Wednesday, December 14, 2005

Ethical question

69 yo male with PMH of hypertension, CAD and DM2 presented to his PCP with fatigue and "falling asleep anywhere." After testing him for anemia, renal disease and thyroid disease, he decided to get a sleep study. The sleep study was grossly positive with an AHI (RDI) of 67 that occurred with both REM and NREM sleep. During the split night portion of the study, his AHI was reduced to 12 with CPAP of 11 cm H20.

He saw me after the study. When asked, he claimed to fall asleep reading the newspaper in the morning on the weekends, watching TV at night and had, on 2 occassions, fallen asleep while driving. He pulled over, napped for 10 minutes and started to drive again. There were no accidents and he needs to drive each day to get to work. He is constantly sleepy while driving and usually drives with the windows down in 20 degree temperatures to keep himself awake.

From our office, we arranged for CPAP to be delivered to his house the day of his appointment.

Would you ask him not to drive? If so, for how long?
Would you report this to the state (this is not required in the state of Michigan).

3 comments - CLICK HERE to read & add your own!:

Jeff H said...

I would advise him (and document) that it is dangerous, and that he should never drive if he feels "sleepy."

Baleeiro said...

Besides the obvious ethical dilemma (danger to others) unfortunately there is also an issue of liability... what if he gets into an accident and claims he was sleepy but "nobody" ever told him it could be dangerous, so I would ask him not to drive until his sleepiness is improved on the CPAP and document it on his chart.

AK said...

The legal requirements vary from state to state - in Massachusetts there is no mandatory reporting. To some extent it matters what the risk to the general population is - you'd obviously approach this case with more caution if he were a bus driver. At a minimum you should document that the patient understands untreated OSA carries a 4-6x increase in the risk of an accident. As for the amount of time you need CPAP before you can drive, a driving simulator study by Turkington (Thorax 2004; 59: 56-59) demonstrated normalization of performance after 3 days of CPAP. I'd err closer to two weeks and, if he still has an RDI of 12, consider tweaking his pressure upwards.

Also of interest - last month's issue of Sleep had a pro/con debate about whether driving sleepy should be illegal.