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Bernstein J. Not the Last Word: Informed Consent, Omakase Style. Clin Orthop Relat Res 2022; 480:452-455. [PMID: 35060928 PMCID: PMC8846354 DOI: 10.1097/corr.0000000000002118] [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] [Received: 12/20/2021] [Accepted: 01/05/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Joseph Bernstein
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Schuijt HJ, Lehmann LS, Javedan H, von Keudell AG, Weaver MJ. A Culture Change in Geriatric Traumatology: Holistic and Patient-Tailored Care for Frail Patients with Fractures. J Bone Joint Surg Am 2021; 103:e72. [PMID: 33974580 DOI: 10.2106/jbjs.20.02149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Medical decision-making for frail geriatric trauma patients is complex, especially toward the end of life. The goal of this paper is to review aspects of end-of-life decision-making, such as frailty, cognitive impairment, quality of life, goals of care, and palliative care. Additionally, we make recommendations for composing a patient-tailored treatment plan. In doing so, we seek to initiate the much-needed discussion regarding end-of-life care for frail geriatric patients.
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Affiliation(s)
- Henk Jan Schuijt
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Soleymani Lehmann
- Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Houman Javedan
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Arvind G von Keudell
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael John Weaver
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Boston, Massachusetts
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Holmes AL, Ibrahim JE. An Ageing Population Creates New Challenges Around Consent to Medical Treatment. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:465-475. [PMID: 34224101 DOI: 10.1007/s11673-021-10113-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 03/06/2021] [Indexed: 06/13/2023]
Abstract
Obtaining consent for medical treatment in older adults raises a number of complex challenges. Despite being required by ethics and the law, consent for medical treatment is not always validly sought in this population. The dynamic nature of capacity, particularly in individuals who have dementia or other cognitive impairments, adds complexity to obtaining consent. Further challenges arise in ensuring that older people comprehend the medical treatment information provided and that consent is not vitiated by coercion or undue influence. Existing mechanisms to address issues surrounding consent for older adults only address incapacity and raise further challenges. As the ageing population increases, these issues are likely to become more profound, thus action is required to address these challenges. Raising awareness, more education, engaging with people with dementia, and conducting further research would assist in beginning to overcome these challenges.
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Affiliation(s)
- Alice L Holmes
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Victorian Institute Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC, 3006, Australia
| | - Joseph E Ibrahim
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Victorian Institute Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC, 3006, Australia.
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McGovern MM, McTague MF, Stevens E, Medina JCN, Franco-Garcia E, Heng M. Impact of Age on Consent in a Geriatric Orthopaedic Trauma Patient Population. Geriatr Orthop Surg Rehabil 2021; 12:21514593211003065. [PMID: 33868766 PMCID: PMC8020399 DOI: 10.1177/21514593211003065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/17/2021] [Accepted: 02/22/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Persistent misconceptions of frailty and dementia in geriatric patients impact physician-patient communication and leave patients vulnerable to disempowerment. Physicians may inappropriately focus the discussion of treatment options to health care proxies instead of patients. Our study explores the consenting process in a decision-making capable orthogeriatric trauma patient population to determine if there is a relationship between increased patient age and surgical consent by health care proxy. Methods: Patients aged 65 and older who underwent operative orthopaedic fracture fixation between 1 of 2 Level 1 Trauma Centers were retrospectively reviewed. Decision-making capable status was defined as an absence of patient history of cognitive impairment and a negative patient pre-surgical Confusion Assessment Method (CAM) and Mini-Cog Assessment screen. Provider of surgical consent was the main outcome and was determined by signature on the consent form. Results: 510 patients were included, and 276 (54.1%) patients were deemed capable of consent. In 27 (9.8%) of 276 decision-capable patients, physicians obtained consent from health care proxies. 20 of these 27 patients (74.1%) were 80 years of age or older. However, in patients aged 70 to 79, only 7 health care proxies provided consent. (p = 0.07). For every unit increase in age, the log odds of proxy consent increased by .0008 (p < 0.001). Age (p < 0.001), income level (p = 0.03), and physical presence of proxy at consult (p < 0.001) were factors associated with significantly increased utilization of health care proxy provided consent. Language other than English was a significant predictor of proxy-provided consent (p = 0.035). 48 (22%) decision-making incapable patients provided their own surgical consent. Discussion: The positive linear association between age and health care proxy provided consent in cognitively intact geriatric orthopaedic patients indicates that increased patient age impacts the consenting process. Increased physician vigilance and adoption of institutional consenting guidelines can reinforce appropriate respect of geriatric patients’ consenting capacity.
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Affiliation(s)
- Madeline M McGovern
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael F McTague
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA
| | - Erin Stevens
- Department of Internal Medicine, Division of Palliative Medicine, Ohio State University, Columbus, Ohio, USA
| | - Juan Carlos Nunez Medina
- Division of Palliative Care & Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Esteban Franco-Garcia
- Division of Palliative Care & Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA
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Humbyrd CJ. Virtue Ethics in a Value-driven World: A Sliding Scale of Informed Consent. Clin Orthop Relat Res 2020; 478:1725-1727. [PMID: 32732557 PMCID: PMC7371078 DOI: 10.1097/corr.0000000000001183] [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] [Received: 01/14/2020] [Accepted: 02/04/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Casey Jo Humbyrd
- C. J. Humbyrd, Associate Professor of Orthopaedic Surgery and Chief, Foot and Ankle Division, Johns Hopkins, University School of Medicine, Baltimore, MD, USA
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Bernstein J, Weintraub S, Morris T, Ahn J. Randomized Controlled Trials for Geriatric Hip Fracture Are Rare and Underpowered: A Systematic Review and a Call for Greater Collaboration. J Bone Joint Surg Am 2019; 101:e132. [PMID: 31567688 DOI: 10.2106/jbjs.19.00407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Geriatric hip fracture is a common condition, and there are many open questions regarding patient management. Among the various types of medical evidence, the prospective randomized controlled trial (RCT) is considered the best. Our primary hypothesis was that small sample size would be seen frequently among RCTs involving geriatric patients with hip fracture. A related hypothesis was that studies from the United States would have particularly large deficits in sample size. Therefore, we asked the following research questions: (1) What is the mean sample size of RCTs involving geriatric patients with hip fracture? (2) How do sample sizes for studies from the U.S. differ from those performed elsewhere? METHODS Following the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, a systematic review of hip fracture RCTs was conducted. The Embase and MEDLINE databases were searched. Additional data included the country of origin, the power of the study, and whether sample size calculations were performed. One hundred and forty-seven RCTs were identified. RESULTS The mean sample size of the 147 RCTs was 134.9. The mean sample size for the 7 American trials was 110.3, and the mean sample size for all trials conducted outside of the United States was 136.1. A sample size that was sufficient to ensure 80% power was used in only 31.3% of the RCTs. CONCLUSIONS RCTs for hip fracture are small and underpowered. Moreover, <5% of the RCT studies have been conducted in the U.S., and they were smaller than those conducted elsewhere. The shortage of American trials may be a feature of the dispersion of geriatric hip fracture care across many hospitals in the United States. If so, better clinical research might require more centralized care (e.g., in specialized geriatric hip fracture centers) or greater collaboration among the many hospitals that provide care.
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Affiliation(s)
- Joseph Bernstein
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara Weintraub
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tyler Morris
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Bernstein J, Weintraub S, Hume E, Neuman MD, Kates SL, Ahn J. The New APGAR SCORE: A Checklist to Enhance Quality of Life in Geriatric Patients with Hip Fracture. J Bone Joint Surg Am 2017; 99:e77. [PMID: 28719564 DOI: 10.2106/jbjs.16.01149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
For geriatric patients with hip fractures, the broken bone is the reason for admission, but only part of the overall disease. Indeed, it may be more helpful to consider the patient having geriatric hip fracture syndrome or sustaining a hip attack, as there are many associated medical, social, psychological, and other problems to which attention must be paid. To that end, we have identified a series of 10 steps, collected into a checklist, that can be undertaken for all patients with geriatric hip fracture. In homage to the maxim "we come into the world under the brim of the pelvis and go out through the neck of the femur," we defined our checklist by the acronym APGAR SCORE, named after the classic checklist of the same name used to assess a newborn child. The 10 elements include attending to problems of Alimentation and nutrition, Polypharmacy, and Gait; initiating a discussion about Advance care planning; correcting any Reversible cognitive impairment; maximizing Social support; checking for and remediating Cataracts or other impairments of vision; assessing for and addressing Osteoporosis; and last, ensuring that Referrals are made and that the patient has a safe Environment after discharge. For the newborn, the Apgar score has been criticized as an imperfect tool, and likewise the problem of geriatric hip fracture will not be solved with this new Apgar score either. Nonetheless, a score of 10 here,1 point for each item, may help to optimize the outcome for this difficult disease.
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Affiliation(s)
- Joseph Bernstein
- 1Departments of Orthopaedic Surgery (J.B., S.W., E.H., and J.A.) and Anesthesiology and Critical Care (M.D.N.), University of Pennsylvania, Philadelphia, Pennsylvania 2Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
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