Cardiac Events While Driving

When a driver suffers a cardiac event such as a heart attack or arrhythmia while driving, the sudden incapacitation may cause a vehicular collision.

Injuries to the driver, passengers, occupants of other vehicles, and pedestrians may be serious or fatal. Costly property damage may also result.

If there's a history of a cardiac condition, symptoms, or known risk factors, treating physicians and other care providers may be considered liable and included in medical malpractice suits.

Keywords

Heart attack, cardiac event, cardiac arrest, arrhythmia, myocardial infarction, syncope, driving, incapacitation, medical regulation, ICD, pacemaker, medical malpractice, driving restrictions, insurance, expert witness, cardiology, independent medical examination

At a glance

Intro:

If a driver's medical history includes a cardiac condition, report of symptoms, or risk factors, doctors and other clinicians may be liable for medical malpractice

Discussion:

  • Cardiac Events and Incapacitation
  • Medical Malpractice Liability for Cardiac Events While Driving
  • Evaluation, Referrals, Diagnostic Testing
  • Treatment and Recommendations
  • Risk of Incapacitation while Driving
  • Defenses for Doctors

DISCLAIMER: Dr. Dalawari shares interesting and relevant medical-legal news in the press. He also shares case verdicts & settlements from the public record. He has no professional or personal relationship to the cases.

Cardiac Events and Incapacitation

A heart attack can incapacitate a driver: it can occur suddenly in someone with a known cardiac history, or in someone unaware they have undiagnosed coronary artery disease or risk factors.

(1). Cardiac syncope, characterized by a sudden, temporary loss of consciousness and postural tone, can also incapacitate a driver. It is associated with an increased risk of future events with incapacitation, and possible sudden cardiac death (2).

Cardiac syncope may be caused by structural cardiovascular abnormalities (eg, myocardial disease, pericardial disease, pulmonary embolism, pulmonary hypertension, cardiac tumors); electrical abnormalities (eg, arrhythmias); or neurally mediated syndromes (eg, vasovagal or neurocardiogenic syncope) (2).

A proper medical evaluation for syncope can help identify which patients are at risk for future adverse events (2).

Medical Malpractice Liability for Cardiac Events While Driving

A doctor may be liable for medical malpractice under certain circumstances if a patient is harmed due to a cardiac event suffered while driving.

If there was a physician-patient relationship, the physician has a duty to meet the standard of care. A breach in the standard of care may be due to an act or omission.

As there are many elements to the evaluation, diagnostic, and treatment process, there are many opportunities to identify a problematic act or omission.

Physicians and patients alike aspire to achieve good health outcomes and ideally hope that any independent medical examination (IME) or cardiology expert witness would agree that the physician met the standard of care.

If not, it's important to determine if the breach in the standard of care caused the harm claimed.

Evaluation, Referrals, Diagnostic Testing

Medical malpractice determinations may center upon whether the patient was adequately screened, or if reported symptoms and risk factors (eg, obesity, smoking, family history) received adequate medical attention (1, 3).

In some patients with cardiac syncope or arrhythmia, the risk of subsequent events and mortality may be significant, and typically increases with age; therefore, physician evaluations play an important role in initiating preventive strategies (3).

Syncope is common, impacting approximately 30% of the population: a cardiac cause is identified for at least 20% of syncope patients, while the underlying cause remains undetermined for roughly 34% of syncope patients (2).

This raises questions about whether diagnostic efforts were conducted in accordance with the applicable standard of care.

It is important for physicians in the ER, urgent care, and primary care setting, who may initially treat the syncope patient, to determine the underlying cause, which may be cardiac or non-cardiac in nature (2).

If a patient's syncope was not properly evaluated and diagnosed as cardiac in nature, and a subsequent adverse event caused a collision, such physicians could potentially be held liable.

The patient's medical history may involve treatment from several clinicians, such as a cardiologist, ER doctors, urgent care clinicians, primary care doctors, and clinicians performing diagnostic testing (2).

This raises questions as to which clinicians, including Nurse Practitioners (NPs) and Physician Assistants (PAs) if any, have medical malpractice exposure.

To diagnose the underlying causation of syncopal episodes, clinicians typically take a careful history, including the details and duration of the syncopal episode, the patient's prior medical history, and family history (2).

Clinicians also conduct a thorough physical examination that includes an evaluation for underlying cardiac pathology and order diagnostic testing, which may include a chest X-ray, electrocardiogram (EKG), echocardiogram, Holter monitor testing, or other tests (2).

Treatment and Recommendations

If the patient received the correct diagnosis, questions may remain about whether medical treatment and recommendations met the standard of care.

  • Would proper evaluation and treatment lead to prescription medication that could prevent cardiac episodes or reduce their frequency (2)?
  • Was the patient an appropriate candidate for a pacemaker or implantable cardiac defibrillator (ICD)?
  • Did the patient have cognitive or other limitations that impacted their medical encounters, or precluded the patient from understanding or adhering to recommendations?

If so, did the clinicians appropriately address the patient's limitations? Was any physician limited by the acts or omissions of another clinician involved in the patient's care?

Risk of Incapacitation While Driving

It is important to determine if the physician properly advised the patient about the risks of driving. As cardiovascular conditions present known risks of sudden incapacitation, federal and state restrictions may limit the ability of a patient with a cardiac history to drive. (3, 4, 5, 6).

Restrictions vary from state to state, and also depend upon the specifics of the patient's health condition; some states require that a license be suspended or surrendered, at least temporarily. (3, 4, 5, 6). Patients with cardiac histories may have an implantable cardioverter defibrillator (ICD) or pacemaker, and may have driving restrictions imposed by law and or by medical guidance (2).

Medical malpractice claims may examine whether the doctor complied with applicable governmental reporting requirements, or informed the patient of any driving restrictions (2).

It may benefit cardiologists to document their actions and demonstrate that they acted in accordance with the standard of care (2).

Patients may be aware of driving restrictions yet disregard them due to pressures to continue driving.

Patients who drive occupationally (eg, truckers, delivery drivers, cab drivers) may suffer a loss of income if precluded from driving; patients who drive to commute to and from work may also face income loss if alternative transportation is unavailable; and patients who drive for routine personal errands (eg, grocery shopping, transporting family) may lack viable alternatives (2).

Defenses for Doctors

Liability is often hotly contested with vigorous defenses, and there may be multiple defendants with separate insurance policies.

While the patient may have suffered ill health, the patient's actions may also come under scrutiny.

  • Was the doctor limited by inaccurate or incomplete information supplied by the patient or family members?
  • Did the patient adhere to recommendations and obtain recommended evaluations and diagnostic testing?
  • Did the patient adhere to treatment recommendations, such as taking prescription medication?
  • Did the patient improperly use alcohol, marijuana, or other drugs?
  • Was the patient aware of driving restrictions and adhere to them?

As the ability to drive is important for independence and wage-earning (3), the motivation to disregard driving restrictions may be powerful.

The vehicle owner may also be liable, particularly if the vehicle owner knew about the patient's health condition and granted permission to use the vehicle despite known risks. If the vehicle owner was a spouse, another family member, or friend, the owner may well have been aware of the risks.

If the owner was an employer or corporation, and the patient was driving to perform job duties (eg, deliveries), the employer or corporation may be liable for failing to implement preventive policies.

Other clinicians who participated in the patient's care may also be questioned, or have helpful information regarding the patient's medical history.

A cardiology expert or independent medical examination (IME) can help assess whether evaluations, referrals, diagnostic testing, and treatment met the standard of care.

It may be that no physician is at fault and that the cardiac event was simply an unpredictable and unfortunate event.

DISCLAIMER:Dr. Dalawari shares interesting and relevant medical-legal news in the press. He also shares case verdicts & settlements from the public record. He has no professional or personal relationship to the cases.

Do you have questions about a medical case or need help understanding treatment plans and options?

Cardio Med Legal Dr. Jasdeep Dalawari

(804) 500-0685 - info@cardiomedlegal.com

REFERENCES:

1. Torpy JM, Lynm C, Glass RM. Myocardial Infarction. JAMA. 2008;299(4):476. doi:10.1001/jama.299.4.476

2. Seger JJ. Syncope evaluation and management. Tex Heart Inst J. 2005;32(2):204-206.

3. Koene RJ, Adkisson WO, Benditt DG. Syncope and the risk of sudden cardiac death: Evaluation, management, and prevention. J Arrhythm. 2017;33(6):533-544. doi:10.1016/j.joa.2017.07.005

4. https://www.fmcsa.dot.gov/regulations/medical/recommended-changes-cardiovascular-disease-guidelines

5. Heart Association re: arrhythmia, syncope
https://www.heart.org/en/health-topics/arrhythmia/symptoms-diagnosis--monitoring-of-arrhythmia/syncope-fainting

6. https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/living-with-your-implantable-cardioverter-defibrillator-icd

7. https://www.mdedge.com/familymedicine/article/62683/cardiology/should-you-restrict-your-cardiac-patient-driving?sso=true#5605JFP_ClinicalInquires1-tab1

8. Sorajja D, Shen WK. Driving guidelines and restrictions in patients with a history of cardiac arrhythmias, syncope,or implantable devices. Curr Treat Options Cardiovasc Med. 2010;12(5):443-456. doi:10.1007/s11936-010-0088-3

9. Margulescu AD, Anderson MH. A Review Of Driving Restrictions In Patients At Risk Of Syncope And Cardiac Arrhythmias Associated With Sudden Incapacity: Differing Global Approaches To Regulation And Risk. Arrhythmia & Electrophysiology Review 2019;8(2):90–8. https://doi.org/10.15420/aer.2019.13.2

10. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2018 Oct 2;72(14):1760]. J Am Coll Cardiol. 2018;72(14):e91-e220. doi:10.1016/j.jacc.2017.10.054

Jasdeep Dalawari MD

About Jasdeep Dalawari MD

Experienced General and Specialist Physician with a demonstrated history of working in the medical practice industry. Skilled in Interventional, Endovascular, Vascular, and General Cardiovascular Medicine; Emergency Medicine; Healthcare Consulting, including Peer Review, Expert Witness, and Utilization Review; and Medical Education. Strong healthcare services professional with an MS focused in Health Administration from Virginia Commonwealth University.