Not the Last Word: Geriatric Hip Fracture Centers: The Time Has Come

Bernstein, Joseph

doi:10.1007/s11999-015-4289-7

Cited by 10 publications

(7 citation statements)

References 19 publications

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“…In addition, our health system is a tertiary care facility in a large city and therefore may not be representative of all hospitals. Further, our health system does not have a dedicated hip fracture service [1], although with such a program, there may be medical physicians or geriatricians who are in a better position to discuss goals of care with the patient and family.…”

Section: Discussionmentioning

confidence: 99%

End-of-life Care Planning and Fragility Fractures of the Hip: Are We Missing a Valuable Opportunity?

Dunn

Ahn

Bernstein

2016

Clinical Orthopaedics &Amp; Related Research

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Background Approximately 20% of all geriatric patients who sustain low-energy hip fractures will die within 1 year of the injury, and approximately 3% will die during the initial inpatient hospital stay. Accordingly, the event of a geriatric hip fracture might be an apt prompt for discussing end-of-life care: in light of the risk of death after this injury, the topic of mortality certainly is germane. However, it is not clear to what degree physicians and patients engage in end-of-life planning even when faced with a hospital admission for this potentially life-threatening condition. Questions/purposes We assessed the frequency with which end-of-life care discussions were documented among a sample of geriatric patients admitted for hip fracture surgery. Methods We studied 150 adult patients, 70 years and older, admitted between September 2008 and July 2012 for the care of an isolated low-energy hip fracture, who did not have documented evidence of end-of-life care planning before the time of admission. For each patient, the medical record was scrutinized to identify documentation of end-oflife care discussions, an order changing ''code status,'' or a progress note memorializing a conversation related to the topic of end-of-life care planning. Results Of the 150 subjects who had no documented evidence of end-of-life care planning at the time of admission, 17 (11%) had their code status changed during the initial hospitalization for hip fracture, and an additional four patients (3%) had a documented conversation regarding end-of-life care planning without a subsequent change in code status. Accordingly, there were 129 (86%) patients who had no record of any attention to end-of-life care planning during the hospital stay for hip fracture surgery. Conclusions Our findings suggest that physicians may be missing a valuable opportunity to help patients and their families be better prepared for potential future health issues. End-of-life care planning respects patient autonomy and enhances the quality of care. Accordingly, we recommend that discussion of goals, expectations, and preferences should be initiated routinely when patients present with a fragility fracture of the hip. Level of Evidence Level IV, therapeutic study.

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Section: Discussionmentioning

confidence: 99%

End-of-life Care Planning and Fragility Fractures of the Hip: Are We Missing a Valuable Opportunity?

Dunn

Ahn

Bernstein

2016

Clinical Orthopaedics &Amp; Related Research

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“…9 Our results should not be taken to derogate the value of a preoperative medical consultation. Geriatric hip fracture patients certainly benefit from the help of medical consultants or even a dedicated hip fracture program 15 : these patients are generally older, and likely have comorbidities such as cardiac, pulmonary, or neurologic disease. However, it seems that preoperative evaluations include additional testing that is, at best, used as a screening procedure with a low positive yield.…”

Section: Discussionmentioning

confidence: 99%

Preoperative Testing for Hip Fracture Patients Delays Surgery, Prolongs Hospital Stays, and Rarely Dictates Care

Bernstein

Roberts

Wiesel

et al. 2016

Journal of Orthopaedic Trauma

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“…To that end, we recommend that once it is determined that the patient cannot provide consent, an ad hoc treatment committee should be convened to determine the optimal treatment of the given patient’s fracture [ 39 ]. This committee would use known information about the patient and general knowledge about patient preferences to guide its recommendation.…”

Section: Urgencymentioning

confidence: 99%

Presumed consent: licenses and limits inferred from the case of geriatric hip fractures

et al. 2017

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BackgroundHip fractures are common and serious injuries in the geriatric population. Obtaining informed consent for surgery in geriatric patients can be difficult due to the high prevalence of comorbid cognitive impairment. Given that virtually all patients with hip fractures eventually undergo surgery, and given that delays in surgery are associated with increased mortality, we argue that there are select instances in which it may be ethically permissible, and indeed clinically preferable, to initiate surgical treatment in cognitively impaired patients under the doctrine of presumed consent. In this paper, we examine the boundaries of the license granted by presumed consent and use the example of geriatric hip fracture to build an ethical framework for understanding the doctrine of presumed consent.DiscussionThe license to act under presumed consent requires three factors: patient incapacity, clinical urgency and clarity on the correct course of action. All three can apply to geriatric hip fracture. The typical patient frequently lacks capacity. Delays in initiating surgical treatment are associated with markedly increased mortality rates. Last, there appears to be consensus that surgery is the preferred treatment. Nonetheless, because there is a window of safe delay during which treating physicians can stabilize the patient, address reversible causes of cognitive impairment and identify surrogate decision makers, presumed consent should be invoked only as a method of last resort.ConclusionsA medical situation need not be characterized by risk of imminent and certain death for presumed consent to be relevant. Rather, there are two distinct windows that must be considered: the time interval in which action may be delayed without danger, and the time interval needed to obtain a better form of consent. Presumed consent is appropriate only when the latter exceeds the former.

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Not the Last Word: Geriatric Hip Fracture Centers: The Time Has Come

Cited by 10 publications

References 19 publications

End-of-life Care Planning and Fragility Fractures of the Hip: Are We Missing a Valuable Opportunity?

End-of-life Care Planning and Fragility Fractures of the Hip: Are We Missing a Valuable Opportunity?

Preoperative Testing for Hip Fracture Patients Delays Surgery, Prolongs Hospital Stays, and Rarely Dictates Care

Presumed consent: licenses and limits inferred from the case of geriatric hip fractures

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