The Quality of Dying in Frail Institutionalized Older Patients After Nonoperative and Operative Management of a Proximal Femoral Fracture: An In-Depth Analysis

Abstract

Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, little is known about the quality of dying (QoD) while this is an integral part of palliative care and could influence decision making on nonoperative- (NOM) or operative management (OM). To identify the QoD in frail patients with a proximal femoral fracture. Data from the prospective FRAIL-HIP study, that studied the outcomes of NOM and OM in institutionalized older patients ≥70 years with a limited life expectancy who sustained a proximal femoral fracture, was analyzed. This study included patients who died within the 6-month study period and whose proxies evaluated the QoD. The QoD was evaluated with the Quality of Dying and Death (QODD) questionnaire resulting in an overall score and 4 subcategory scores (Symptom control, Preparation, Connectedness, and Transcendence). In total 52 (64% of NOM) and 21 (53% of OM) of the proxies responded to the QODD. The overall QODD score was 6.8 (P25-P75 5.7-7.7) (intermediate), with 34 (47%) of the proxies rating the QODD ‘good to almost perfect’. Significant differences in the QODD scores between groups were not noted (NOM; 7.0 (P25-P75 5.7-7.8) vs OM; 6.6 (P25-P75 6.1-7.2), P = .73). Symptom control was the lowest rated subcategory in both groups. The QoD in frail older nursing home patients with a proximal femoral fracture is good and humane. QODD scores after NOM are at least as good as OM. Improving symptom control would further increase the QoD.

Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates

“…We also observed improved GOC documentation, which may in turn provide objective evidence of advance care planning services for Medicaid billing. The opportunity for goal clarification and nonoperative management of select patients is reinforced by a recent multicenter study from the Netherlands examining a standardized shared decision-making process for frail patients with proximal femoral fractures 43 . More than half (88) of the 172 enrolled patients elected nonoperative management, and these patients were compared with the 84 patients managed with surgery in a noninferiority analysis; their quality of life was not significantly different and they had a lower rate of adverse events.…”

Shared decision-making for non-operative management versus operative management of hip fractures in selected frail older adults with a limited life expectancy: a protocol for a nationwide implementation study

“…5 8-10 Quality of life after NOM was valued non-inferiorly and the majority of the nextof-kin rated the quality of dying of their relative as very good. 5 8 Despite higher mortality rates in patients opting for NOM, the option to allow patients to pass away in a familiar environment was a compelling factor in favour of NOM in this select population. 11 Both operative and NOM can thus be effective treatment options as part of palliative care in selected frail older adults with a limited life expectancy.…”

“…1 2 Studies show that >30% of patients die within 1-year post hip fracture, with 6-month mortality rates in older adults with dementia exceeding 55%, often with low quality of life in the months preceding death. [3][4][5] These patients, in their final phase of life, often…”