Dr Andrew Black
Chairman Driving Committee, Epilepsy Society of Australia
Comprehensive Epilepsy Program, The Queen Elizabeth Hospital, Woodville SA
The Commonwealth of Australia is a Federation of States and Territories and each retains its own Parliament and Laws and a separate Public Administration.
Driving Licences are issued by each State and Territory, and the methods employed to ensure “driving fitness’ vary considerably. For example, Victoria uses a Medical Advisory Board for assessing epilepsy in applicants for a licence, but places little obligation on licence holders or their doctors to report subsequently on the state of seizure control. South Australia makes use of a statute requiring medical practitioners to report any patient whose condition is likely to endanger the public, and obtains regular review assessments of any driver whose licence is endorsed with a medical disability. This requirement is currently under review. Drivers themselves will be responsible for advising the Registrar. The responsibility of doctors for reporting will occur if driving is known to continue despite advice to cease.
In 1988 an attempt was made to establish national medical guidelines for drivers. In 1993 The Epilepsy Society of Australia submitted a document recommending an approach to the assessment of driving licence holders with a history of seizures. The Society has engaged in further liaison with the body required to implement uniform Australian standards through a publication “Assessing Fitness to Drive, 2nd Edition” distributed in 2001.
Epilepsy/ Circumstance Seizure Free Interval
1. Recently Diagnosed 3-6 months
2. Chronic and active up to 2 years
3. Isolated Seizure 3-6 months
4. Recurrence on AED-withdrawal, or on provocation 1 month
5. Recurrence without provocation 3 months
6. Seizures only while asleep 12 months free of waking seizures
7. Temporal lobectomy 12 months
8. Accident resulting 12 months
(b) on consultant advice (low risk)
(a) cease driving until off AED 3 months
(b) no restriction
Epilepsy, considered a chronic condition with little likelihood of remission was a bar to driving before the 1940’s. With the advent of effective anti-epileptic drugs some cases could be controlled and a “two year rule” of freedom from seizures achieved a degree of consensus until the seventies saw a liberalisation of policies in many parts of the world. In South Australia guidelines have recognised many logical exceptions to the two year rule since the late seventies, and a growing acceptance of a more liberal approach has emerged Australia wide as in Europe and the United States of America.
The Bureaucracy responsible for the National Guidelines have stressed the obligation of medical practitioners to ensure that patients at risk do not drive. The Epilepsy Society of Australia has led other sections of the Profession in arguing that reporting should only occur in cases where a patient has persistently and irresponsibly failed to follow advice to cease driving. The Society has also ensured that the common law obligation of drivers themselves to behave responsibly is incorporated in the guidelines.
Once treatment is started nearly three out of four patients achieve long term control? Epilepsy from this perspective has a good prognosis and driving need be curtailed for no more than 3-6 months if the patient is seizure-free from the start of treatment.
With continuing seizures, however epilepsy has a poor prognosis, and such cases need to establish a sustained change over a period of two years. Improved management, including the use of novel anti-epileptic drugs will change the outlook for some, and a period of twelve months may be sufficient to test such a response.
Each case requires assessment. If found to be due to provoking and non-recurring circumstances driving need not be curtailed beyond three months, otherwise a period of 3-6 months is recommended, as for newly diagnosed epilepsy.
Should be fully assessed. In many cases driving may need to be curtailed for three months. If recurrence is due to drug-withdrawal or under identified provocative circumstances, driving may be resumed a month after re-institution of previously effective treatment and avoiding provocation.
Are not a bar to driving providing a pattern is established with no waking seizures over a twelve month period.
While such an occurrence may be quite coincidental it is known that certain seizures are much more likely to cause accidents than others (tonic-clonic and complex partial without aura around 75%; absence, simple partial and complex partial with aura around 33%).
If this is attempted while there is a substantial risk of recurrent disabling seizures, driving should cease until three months after full withdrawal. However it is not logical to restrict driving if graduated withdrawal is made on the basis of evidence indicating that recurrence risk is low.
The Guidelines make it clear that a conservative view will be taken about the time needed for seizure freedom if information is provided by general medical advisers. Assessment by an experienced Consultant is advocated so that the most complete and defined diagnosis can be made, eg at the syndromal level. In such circumstances prognosis is rather clearer and a more liberal view may be accepted. The many exceptions to be encountered such as ‘safe’ seizures, prolonged warnings and other special cases are recognised, provided appropriate Consultant evidence is offered. No consensus has been reached regarding the suitability of a person whose seizures continue, but infrequently.
The Australian Approach is a reasonably liberal one, but it recognises the appropriateness of the two year rule in those whose epilepsy has continued to be active. Infrequent seizures remain an unresolved issue. It is accepted that the majority of those with recently diagnosed epilepsy will achieve remission, and their driving need not be restricted after three to six months. An individual approach is accepted, provided expert recommendation is made by a suitably experienced Consultant.
Assessing Fitness to Drive, 2nd Edition, AUSTROADS, Sydney 2001: Updated April 2002