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Driving (or not) after critical illness

The national public health burden attributable to impaired recovery from critical illness is substantial. Over recent years, there has been an increasing recognition of and commitment to address the physical, psychological and social aspects of post-intensive care recovery. Hence, the provision of multi-modal rehabilitation after critical illness, which is now enshrined in the NICE Guideline 83 published in 2009, and the first edition of the Core Standards for Intensive Care Units published in 2013. The General Provision of Intensive Care Services document, which relates to the entire nature and scope of an intensive care medicine service, due for publication in 2015, will further formalise the need for intensive care follow-up services. One crucially important milestone along the recovery and rehabilitation pathway from critical illness is the return to driving one’s vehicle. The number of drivers continues to increase, with 32 million people in Great Britain holding a full driving licence in 2013. Of particular note is the proportion of older (>70 years) people holding a full driving licence which has increased from 29% to a striking 62% in the last eight years. Driving is an advanced task which signifies a step-wise reacquisition of independence. Many patients, therefore, regard their return to driving as a valuable recovery goal. Clinicians might also use a patient’s return to driving as an objective marker of recovery, since it requires both physical and mental complex functioning. For some patients, the return to driving will represent the chance to return to work, either by enabling commuting or for employment duties. There are over 300,000 large goods vehicle drivers and 300,000 taxi and private hire vehicle drivers in England and Wales, not to mention many other professionals who drive as part of their job (e.g. emergency services, delivery services, pilots, boat captains, train and bus drivers) and workers who operate other motorised machinery. Thus, the economic consequences of driving ineligibility decisions are substantial. However, there is very little insight and guidance available about when and how patients recovering from critical illness should return to driving. The DVLA medical standards of fitness-to-drive document states that ‘‘In the interests of road safety, those who suffer from a medical condition likely to cause a sudden disabling event at the wheel or who are unable to safely control their vehicle from any other cause, should not drive.’’ The document gives detailed legally-binding guidance about driving ineligibility and duration of ineligibility for a number of medical disorders. The standards differ for group 1 (ordinary driving licence) and group 2 (vocational/ passenger carrying vehicle) entitlement, the latter being justifiably more stringent. A recent analysis shows that many of these DVLAspecified disorders are commonly diagnosed during the course of a critical care admission. In a six-month audit of 440 sequential admissions at a UK university hospital’s general adult intensive care unit, 70 (16%) of patients acquired a new DVLA-relevant diagnosis, and the range of these diagnoses was diverse (Table 1). In addition, a discharge notes review revealed that evidence of identification and communication of these diagnoses to receiving teams in the hospital was almost universally absent. Mention of driving eligibility was present in only 2 (3%) of these 70 affected patients’ ICU discharge summaries. This might equate to approximately 136 ‘‘care omissions’’ per year in our hospital. Driving eligibility is therefore a common issue for ICU patients, and perhaps not one about which ICU staff are actively communicating about with other healthcare professionals nor patients. One significant limitation of the DVLA medical standards document is that it only addresses the ‘‘diagnosis-based’’ aspect of driving eligibility. Although necessary, this diagnosis-based strategy is certainly not sufficient, because it does not account for the wide range of physical, cognitive and pharmacological impairments that are common consequences of critical illness and that might overtly or covertly affect one’s ability to operate a vehicle. That said, in a preliminary paragraph entitled ‘‘driving after surgery’’, the DVLA document states: