Physicians' perspectives of prognosis and goals of care discussions after hip fracture

Abstract

Background Hip fracture often represents a major transition in patients' health, with a 1‐year mortality rate between 25% and 30% and a challenging recovery course. Caring for hip fracture patients presents opportunities for goals of care discussions that include prognostic information and guidance about functional dependence. Methods We conducted qualitative, semi‐structured interviews with 23 attending physicians involved with the care of hip fracture patients, including orthopedic surgeons, anesthesiologists, internists, and geriatricians, across 13 health systems in the United States and Canada. Questions addressed knowledge and interpretation of prognosis, discussing prognosis and goals of care, and timing and prioritization of surgery. Interviews were analyzed using a constructivist grounded theory approach to identify themes and develop a coding taxonomy. Results Physicians agreed that hip fracture had a considerable 1‐year mortality, felt that it was important to discuss prognostic outcomes and the recovery process, wanted to elucidate patients' priorities, and often promoted timely surgery. Physicians perceived challenges when discussing mortality data with new patients in an acute setting. They more easily discussed outcomes related to functional dependence and quality of life. Some physicians used iterative communication as a strategy to have in‐depth conversations in a busy perioperative setting. Conclusion Providing timely, compassionate care for hip fracture patients is challenging. There are opportunities to study iterative communication to encourage dialogue at key points of patient care to better discuss prognosis and recovery and bolster coordinated multidisciplinary care that focuses on patients' goals and values.

Telling the whole truth to patients before hip fracture repair surgery. Cross sectional study.

“…Time constraints were previously noted by orthopedic surgeons as a barrier to discussing the risks and prognosis with hip fracture patients [2,10].…”

“…This too has been observed in the eld of orthopedic surgery. Thus, in a North American study, orthopedic surgeons involved in caring for hip fracture patients described discomfort when discussing mortality rates with patients and found it easier to discuss outcomes related to functional status or other perioperative complications [10]. Moreover, there is some uncertainty regarding the outcome or the belief that the patient will not be capable of understanding the information or may not be interested in receiving it [6,8].…”

“…This is particularly evident in the eld of orthopedic surgery, where malpractice claims paid to plaintiffs are higher than in other specialties, with a frequent cause of these claims being insu cient disclosure regarding the risks of orthopedic surgical procedures [5]. The failure of orthopedic surgeons to discuss the risks and prognosis of orthopedic procedures has been demonstrated in several recent studies [2,10].…”

“…Moreover, there is some uncertainty regarding the outcome or the belief that the patient will not be capable of understanding the information or may not be interested in receiving it [6,8]. Furthermore, the urgent nature of hip fractures and the need to perform repair surgery within 48 h of patient presentation constitutes a potential barrier to discussing risks and prognosis with hip fracture patients [2,10].…”

The Portuguese Public Hospitals Performance Evolution before and during the SARS-CoV-2 Pandemic (2017–2022)

“…Hip fracture has long been reported as an essential predictor of in-hospital mortality in patients aged 65 years or older [59]. Two days (48 h) of patient presentation is the limit of time recommended by the American Academy of Orthopedic Surgeons for hip surgery [60] to prevent complications. Thus, this indicator is a good proxy for hospital timeliness.…”