Palliative Care in the Hip Fracture Patient

Abstract

Introduction: Older patients with hip fracture have a 20% to 30% mortality rate in the year after surgery. Nonoperative care has higher 1-year mortality rates and is generally only pursued in those with an extraordinarily high surgical risk. As the population ages, more patients with hip fracture may fall into this category. The orthopedic surgeon is typically the main consultant responsible for deciding between surgery and conservative management, and the reasoning behind one decision over the other is often poorly understood. We undertook a review to determine decision-making tools for surgery in high-risk patients with hip fracture. Materials and Methods: A review was conducted using PubMed to determine articles published using the terms palliative care, conservative care, nonoperative, hip fracture, orthopedic procedures, fracture fixation, and surgery. Our search resulted in 13 articles to review. These were further screened to determine tools for use in surgical decision-making. Results: Several potential decision-making tools were found in our search. The potential tools to identify patients who would benefit from nonoperative treatment included the Palliative Performance Scale for severe dementia, the Lawton Instrumental Activities of Daily Living and Katz Activities of Daily Living scales for prefracture immobility, a combination of clinical signs and laboratory tests to determine risk of imminent death, and the Charlson Comorbidity Score for additional serious comorbidities. No tools have been prospectively tested in a clinical setting. Discussion: Evaluation of each patient using a variety of decision making tools should help the orthopedic surgeon determine which patients would be better suited to non-operative management. After determining the benefit of non-operative care, they must effectively allow the fracture to heal while ameliorating pain. Palliative care physicians can fulfill this role by providing support and symptom relief. Conclusions: Surgical decision-making for hip fracture repair in the elderly patients is not straight forward. Several tools may be helpful to the surgeon in determining who may be better suited for nonoperative care or a palliative care referral. Prospective data do not exist in these decision-making tools.

Dementia and patient outcomes after hip surgery in older patients: A retrospective observational study using nationwide administrative data in Japan

“…The prevalence of in-hospital death, in-hospital pneumonia, and in-hospital fracture for people with and without dementia were 2.11% vs. 1.11% (p < .001), 0.15% vs. 0.07% (p = .007) and 3.76% vs. 3.05% (p < .001), respectively (Table 3). The medians (inter quartile range) length of hospital stay in the total sample and in people with and without dementia were 26 (19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38), 26 (19-39) and 25 (19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37) days, respectively (p = .758).…”

“…Second, there may be some unmeasured confounders that might affect patient outcomes (e.g., whether it was a scheduled or emergency surgery and the severity of dementia). Patients with severe dementia are more likely to choose non-operative treatment for hip fractures [ 37 ]. In this study, we focused on cases with hip surgery, which might have involved those with relatively mild dementia.…”

Caring for Patients With Dementia at End of Life

“…In this case the progression of disease, particularly if there has been cessation of treatments, can be clearly identified as the direct cause of death. 32,33 In dementia patients however, the time from diagnosis to death is much longer and varied. In Alzheimer's dementia the length of survival after diagnosis is typically several years.…”

“…In this case the progression of disease, particularly if there has been cessation of treatments, can be clearly identified as the direct cause of death. 32,33…”

Predictors of In-Hospital Mortality in Older Adults Undergoing Hip Fracture Surgery: A Case–Control Study

“…Knowledge of potential prognostic factors predictive of a high in-hospital mortality risk following hip fracture repair would enable clinicians to discuss with patients and their families potential fatal complications and alternative choices such as palliative treatment. 10 However, in addition to advanced age, which has been a major research focus, there remains a paucity of available data in the literature regarding other age-independent predictors. 11 The prevalence of in-hospital mortality following hip fracture surgery in older adults is also a topic for which relevant data are insufficient and further investigation is necessary.…”