How should oncology nurses navigate this sensitive discussion with patients and their families?
Cathy is 76 years old and has been living with metastatic breast cancer for more than 7 years. Her home is 240 miles from her oncology center. Although she has relied on her adult daughter and friends to accompany her to appointments, as her disease has progressed, Cathy has had difficulty finding help with travel.
Cathy has enrolled in a phase I clinical trial, which requires more frequent trips to her oncology center for treatment. She does not have the resources to pay for a hotel. When asked about her ability to drive after treatments, she says sometimes severe fatigue causes her to pull off the road and sleep for a few hours. However, she is adamant that she is a safe driver. The oncology nurse notes that her current medication list includes oxycodone (Oxycontin), bupropion (Wellbutrin), lorazepam (Ativan), pregabalin (Lyrica), and zolpidem (Ambien).
Although the above scenario may seem extreme, nurses are often faced with similar situations when caring for their patients. What constitutes a high-risk driver? When should a patient be advised to stop driving? And how should oncology nurses approach patients and families about this sensitive issue?
Motor vehicle injuries persist as the secondleading cause of injury-related deaths in individuals over the age of 25.1 Traffic safety programs have had some success in reducing crash rates for all drivers, but the fatality rate for drivers over 65 has remained high. Unfortunately, there are no official guidelines for when to advise patients to stop driving.
Oncology nurses are in a unique position to address this problem. The conversation may be initiated by a concerned caregiver. Asking permission to speak with caregivers for additional information is important. This is a sensitive issue, so approach this discussion with empathy and compassion. Take the time to listen to the concerns of your patients and their caregivers, and help them identify realistic, safe goals. Exercise sensitivity when asking patients about how they perceive their driving habits, as they will almost always downplay any problems for fear of losing their license.
Clinical risk factors that may indicate impaired driving include decreased physical and cognitive abilities. Simple questions to screen for impairment include:
• How did you get here today?
• Do you drive to the grocery store or the bank or for other day-to-day errands?
• Is your vision affected when you drive at night?
• Has anyone ever expressed concern that you may not be as safe on the road as you once were?
• Have you been involved in any accidents within the past 6 months?
Patients must understand that their safety comes first. The following are signs of a potential safety risk:
• Difficulty with remembering the difference between the gas and brake pedals
• Inability to maintain a consistent speed
• Following too closely and/or driving too slowly, which may indicate a difficulty with perception
• Not providing appropriate turn signals
• Delayed response to unexpected situations
• Hitting curbs when making turns
• Minor accidents causing scrapes and dents and/or multiple fender benders
• Frequent close calls 2
Engaging other team members in the discussion can be helpful. In some states, physicians are required to report to the Department of Motor Vehicles (DMV) patients who may be considered at risk. Physicians can often initiate the conversation with the patient, and social workers are also important resources for helping to explore alternative means of transportation.
Pharmacists can help review medication history and use of OTC drugs and anticipate drug-drug interactions. Medication classes that may impair a patient’s driving ability include anticholinergics, anticonvulsants, antidepressants, antiemetics, antihistamines, antihypertensives, antiparkinsonians, antipsychotics, benzodiazepines, muscle relaxants, narcotic analgestics, and stimulants.
All states have their own DMVs, so the rules vary across the country. Recommending that a patient’s license be revoked for medical reasons can often entail a difficult and time-consuming process. The physician—nurse relationship is important for ensuring that you are working as part of the team and not in isolation. In addition, DMV.org is an excellent resource for patients and families who are trying to determine driver safety.
When a safety risk is identified and a patient is deemed unable to drive, families must set up an alternative means of transportation. Uber, taxis, and friends are possible solutions. As part of the American Cancer Society’s Road to Recovery Program, volunteers donate their spare time to offering rides for patients with cancer. In addition, some communities have churches, local nonprofits, and senior centers that can assist with transportation.
If a patient’s license is revoked, nurses should discuss with caregivers and family members the impact this can have on the patient’s quality of life. Limitations on socializing with others can lead to depression, for instance. 3 Caregivers need to be aware of this potential and stay in close contact with the patient’s primary care provider as well as other identified support staff. This can include a chaplain and a psychologist.
In Cathy’s case, we reached out to our social worker. A family conference was facilitated with the patient and her daughter so we could share our concerns about Cathy’s safety. Once her daughter recognized the seriousness of the situation, she made an effort to accompany her mother to all future appointments. We were able to help Cathy identify nearby affordable housing so she could avoid having to travel far on the days when treatment was long, as well as additional travel resources in her own community that she was unaware of. We feel that we achieved our goal of ensuring her safety but realize the ongoing support that will be required to ensure Cathy is still maintaining an acceptable quality of life.
1. Centers for Disease Control and Prevention. 10 leading causes of injury deaths by age group highlighting unintentional injury deaths, United States — 2017. cdc.gov/injury/images/lc-charts/leading_causes_of_death_by_age_group_unintentional_2017_1100w850h.jpg.
2. AARP. We need to talk: the difficult driving conversation. 2016. aarp.org/auto/driver-safety/info-2016/when-to-stop-driving-in-older-age.html
3. Chihuri S, Mielenz TJ, DiMaggio CJ, et al. Driving cessation and health outcomes in older adults. J Am Geriatr Soc. 2016;64(2):332-341. doi: 10.1111/jgs.13931.