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Medical aspects of fitness to drive – A guide for health practitioners

This guide is to assist health practitioners in assessing the fitness to drive of any individual. It also sets out the responsibilities and obligations of health practitioners.

1. General matters

This section covers:

1.1 Legal obligations on medical practitioners

Part 7 and part 13 of the Land Transport (Driver Licensing) Rule 1999 requires medical examinations to be carried out with regard to the medical policies and standards contained in the NZ Transport Agency (the Agency) booklet Medical aspects of fitness to drive: A guide for medical practitioners. This booklet is therefore part of New Zealand's legislation framework, although it remains a guide to good practice rather than legally enforceable criteria.

Medical practitioners have two main legal obligations relating to fitness to drive under transport legislation. The law requires:

  • medical practitioners to advise The Agency (via the Chief Medical Adviser) of any individual who poses a danger to public safety by continuing to drive when advised not to (section 18 of the Land Transport Act 1998 - see section 1.4)
  • medical practitioners to consider Medical aspects of fitness to drive when conducting a medical examination to determine if an individual is fit to drive.

There are also obligations under section 19 of the Land Transport Act 1998 (see section 8 and appendix 2 of this booklet) for certain persons to undertake actions relating to patients subject to a Compulsory Inpatient Treatment Order.

Section 18 of the Land Transport Act 1998 also provides that a medical practitioner or registered optometrist who gives notice in good faith¹ under section 18 will not be subject to civil or professional liability because of any disclosure of personal medical information in that notice.

¹ An act that is done in good faith is if the act was done honestly with no ulterior motive, even if done negligently.

1.2 General factors for medical practitioners to consider

In assessing an individual's fitness to drive, remember that the issue is often not whether the individual has a particular medical condition, but whether the condition has produced significant risk factors in respect to an individual's ability to drive safely and whether they are a danger to themselves or others.

Medical practitioners should consider the following general factors, in addition to the guidance outlined under each section, when assessing an individual for fitness to drive:

  • Individual's ability to drive safely, eg some individuals may not respond well to treatment, and therefore may not be able to drive at the end of the recommended minimum period of refraining from driving
  • Risk of serious motor crashes due to sudden driver failure, eg presence of any factors that may cause sudden loss of vision or sudden impairment of driving ability
  • Type of licence held and type of driving undertaken - professional drivers spend up to an entire working week in their vehicle, and that vehicle can weigh greater than 25,000kg or carry many passengers. A crash involving such a vehicle could put many people at risk. In addition to the type of licence or endorsement held, the type of driving an individual undertakes should also be considered, eg if an individual regularly drives buses or unloads heavy vehicles
  • Medication - consider the effects of medications, and likely compliance with medications, on the individual's ability to drive safely
  • Individual's motor vehicle crash history (if known) - medical practitioners may need to recommend a longer period of refraining from driving if an individual has a history or pattern of crashes that may be associated with their condition. Where a medical practitioner is aware of a medically related crash, they must inform the Agency if the individual's medical condition remains unresolved and the individual is likely to continue to drive (refer to section 1.4)
  • Presence of multiple medical conditions - where an individual has one or more medical conditions, consider any possible combined effects on their ability to drive safely.

1.3 Medical examinations

Medical practitioners must recognise their role in conducting the examination. Driving is not a right and the medical practitioner has a legal and ethical obligation to ensure that the safety of other road users, as well as the individual, is the primary concern in making any decision on fitness to drive.

It is tempting for the medical practitioner to act as an advocate for their patients but this is inappropriate. In situations where this cannot be resisted, medical practitioners should be prepared to disqualify themselves and refer their patients to another medical practitioner. This may be a wise procedure under other circumstances as well, especially when there is a risk of damaging an established therapeutic relationship. Nonetheless, as a normal rule, the examiner is expected to be the patient's regular general practitioner.

Part 7 and part 13 of the Land Transport (Driver Licensing) Rule 1999 requires medical examinations to be carried out with regard to the guidance contained in this booklet. The approved form of medical certificate requires the medical practitioner or a registered optometrist, as appropriate, to sign that the examination has been carried out with regard to this booklet and that the requirements for certifying a person fit to drive have been followed.

Changes in medical assessment practices

Technology or knowledge on assessing fitness to drive may change over time. Therefore, where this guide recommends a particular test or examination, if a different test or examination is subsequently generally used that achieves a similar level of assessment, then this can be used.

Medical practitioners, optometrists and occupational therapists are expected to keep themselves apprised of major changes in medical knowledge that may influence their assessment or treatment of drivers.

Medical certificates

The Agency has developed a medical certificate for medical practitioners to use. Copies of this certificate are available on the automated ordering system or from the Agency's Transport Registry Centre in Palmerston North (0800 822 422 ext 8089).

The extent of the examination

The extent of a medical examination for fitness to drive will depend partly on:

  • the nature of the licence required, and
  • the purpose of the medical examination.²

It is important that a medical practitioner undertakes the appropriate level of examination, even when they know the individual well.

² For example, a cardiologist would not be expected to conduct a full examination of the patient as detailed in this guide but rather conduct the appropriate level of cardiac examination.

Differences in examination requirements between private and commercial drivers

Commercial drivers are expected to meet higher safety standards than other motorists.

The Land Transport (Driver Licensing) Rule 1999 defines classes of driver licence and types of licence endorsement (see appendix 3). This Rule also provides the requirements for obtaining and renewing licences for the various categories of commercial driver, including the requirement to produce a medical certificate applicable to the class of licence or type of endorsement.

Given the potential severity of a crash involving a commercial vehicle, the following commercial type drivers applying for or renewing their licence or endorsement must be examined thoroughly:

  • classes 2, 3, 4 or 5
  • passenger endorsement (P)
  • vehicle recovery endorsement (V)
  • driving instructor endorsement (I)
  • testing officer endorsement (O).

The medical examination requirements for lower (private) licence classes or endorsement types are generally less than for commercial drivers. Lower licence classes or endorsement types include:

  • classes 1 or 6
  • the following endorsement types:
    • dangerous goods endorsement (D)
    • forklift endorsement (F)
    • roller endorsement (R)
    • tracks endorsement (T)
    • wheels endorsement (W).

Examination of older drivers

Examination of the older driver has particular problems, especially in respect to cognitive skills and reaction times. Factors to check for older drivers are outlined in section 9. Whenever there is doubt about a person's abilities and fitness to drive, the person should be assessed by an occupational therapist with training in driver assessment.

General elements of an examination

The examination should include:

  • a careful history, noting particularly whether the person has been found unfit to drive a motor vehicle in the past and the reasons
  • particular attention to any history of: epilepsy or other conditions of impaired consciousness; neurological conditions; mental disorders; diabetes; severe hypertension and other cardiovascular conditions, especially ischaemic heart disease; locomotor disorders; or hearing or visual problems
  • a note of any medications that might affect the ability to drive safely.

Clinical examination

The clinical examination itself should include:

  • cardiovascular system
  • respiratory system
  • musculoskeletal system
  • central nervous system (noting especially matters such as coordination and sensory loss)
  • vision (according to the specific requirements of section 6)
  • hearing.

In the report, also note any cognitive or psychiatric issues or defects of mental capacity sufficient to affect driver safety.

Additional tests may be required when clinical examination has raised the possibility of potentially significant problems.

It is important that a proper record is kept of any examination undertaken in the individual's clinical notes. This is not in order to ‘police’ medical practitioners’ records, but for the practitioner's protection in medico-legal cases and in order to be able to deal with any questions and appeals that may arise.

1.4 Reporting an individual's unfitness to drive

A medical practitioner must report that an individual is unfit to drive or should only drive with certain licence conditions if:

  • the medical practitioner provides a medical certificate for driver licensing renewal or application purposes
  • the individual is likely to continue to drive contrary to medical advice (section 18 of the Land Transport Act 1998).

Section 18 of the Land Transport Act 1998 requires medical practitioners to advise the Agency in cases where the mental or physical condition of the licence holder is such that, in the interests of public safety, the person should not be permitted to drive or only permitted to drive subject to limitations and conditions - and it is considered that the person is likely to drive against medical advice. The full wording of this section is set out in appendix 1.

There are also reporting requirements under section 19 of the Land Transport Act 1998 (outlined in section 8 of this guide) that relate to individuals subject to a Compulsory Inpatient Treatment Order, or special patients under the Mental Health (Compulsory Assessment and Treatment) Act 1992.

Procedures for notifying the Agency of an individual under section 18 of the Land Transport Act 1998

The general steps are:

  • inform the individual that they are unfit to drive and the reasons for this
  • if the individual accepts they are unfit to drive and advises that they will not drive, take no further action
  • if the individual does not accept the advice and is likely to continue to drive, advise the Agency (section 18 of the Land Transport Act 1998) - an example section 18 notification letter is outlined in appendix 4.

Other advice

Medical practitioners may wish to advise patients in writing, as well as verbally, that they are unfit to drive and when they can expect the situation to be reviewed. Some individuals may need to be advised that they are unfit to drive in the presence of a third party, such as a supportive family member.

The Agency's possible actions following notification under section 18 of the Land Transport Act 1998

A number of options are available to the Agency, including:

  • requiring the licence holder to undergo further examination (which could include an assessment by an occupational therapist or a specialist) by an appropriate practitioner nominated by the Agency
  • imposing licence conditions
  • medically suspending an individual's licence, subject to further investigation
  • revoking an individual's licence.

Medical practitioners can usually successfully negotiate short-term cessation of driving with patients. However, if longer periods are necessary, it is recommended that medical practitioners advise their patients both verbally and in writing. It is also recommended that the patient be told how soon they might expect to have this situation reviewed. If a practitioner suspects that a patient is continuing to drive against medical advice, they are legally obliged to inform the Agency under section 18 of the Land Transport Act 1998 (see above).

Where the guidance may appear inappropriate for an individual

The guidance provided may not be appropriate for all individuals, given the range of manifestations of some medical conditions. The Agency may decide to grant an individual a licence or renew a licence where the guidance is considered inappropriate for an individual. This may include the granting of conditional or restricted licences, such as a licence that requires the licence holder to have an annual medical review.

If a medical practitioner considers that the advice is inappropriate for an individual, they should write to the Chief Medical Adviser, outlining the individual's circumstances. As a general rule, for commercial drivers and/or for conditions that may include the possibility of sudden loss of consciousness or sudden inability to control a vehicle, a favourable specialist report will generally be required.

1.5 Second opinions and dealing with individuals who are not regular patients

Care should be taken when medical practitioners are providing second opinions or dealing with individuals who are not regular patients. For some individuals, the potential prohibition on driving may encourage them to deceive medical practitioners about their fitness to drive.

Medical practitioners in these situations should:

  • ask permission from the individual to request their medical file from their regular practitioner
  • conduct a more thorough examination of the individual than usually would be undertaken
  • ask the individual if they have any of the conditions listed on the medical certificate, eg. epilepsy.

1.6 Individual's rights of appeal of a licensing decision

An appeal system enables any individual to appeal against the Agency's decision to suspend or revoke a licence or place conditions on a licence. Section 106 of the Land Transport Act 1998 provides that any person who is dissatisfied with any decision made under the Act by the Agency in respect of driver licensing may appeal to a district court.

1.7 Issues associated with the disclosure of personal information

Liability for disclosure of personal medical information to the Agency

If a practitioner advises the Agency that a person is unfit to drive under section 18, and does so in good faith, they will not be subject to civil or professional liability resulting from the disclosure of personal medical information.

The DL9 medical certificate and the DL12 eyesight certificate require a licence applicant to consent to the release to the Agency of any medical records relevant to their application.

Privacy Act 1993

It is important to note that principle 11 of the Privacy Act 1993 advises that personal information may be disclosed where such disclosure is necessary ‘to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution and punishment of offences’. The NZ Transport Agency is a public sector organisation and section 18 of the Land Transport Act 1998 requires medical practitioners to provide information about their patients under certain circumstances. In these circumstances, the provisions of the Privacy Act that protect such information do not apply. Principle 11 of the Privacy Act 1993 also recognises that the disclosure of personal information may be necessary to prevent or lessen a serious and imminent threat to:

  • public health or public safety, or
  • the life or health of the individual concerned or another individual.

Evidence Amendment Act (No. 2) 1980

The provisions of the Evidence Amendment Act (No. 2) 1980 regarding disclosure of communications to a medical practitioner or clinical psychologist do not apply to disclosures made under section 18 of the Land Transport Act 1998.

1.8 Occupational therapists

If there is doubt regarding an individual's fitness to drive, an assessment by an occupational therapist may be appropriate.

Occupational therapists with specialist skills in driver assessment offer services in most centres. Occupational therapists offer a thorough, independent, objective assessment of driving ability, which is a valuable adjunct in determining fitness to drive.

Occupational therapists interpret how illness, trauma and subsequent disability may impact on an individual's ability to perform their usual functions. Driving is an activity that requires a combination of sensory, motor, cognitive and perceptual skills. Occupational therapists are aware of the high priority individuals give to their driving independence and of the associated complexity in determining fitness to drive.

Occupational therapists are concerned that people with disabilities, including age-related disability, are assisted to be independent in the activity of driving where technical and financial resources allow. Those with a disability that results in them being unsafe are advised to relinquish driving privileges.

Assessments cover a wide range of skills required for the safe operation of a vehicle:

  • Biomechanical problems are evaluated and recommendations made for the acquisition of suitable vehicles and appropriate vehicle modifications, with consideration given to lifestyle and mobility devices such as wheelchairs.
  • Cognitive skills are assessed, including concentration, decision making, eye