Original article—liver, pancreas, and biliary tract
Legal Ramifications for Physicians of Patients Who Drive With Hepatic Encephalopathy

https://doi.org/10.1016/j.cgh.2010.08.002Get rights and content

Background & Aims

Hepatic encephalopathy, a spectrum of neuropsychiatric abnormalities that can occur in patients with liver dysfunction, negatively affects driving performance, but no study has examined legal ramifications. We studied state requirements for reporting hepatic encephalopathy and investigated whether lawsuits have been completed against physicians or patients for motor vehicle accidents that were related to hepatic encephalopathy.

Methods

We contacted motor vehicle departments from all 50 states and examined motor vehicle codes and legal databases to search for hepatic encephalopathy–related lawsuits.

Results

Definitions of a medically impaired driver varied considerably. No state specifically mentioned hepatic encephalopathy or patients with advanced liver disease. Only 6 (12%) of the states had mandatory reporting laws for drivers who have medical impairment, and 25 of the remaining 44 states (57%) provided legal immunity to physicians for reporting such patients. The legal databases did not contain any cases against physicians for failure to warn against driving or diagnose hepatic encephalopathy that resulted in an accident. There were no lawsuits identified against an encephalopathic patient for causing a motor vehicle accident.

Conclusions

Only 6 states require physicians to report drivers with medical impairments. Hepatic encephalopathy is not specifically addressed in any state vehicle code. There are no completed lawsuits against physicians or patients for motor vehicle accidents associated with driving impairment from hepatic encephalopathy. In the absence of definitive laws, the onus of responsibility for identifying potentially hazardous drivers might still lie with the physician; physicians should carefully evaluate patients for driving abilities.

Section snippets

Materials and Methods

To determine the requirements for reporting potentially impaired drivers, we contacted each state's motor vehicle department via telephone and by fax, reviewed the motor vehicle code of each state, and reviewed appropriate existing databases and references. These databases were all accessed electronically on March 22, 2010, and are included online as supplemental material and references (Supplementary Table 1). The direct response from the state was considered the primary information source. In

Results

Review of the vehicle codes revealed significant differences regarding the medically impaired driver. The definition of a medically impaired driver varied considerably. The presence of a seizure disorder as well as general terms such as “cognitive impairment”, “neuropsychiatric conditions”, and conditions associated with “lapses in consciousness” were commonly noted. None of the motor vehicle codes specifically mentioned hepatic encephalopathy or referred to impairment from advanced liver

Discussion

HE represents a spectrum (ranging from MHE to overt HE) of neuropsychological abnormalities seen in patients with advanced liver disease. MHE occurs in 30%–80% of cirrhotic patients and can impair a patient's life.2, 3, 4, 5 MHE might be overlooked on a standard neurologic evaluation, because the diagnosis is only possible by using specialized psychometric and neurophysiological measures, which have limited availability in practice.15, 16, 17 Only 28% of polled hepatologists tested the majority

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  • Cited by (16)

    • EASL Clinical Practice Guidelines on the management of hepatic encephalopathy

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      There are no clear published guidelines on driving for patients with covert HE with or without recent overt HE. Expert consensus recommends avoidance of driving after an episode of overt HE176 as most patients with HE experience significant “lapses of consciousness” following a recent or current episode.186 Verbal and written advice to avoid driving following an episode of overt HE should be given to patients and caregivers.

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    • In Patients With Cirrhosis, Driving Simulator Performance Is Associated With Real-life Driving

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      Citation Excerpt :

      The impact of driving on daily function cannot be discounted; therefore, subjects with MHE with poor driving history and driving simulator performance and those with recent alcohol abstinence should be specifically targeted for counseling. Although currently there is no current firm legal basis for doing so, the need to address this issue is an ethical one toward preventing car crashes and violations.21–23 Indeed, in a recent survey, only a minority of clinicians were aware of their local driving laws.24

    • Treatment of Overt Hepatic Encephalopathy

      2015, Clinics in Liver Disease
      Citation Excerpt :

      The legal issue surrounding HE has been addressed several times—only 6 states require providers to report medically impaired drivers, and HE is not mentioned specifically in any state.13,14 Furthermore, the most recent survey found no completed lawsuits against physicians or patients for motor vehicle accidents associated with driving impairment caused by HE.13 Despite these facts, the authors concluded that the responsibility of identifying potentially hazardous drivers might still lie with the physician.

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    This article has an accompanying continuing medical education activity on page e17. Learning Objectives—At the end of this activity, the learner should recognize the impact that hepatic encephalopathy has on driving safety and the current role of the physician in management of this problem.

    Conflicts of interest The authors disclose no conflicts.

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