less, at the discretion of its DMV). State by state list of rules on seizure-free intervals can be found here.
The Position Statement recommended three months.
Three months of seizure freedom is preferred as a minimum requirement, starting from the date of the most recent seizure. Evidence suggests that universal requirements for seizure-free intervals longer than 3 months do not reduce MVAs or fatalities.
This minimum might be modified by a medical review board in individual cases.
Shortening the interval might be justified for the following reasons:
- Seizures during practitioner-directed medication changes.
- Focal seizures without impaired awareness (e.g., focal aware seizures) that do not interfere with motor control.
- Established pattern of seizures occurring exclusively during sleep (sometimes referred to “nocturnal seizures”).
- Seizures secondary to provoking factors that are unlikely to recur (such as metabolic, toxic, or infectious conditions, or other acute illnesses).
Lengthening the interval might be justified for the following reasons:
- Unambiguous nonadherence with medications or medical visits.
- Seizures related to substance use disorder.
- Prior crashes due to seizures.
- Prior record of MVAs or violations of driving regulations (if driving record is available).
- Increasing number of seizures in the recent past from prior baseline.
- Seizures refractory to multiple antiseizure treatments.
- Frequent seizures after a seizure-free period.
- Individual is having recurrent seizures of which they are unaware.
- Structural brain lesion (e.g., stroke, cortical dysplasia, or tumor) or a brain disease likely to worsen over time (e.g., Alzheimer disease or malignancy).
What About Reporting?
The Position placed the onus of reporting onto the patient (the driver). Physicians should be allowed to report. They should not be mandated to report. And, whether or not they report, they should receive legal immunity.
Patients with seizures should be responsible for self-reporting the condition to the DMV when initially diagnosed as well as on the recurrence of seizures…Individuals should be informed that if they experience a seizure they should cease driving, consult their practitioners, and promptly notify the DMV. The obligation to self-report should be stated in writing on the license application and renewal forms.
If a practitioner believes the patient has not self-reported and is endangering the public by driving, the practitioner should be legally authorized to report the patient, and immunized from liability for doing so, but should not be mandated to report or be exposed to liability for failing to do so. Practitioners should inform patients before reporting and should document such interactions in the patient’s medical record…
Comparisons of matched populations with epilepsy who are and are not subject to mandatory reporting suggest that mandatory reporting by practitioners does not decrease the risk of MVAs but does increase the likelihood of unlicensed driving…
Professional medical organizations such as the American Medical Association and the American College of Emergency Physicians recommend that practitioners make individualized assessments about risk to the patient’s and public’s safety, rather than mandatory reporting of entire classes or diagnoses, except where compelling evidence exists for a public benefit of such categorical reporting.
For these reasons, we recommend that practitioners not be mandated to report seizure activity. We do recommend that practitioners be permitted to report seizures to licensing authorities, especially in cases where they have reason to believe that a patient is engaging in unsafe driving practices against medical advice.
Provider Immunity?
The answer was yes.
In addition, the Position Statement argued against any physician report being used in ANY legal proceeding.
To protect the practitioner-patient relationship, practitioners should be immunized from liability for deciding not to report a patient to the DMV, if in their best judgment, there is no indication to do so. In addition, practitioners should have immunity for reporting or not reporting patients who have seizures or other episodes involving loss of consciousness or bodily control. The immunity clause should also cover the contents of the report and should prohibit the report from being used in other legal proceedings.
Commercial Driving?
The Position Statement recognized that the aggregate risk is different with commercial drivers. Regulations will likely need to be more restrictive. That said, the Position Statement was not prescriptive.
Professional drivers include (but are not limited to) individuals licensed to drive commercial trucks, buses, ambulances, or taxis, as well as those contracting with ride-share networks. Because professional drivers are likely to spend more time driving and to drive larger vehicles and/or vehicles with multiple passengers, federal and state regulations on professional driving after seizure occurrence are stricter than those imposed on private drivers after seizures.
Other Items in the Bucket?
Functional seizures, also known as psychogenic non-epileptic seizures, were addressed. Typically, this is NOT considered a form of epilepsy.
Some non-epileptic seizures (NES) are caused by mental or emotional processes, rather than by a physical cause. This type of seizure may happen when someone’s reaction to painful or difficult thoughts and feelings affect them physically. These are called functional seizures.
These NES used to be called ‘pseudoseizures’. This name is unhelpful because it suggests that the person is not having ‘real’ seizures or their seizures are deliberately ‘put on’.
Functional seizures happen unconsciously, which means that the person has no control over them and they are not put on. This is the most common type of NES.
Functional seizures are sometimes known as non-epileptic attacks. People who have non-epileptic attacks may be described as having ‘non-epileptic attack disorder’ (NEAD).
These terms are not always helpful because they describe the condition by saying what it is not rather than saying what it is.
Functional seizures are associated with increased risk of MVA. The Position Statement noted:
The limited evidence available suggests that individuals with functional seizures do have motor vehicle collisions because of these events and may have a higher rate of collisions (though a lower rate of severe injuries) compared with individuals with epileptic seizures).12
Given these limited data, we recommend that individuals with functional seizures involving alterations in responsiveness and/or involuntary movements potentially affecting their ability to control a vehicle receive driving counseling and restriction similar to that given to individuals with epileptic seizures.
Summary
The Position Update is long overdue. States should provide clear guidance as to what it expects of drivers. The states should adopt a three-month minimum seizure free interval, with exceptions allowed, or the period lengthened, based on individualized circumstances. The onus of reporting should be on the driver. Healthcare professionals should be allowed to report, but not mandated to report to the DMV. Any report or lack thereof should be associated with legal immunity.
Importantly, the Position Statement is just a set of recommendations. It does NOT have the force of law. Physicians should educate themselves as to what is currently required, by law, if anything, on this subject in their state. State by state requirements can be found here, with the usual caveat, that the list may not be complete, fully accurate or up to date.
What do you think?
