Hip fracture: a trigger for palliative care in vulnerable older adults.

Abstract

examined the survival and functional outcomes after hip fracture in 60 111 US long-term nursing home residents who were hospitalized with an acute hip fracture. Using a retrospective cohort study design and large national data sets (Medicare claims and Nursing Home Minimum Data Set), this study characterized patterns and risk factors of survival and new total dependence in locomotion after hip fracture in this uniquely vulnerable subset of patients with hip fractures. By 180 days after hip fracture, 36% of patients had died, including 46% of all male patients. Moreover, among patients who had some degree of functional independence in locomotion at baseline, 54% had either died or developed new total dependence in locomotion within 180 days of hip fracture. In these patients, risk factors most highly associated with decreased survival and new total dependence in locomotion after hip fracture were nonoperative fracture management, male sex, age over 90 years, advanced comorbidity, and severe cognitive impairment. The novel findings from the study by Neuman and colleagues 4 have tremendous implications on the clinical care of vulnerable older adults with hip fractures. The prognostication of survival and functional outcomes after hip fracture in long-term nursing home patients has historically been a challenge for practitioners because of limited evidence in the medical literature. Results from the current study strongly demonstrate that mortality and functional dependence, particularly among the very old and those with advanced comorbidity and cognitive impairment, are exceedingly common among nursing home residents after hip fracture. These extreme rates of mortality and functional disability place palliative care, front and center, in the clinical management of hip fracture in vulnerable older adults. Palliative care is a new interdisciplinary specialty that focuses on improving quality of life for patients and families by providing an added layer of support (pain and symptom management, goals of care discussions, care coordination) in the setting of serious illness. Palliative care is provided concurrently with all other disease-directed or curative treatments. Hospice, conversely, is care focused exclusively on comfort for patients with a prognosis of 6 months or less if the disease follows its usual course and who are willing to relinquish curative treatments. Orthopedic surgery and rehabilitation facilitate early mobilization and are the standard and mainstay of hip fracture treatment (Figure). More often than not, palliative and hospice care are only considered in instances when a patient with hip fracture deteriorates beyond the point of achieving meaningful recovery despite receiving this “old” model of care. Given the high rates of mortality and functional dependence after hip fracture in nursing home residents, we conceive a “new” model for hip fracture care in which palliative care is implemented at the onset of hip fracture and complements standard care in postfracture management. Furthermore, hospice care should be considered and administered early if appropriate, in the most vulnerable nursing home residents including the oldest-old and those with advanced comorbidity and cognitive impairment. Palliative care program for long-term nursing home residents who sustained hip fracture must provide patientcentered comprehensive interdisciplinary care for the residents and their families, with particular focus on effective communication, care planning and coordination, symptom management, psychosocial, spiritual and bereavement sup