Friday, September 5, 2008

Medications and Driving - Informed Consent?

The WSJ Health Blog highlighted a second case out of Massachusetts where a patient and their prescribing physicians (five of them) are being sued for a motor vehicle accident that occurred while the patient/driver was taking opioids. The reason the physicians are being sued is for negligence in education or counseling to the patient regarding driving and opioids. To my knowledge the pharmacy or pharmacists dispensing the medication are not involved in the lawsuit.

The Massachusetts Supreme Court ruled in favor of the plaintiff in a similar lawsuit against a prescribing physician in December.

Some quick details of each of the cases.

Dec 2007 Ruling
: 75 year old male with COPD and lung cancer on oxycodone, Zaroxolyn, prednisone, Flomax, potassium, Paxil, oxazepam, and furosemide. While driving his car, he killed a 10 year old boy. PCP sued successfully.

Aug 2008 Case:
77 year old female with breast cancer. Medications are not revealed at this time. Killed physician and secretary inside radiation oncology clinic with car while trying to park. 5 MD's including PCP are defendants.

Opioids are a common class of medications in the palliative care toolkit for symptom control and thus our field needs to be aware of potential legal consequences of our frequent prescription tendencies. This is particularly relevant because opioids and many other common palliative care medications can cause cognitive impairments. Cases like this make me think there will be an even greater barrier to prescribing these medications appropriately and effectively. Clinicians are already crunched for time, and to include counseling for avoidance of driving for EVERY possible medication that could cloud thinking would be an impossible task.

And there are way too many questions:

  • Where does the liability stop?
  • Is the pharmacist liable?
  • Is the weekend on-call doctor who sees the patient in the hospital while they are already on medications that may alter mental status liable, because they did not say anything?
  • How about the drug maker for not having clear warnings on the insert (that no patient reads)?
  • If we start blanket counseling does that mean I should counsel the comatose patient in the ICU on ativan and morphine drips just in case they survive and still need these medications post discharge?
  • How do we determine which drug classes to apply this to since lasix was implemented in the first case?
  • How would hospice agencies be affected?
  • What about the hospice nurse who actually sees the patient and knows they are driving as opposed to the physician who may presume the patient is home/bed bound while on hospice?
I am not saying the medical community should have no role , but what is reasonable, and what is effective in preventing horrible tragedies such as these two cases? Taking away driving privileges has always been a source for consternation in families and in the medical community and there is no simple rule or guideline to follow. Does anyone have a good journal article to help clarify the role of the medical professional in discussing driving responsibilities with patients?

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