Kørselsforbud - hvorfor lige mig? Lægens dilemma verden rundt Janko Moritz, Søvnapnøklinikken Slagelse
Fakta 1 søvnapnø (SA) desaturation og hyperkapni søvn fragmenteres REM og dyb søvn reduceres træthed og søvnighed opmærksomhed og koncentration påvirkes risiko for trafikuheld (aktiv) stiger med 2,52 (f.eks. Sassani A, Findley LJ, Kryger M, Goldlust E, George C, Davidson TM: Reducing motorvehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep.2004;27:453-8)
Fakta 2 SA kun 1/4 angiver søvnighed som hovedproblem (3/4 manglende energi, motivation og udmattelse) mænd har højere risiko for ulykker end kvinder med samme AHI AHI og søvnighed, AHI og u-risiko hænger ikke sammen (Young T, Blustein J, Finn L, Palta M: Sleep-disordered breathing and motor vehicle accidents in a population-based sample of employed adults. Sleep. 1997;20:608-13)
Kørselsforbud AHI- relateret? Danmark: Hvis ansøger lider af søvnapnø i middelsvær til svær grad (dvs. AHI >15), er fast natlig behandling med CPAP/BiPAP en forudsætning for at Sundhedsstyrelsen sædvanligvis kan anbefale kørekort... USA UK Tyskland lapse of consciousness excessiv daytime sleepiness messbare auffällige Tagesschläfrigkeit
søvnighed: vurdering anamnese egenvurdering: EPWORTH, Stanford-skala reaktionstid: hurtige, nemme test (ca.15 min) med referenceværdier, gratis på nettet, f.eks. Psychomotor Vigilance Task (PVT) Trail- Making- Test (TMT) Wiener Testsystem EEG baserede, tidskrævende us. (24 h): MSLT, MWT
USA (CA) UK D
USA 1994: ad hoc American Thoracic Society: Sleep Apnea, Sleepiness, and Driving Risk mht. kørselsforbud (KF): lægens situation uoverskuelig og utryg lægen bør ikke være myndighedernes værktøj kategoriske løsninger anbefales ikke
USA 1994: ad hoc INTERACTIVE MODEL OF RESPONSIBILITIES læge + patient + kørekortkontor (KKK) læge: detaljeret information, kontroller patient: viser forståelse og ansvar KKK: udtaler sig om evt. kørselsforbud, evt. videregående us.
High risk driver (1994)...being that person with severe daytime sleepiness accompanied by historic evidence of an unintended motor vehicle crash alvorlig søvnighed i dagtimerne utilsigtet trafikuheld i fortiden behandles og kontrollers efter 2 måneder ved non-compliance indberettes pt.
USA: situation i dag 50 delstater = 50 forskellige ordninger permissive, funktionelle og kategoriske lægen informerer pt. juridiske konsekvenser indberetter evt. til KKK KKK afgør kørselsforbud
California 2012 California Code of regulation 2806 (a)... lapses of consciousness...involve: (1) a loss of consciousness or a marked reduction of alertness or responsiveness to external stimuli; and (2) the inability to perform one or more activities of daily living; and (3) the impairment of the sensory motor functions used to operate a motor vehicle (b) Examples of medical conditions that do not always, but may progress to the level of functional severity described in subsection (a)... include... sleep apnea...
California 2012 CCR 2810...a physician and surgeon shall notify the local health officer within seven (7) calendar days of every patient 14 years of age or older, when a physician and surgeon has diagnosed a disorder characterized by lapses of consciousness (Section 2806) in a patient...
California 2012: KKK No action Medical probation Type II (efter 3-5 måneder) Medical probation Type III (efter 6 måneder, gentages) Suspension (tidsbegrænset, revurdering) Revocation (for altid)
UK 2011 - Drive and Vehicle Licensing Agency DVLA At a glance for medical practitioners SLEEP DISORDERS Including Obstructive Sleep Apnoea syndrome causing excessive daytime / awake time sleepiness GROUP 1 (personbiler m.f.) Driving must cease until satisfactory control of symptoms has been attained GROUP 2 (lastbiler, busser m.f.) Driving must cease until satisfactory control of symptoms has been attained, with ongoing compliance with treatment, confirmed by consultant / specialist opinion. Regular, normally annual, licensing review required.
UK 2011: Hvem har ansvaret? 1.The driver is legally responsible for informing the DVLA about such a condition or treatment. However, if a patient has such a condition, you should explain to the patient: (a) that the condition may affect their ability to drive (if the patient is incapable of understanding this advice, for example, because of dementia, you should inform the DVLA immediately), and (b) that they have a legal duty to inform the DVLA about the condition. 2. If a patient refuses to accept the diagnosis, or the effect of the condition on their ability to drive, you can suggest that they seek a second opinion, and help arrange for them to do so. You should advise the patient not to drive in the meantime. 3. If a patient continues to drive when they may not be fit to do so, you should make every reasonable effort to persuade them to stop. As long as the patient agrees, you may discuss your concerns with their relatives, friends or carers. 4. If you do not manage to persuade the patient to stop driving, or you discover that they are continuing to drive against your advice, you should contact the DVLA immediately and disclose any relevant medical information, in confidence, to the medical adviser. 5. Before contacting the DVLA you should try to inform the patient of your decision to disclose personal information. You should then also inform the patient in writing once you have done so.
UK 2011- kørselsforbud On receipt of all the required medical evidence... a licence is accordingly issued or revoked/refused. The Secretary of State in the person of DVLA s medical advisers alone can make this decision.
Tyskland 2007 Fahrerlaubnisverordnung (bilag 4): SA ubehandlet KK personbiler nej, hvis der er målbare påfaldende søvnighed i dagtimerne til stede KK lastbiler nej, hvis der er målbare påfaldende søvnighed i dagtimerne til stede SA behandlet ja, hvis der er ikke længere målbare påfaldende søvnighed i dagtimerne ja, hvis der er ikke længere målbare påfaldende søvnighed i dagtimerne; regelmæssige kontroller
Tyskland 2007 hvordan målbar? hvad mener påfaldende? hvilken kontrol og hvornår? tavshedspligten tillader ikke indberetning ingen revurdering af kørekort ergo: diagnose SA faktisk uden konsekvens
resume KF AHIbaseret hvem pålægger KF hvem indberetter SA kontrolperiode DK ja (>15) læge (KKK) ingen (læge) 6 måneder USA (CA) nej KKK læge min. 3 mån. GB nej KKK patient ikke fastlagt D nej (KKK) ingen ikke fastlagt