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Laane D, Kroes T, van den Berg A, de Jongh M, The R, Van der Velde D, Nijdam T. Patient and proxy perspectives in decision-making for geriatric hip fracture management in the Netherlands: a qualitative study. BMJ Open 2024; 14:e082093. [PMID: 38858152 PMCID: PMC11168140 DOI: 10.1136/bmjopen-2023-082093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/09/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVE The objective of this study was to explore the perspectives with the decision-making process between surgery and palliative, non-operative management of geriatric hip fracture patients and their proxies. DESIGN A qualitative interview study was performed. Patients and proxies were asked to participate in semi-structured interviews. Data were analysed using reflexive thematic analysis according to Braun and Clarke's six-step guide. SETTING AND PARTICIPANTS Hip fracture patients in the Netherlands were eligible for inclusion. For hip fracture patients with a pre-existing diagnosis of dementia and for patients who opted for palliative, non-operative management, proxies were included. RESULTS A total of 16 interviews were conducted, consisting of 4 patient interviews and 12 proxy interviews. Five themes were identified during thematic analysis: (1) underlying patient values, (2) the provision of information, (3) reasons to consider either palliative, non-operative management or surgery, (4) involvement in decision and (5) realisation of expectations. Information provided by the physician varied in terms of desired level of detail but involved discussing the advantages and disadvantages of surgery and palliative, non-operative management. Patients and proxies underscored the importance of achieving optimal quality of life, and the disparity between expected and actual treatment outcomes was unpleasant and negatively influenced the overall experience. CONCLUSIONS In-depth analysis provided a unique insight into the patient and proxy perspectives in shared decision-making for geriatric hip fracture management in the acute setting. Overall, there were differences between reported experiences and preferences of participants. This heterogeneity stresses the importance of keeping a person-centred approach during shared decision-making. Other key considerations during shared decision-making include physicians informing patients from professional experience and communicating sensitively about both treatment options and prognosis. Physicians should aim to provide realistic, sensitive and timely information to both patients and proxies during the choice between curation and palliation for their hip fracture.
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Affiliation(s)
- Duco Laane
- Department of Trauma Surgery, St Antonius Hospital Location Utrecht, Utrecht, Netherlands
| | - Thamar Kroes
- Department of Trauma Surgery, St Antonius Hospital Location Utrecht, Utrecht, Netherlands
| | - Arda van den Berg
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, Netherlands
| | - Mariska de Jongh
- Department Trauma TopCare, Elisabeth-TweeSteden Hospital, Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, Netherlands
| | - Regina The
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, Netherlands
| | - Detlef Van der Velde
- Department of Trauma Surgery, St Antonius Hospital Location Utrecht, Utrecht, Netherlands
| | - Thomas Nijdam
- Department of Trauma Surgery, St Antonius Hospital Location Utrecht, Utrecht, Netherlands
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Ponds NHM, Raats JH, Brameier DT, Schuijt HJ, Cooper L, Sagona A, Javedan H, Weaver MJ. Beyond Mortality: Severely Frail Femur Fracture Patients Can Regain Independence after Surgery. J Clin Med 2024; 13:3197. [PMID: 38892908 PMCID: PMC11172540 DOI: 10.3390/jcm13113197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/03/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79-92), and a median FI-CGA of 0.48 (IQR 0.43-0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions.
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Affiliation(s)
- Noa H. M. Ponds
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
- Department of Surgery, St. Antonius Hospital, 3543 AZ Utrecht, The Netherlands
| | - Jochem H. Raats
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
- Department of Surgery, St. Antonius Hospital, 3543 AZ Utrecht, The Netherlands
| | - Devon T. Brameier
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Henk Jan Schuijt
- Center for Geriatric Trauma, St. Antonius Hospital, 3543 AZ Utrecht, The Netherlands
| | - Lisa Cooper
- Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
- Department of Geriatric Medicine, Rabin Medical Center, Tel Aviv 4941492, Israel
| | - Abigail Sagona
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Houman Javedan
- Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Michael J. Weaver
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
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Paradis BE, Klein BJ, Bartlett LE, Cohn RM, Bitterman AD. Goals of Care Discussions in Orthopaedic Surgery: Geriatric Hip Fractures. J Arthroplasty 2024; 39:1144-1148. [PMID: 38462140 DOI: 10.1016/j.arth.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Due to the severity of hip fracture complications in the geriatric population, including major morbidity and mortality, it is crucial to establish treatment goals and manage expectations as a patient-centered multidisciplinary team. Goals of care (GOC) are personalized treatment programs designed to align with the individual patient's values and preferences. There is a paucity of literature on the topic of GOC discussions, especially regarding orthopaedic injuries. Therefore, this narrative review aims to provide an account of GOC discussions related to geriatric hip fractures. METHODS We reviewed articles published on GOC between 1978 and 2024. The articles were identified by searching PubMed and Google Scholar. We utilized the search terms GOC discussions and hip fracture, with additional descriptors including arthroplasty and geriatric. RESULTS There were 11 articles that met the selection criteria and were published between 1978 and 2024. Five articles were published on GOC discussions in orthopaedic surgery, while the remaining 6 articles were published in non-orthopaedic fields. There was one systematic review, 2 narrative reviews, 6 observational studies, and 2 descriptive studies. Supplemental commentary from non-orthopaedic specialties and the fields of law and medical ethics was included to assist in highlighting barriers to GOC discussions and to explore potential strategies to enhance GOC discussions. CONCLUSIONS Goals of care discussions provide a framework for treatment decisions based on an individual patient's values and cultural beliefs; however, these conversations may be limited by perceived time constraints, patient health care literacy, and physicians' misconceptions of what is most important to discuss. While no clear consensus was identified regarding strategies for improving GOC discussions in geriatric patients who have hip fractures, the authors recommend standardized training programs, expedited family meetings, multidisciplinary team involvement, assistive technology such as Outcome Prioritization Tool, and the incorporation of GOC discussions into institutional hip fracture pathways.
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Affiliation(s)
- Brienne E Paradis
- University of New England College of Osteopathic Medicine, Biddeford, Maine
| | - Brandon J Klein
- Zucker School of Medicine at Hofstra/Northwell Health, Huntington Hospital Orthopaedic Surgery Residency Program, Huntington, New York
| | - Lucas E Bartlett
- Zucker School of Medicine at Hofstra/Northwell Health, Huntington Hospital Orthopaedic Surgery Residency Program, Huntington, New York
| | - Randy M Cohn
- Zucker School of Medicine at Hofstra/Northwell Health, Huntington Hospital Orthopaedic Surgery Residency Program, Huntington, New York
| | - Adam D Bitterman
- Zucker School of Medicine at Hofstra/Northwell Health, Huntington Hospital Orthopaedic Surgery Residency Program, Huntington, New York
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Scuderi GR, Mont MA. Goals of Care: A Patient-Centered Assessment. J Arthroplasty 2024; 39:1142-1143. [PMID: 38462139 DOI: 10.1016/j.arth.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
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Zeelenberg ML, Oosterwijk PC, Willems HC, Gosens T, Den Hartog D, Joosse P, Loggers SAI, Nijdam TM, Pel-Littel RE, Polinder S, Schuijt HJ, Wijnen HH, Van der Velde D, Van Lieshout EMM, Verhofstad MHJ. 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. BMJ Open 2024; 14:e083429. [PMID: 38631829 PMCID: PMC11029367 DOI: 10.1136/bmjopen-2023-083429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/12/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND AND PURPOSE Recent research has highlighted non-operative management (NOM) as a viable alternative for frail older adults with hip fractures in the final phase of life. This study aims to guide Dutch physicians and hospitals nationwide in a standardised implementation of shared decision-making regarding surgery or NOM in selected frail older adults with a hip fracture. METHODS AND ANALYSIS The patient population for implementation includes frail older adults aged ≥70 years with an acute proximal femoral fracture, nursing home care or a similar level of care elsewhere and at least one additional criterion (ie, malnutrition, severe mobility impairment or ASA≥4). The 2-year implementation study will be conducted in four phases. In phases 1 and 2, barriers and facilitators for implementation will be identified and an implementation protocol, educational materials and patient information will be developed. Phase 3 will involve an implementation pilot in 14 hospitals across the Netherlands. The protocol and educational material will be improved based on healthcare provider and patient experiences gathered through interviews. Phase 4 will focus on upscaling to nationwide implementation and the effect of the implementation on NOM rate will be measured using data from the Dutch Hip Fracture Audit. ETHICS AND DISSEMINATION The study was exempted by the local Medical Research Ethics Committee (MEC-2023-0270, 10 May 2023) and Medical Ethics Committee United (W23.083, 26 April 2023). The study's results will be submitted to an open access international peer-reviewed journal. Its protocols, tools and results will be presented at several national and international academic conferences of relevant orthogeriatric (scientific) associations. TRIAL REGISTRATION NUMBER NCT06079905 .
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Affiliation(s)
- Miliaan L Zeelenberg
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Hanna C Willems
- Department of Geriatrics, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Taco Gosens
- Department of Orthopaedic Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Pieter Joosse
- Department of Trauma Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Sverre A I Loggers
- Department of Trauma Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Thomas Mp Nijdam
- Department of Surgery, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | | | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Henk Jan Schuijt
- Department of Trauma Surgery, Sint Antonius Hospital, Utrecht, the Netherlands
| | - Hugo H Wijnen
- Department of Clinical Geriatrics, Rijnstate, Arnhem, the Netherlands
| | | | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Zabawa L, Choubey AS, Drake B, Mayo J, Mejia A. Dementia and Hip Fractures: A Comprehensive Review of Management Approaches. JBJS Rev 2023; 11:01874474-202312000-00002. [PMID: 38079493 DOI: 10.2106/jbjs.rvw.23.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.
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Affiliation(s)
- Luke Zabawa
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Apurva S Choubey
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Brett Drake
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Joel Mayo
- University of Illinois College of Medicine, Chicago, Illinois
| | - Alfonso Mejia
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
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Schuijt HJ, Smeeing DPJ, Verberne WR, Groenwold RHH, van Delden JJM, Leenen LPH, van der Velde D. Perspective; recommendations for improved patient participation in decision-making for geriatric patients in acute surgical settings. Injury 2023; 54:110823. [PMID: 37217400 DOI: 10.1016/j.injury.2023.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 04/20/2023] [Accepted: 05/13/2023] [Indexed: 05/24/2023]
Abstract
Geriatric patients often present to the hospital in acute surgical settings. In these settings, shared decision-making as equal partners can be challenging. Surgeons should recognize that geriatric patients, and frail patients in particular, may sometimes benefit from de-escalation of care in a palliative setting rather than curative treatment. To provide more person-centred care, better strategies for improved shared decision-making need to be developed and implemented in clinical practice. A shift in thinking from a disease-oriented paradigm to a patient-goal-oriented paradigm is required to provide better person-centred care for older patients. We may greatly improve the collaboration with patients if we move parts of the decision-making process to the pre-acute phase. In the pre-acute phase appointing legal representatives, having goals of care conversations, and advance care planning can help give physicians an idea of what is important to the patient in acute settings. When making decisions as equal partners is not possible, a greater degree of physician responsibility may be appropriate. Physicians should tailor the "sharedness" of the decision-making process to the needs of the patient and their family.
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Affiliation(s)
- H J Schuijt
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, Utrecht University Medical Center, Utrecht, the Netherlands.
| | - D P J Smeeing
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - W R Verberne
- Department of Internal Medicine, Utrecht University Medical Center, Utrecht, the Netherlands
| | - R H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - J J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht, the Netherlands
| | - L P H Leenen
- Department of Surgery, Utrecht University Medical Center, Utrecht, the Netherlands
| | - D van der Velde
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
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