Palliative care in hip fracture management
Authors:   , Nijdam Thomas Marcus Paulus 
Published: November 2023

With surgery, the former unequivocal treatment option for hip fracture patients, shared decision-making was not common practice in hip fracture management. With limited options, even the most frail patients were guided to the operating room (OR) for hip surgery.1,2 Patients were operated for pain reduction through removal or stabilization of the fracture line, with the aim to optimize quality of life.3 With the majority of the hip fracture patients dismissed to rehabilitate in good clinical conditions after surgery, the less fortunate patients could easily be overshadowed by those in good clinical condition.4–6 However, the less fortunate patients, who more often had prolonged length of hospital stay, postoperative complications, and sometimes even death, seem to have common characteristics.7,8 Surgeons are notorious for their expertise in operative management and their ability to be very decisive in acute settings. However, evidence raises that surgery provides little advantage over non-operative treatment in certain situations. Also, these patients, do not always have a vote in the decision-making process. The patients’ preferences are regularly not taken into account before opting for operative management, which nowadays feels like an overlooked opportunity. The operative trajectory, namely, carries risks with increased odds of adverse outcomes, especially for frail geriatric patients. Frailty is a complex and evolving condition. Reversing or halt the frailty progression in geriatric patients is an exceptionally arduous task for current healthcare.12,13 However, early recognition of frailty goes beyond the fracture line. Instead, it involves managing the patient with enhanced orthogeriatric pathways and providing tailor-made rehabilitation, which can aid and support the frail patient in coping with their geriatric health limitations effectively. Most hip fracture patient are healthy individuals, and do no not require an extensive shared decision-making process in the emergency department, as their treatment goals primarily center around rapid recovery, and surgery can expedite this process.17–20 Therefore, the call for Shared Decision-Making (SDM), does not apply to every situation. With more qualitative studies on SDM and non-operative management in hip fracture management, the patients and proxy perspectives can be taken into account in future management and in future research.21,22 These subjects show very important, new insights and causing accelerated changes in hip fracture management, both nationally and internationally.23 For the frail patients with a very limited life expectancy fracturing a hip, operative treatment should not primarily be the first thought of the surgeon.24 Basic instincts of the physician need to be involved, and the initial response should be identifying patients’ preferences and treatment goals. These changes in attitude, would lead to a paradigm change in which SDM becomes fundamental in hip fracture care among geriatric patients. Overall, we can state that palliative non-operative management (P-NOM) is well received by hip fracture patients and family and will provide a viable option for frail geriatric patients. The patient-centered approach has gained substantial attention since the introduction of orthogeriatric pathways, which emphasize teamwork in the care of trauma patients. Valuable insights have been gained through the multidisciplinary perspective applied in hip fracture management. This holistic vision has been effectively employed as the foundation for P-NOM, a model tailored to the specific needs of the most frail geriatric hip fracture patients. Our studies nonetheless, also revealed important themes of improvement (frailty, pain management, ACP and the holistic approach) and will give direction for future P-NOM research. In the future, predictive models, goals of care, and the immune system all could be useful as an addition in the patient-centered decision-making process. Ultimately, these subjects could aid the physicians, patients and family to give insights in the postoperative or palliative course after sustaining a hip fracture.