Purpose: For geriatric hip fracture patients, the decision between surgery and palliative, non-operative management is made through shared decision making (SDM). For this conversation, a physician must be familiar with the patient’s goals of care (GOC). These are predominantly unknown for hip fracture patients and challenging to assess in acute setting. The objective was to explore these GOC of geriatric patients in case of a hip fracture. Methods: An expert panel gathered possible outcomes after a hip fracture, which were transformed into statements where participants indicated their relative importance on a 100-point scoring scale during interviews. These GOC were ranked using medians and deemed important if the median score was 90 or above. Patients were aged 70 years or older with a hip contusion due to similarities with the hip fracture population. Three cohorts based on frailty criteria and the diagnosis of dementia were made. Results: Preserving cognitive function, being with family and being with partner scored in all groups among the most important GOC. Both non-frail and frail geriatric patients scored return to pre-fracture mobility and maintaining independence among the most important GOC, where proxies of patients with a diagnosis of dementia scored not experiencing pain as the most important GOC. Conclusion: All groups scored preserving cognitive function, being with family and being with partner among the most important GOC. The most important GOC should be discussed when a patient is presented with a hip fracture. Since patients preferences vary, a patient-centered assessment of the GOC remains essential.

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.

(1) Background: Hip fracture patients with very limited life expectancy can opt for non-operative management (NOM) within a palliative care context. The implementation of NOM in the palliative context may affect the mortality of the operatively treated population. This retrospective cohort study aimed to determine whether the operatively treated geriatric hip fracture population would have a lower in-hospital mortality rate and fewer postoperative complications after the introduction of NOM within a palliative care context for patients with very limited life expectancy. (2) Methods: Data from 1 February 2019 to 1 February 2022 of patients aged 70 years or older were analyzed to give a comparison between patients before and after implementation of NOM within a palliative care context. (3) Results: Comparison between 550 patients before and 485 patients after implementation showed no significant difference in in-hospital or 1-year mortality rates (2.9% vs. 1.4%, p = 0.139; 22.4% vs. 20.2%, p = 0.404, respectively). Notably, post-implementation, fewer patients had prior dementia diagnoses (15% vs. 21%, p = 0.010), and intensive care unit admissions decreased (3.5% vs. 1.2%, p = 0.025). (4) Conclusions: The implementation of NOM within a palliative care context did not significantly reduce mortality or complications. However, NOM within palliative care is deemed a more patient-centered approach for geriatric hip fracture patients with very limited life expectancy.

Background: Geriatric hip fractures remain associated with significant mortality and morbidity. Identifying factors associated with such outcomes is an important step for improvement of prognostication and supporting individualized care. Sarcopenia is a known risk factor for mortality and thigh muscle measurements on plain radiographs can serve as a proxy measure of sarcopenia. Therefore, the objective was to determine whether radiographic thigh muscle measurements were independently associated with 1-year mortality following hip fracture surgery. Methods: All consecutive patients aged 70 years or older undergoing operative treatment for an isolated hip fracture at 2 urban Level 1 trauma centers between 2018 and 2020 with preoperative radiographs displaying the distal-and-middle femur were included. Thigh muscle diameter and soft tissue size was measured on anteroposterior and lateral radiographs using standardized anatomical landmarks. Multivariable logistic regression was performed to determine if there were independent associations with 1-year mortality for the variables assessed. Inter-rater reliability for each measurement was evaluated by calculating intraclass correlation coefficients (ICCs). Results: One hundred ninety-nine patients (median age 85 years, 68% female) were included. One-year mortality was 22%. After adjusting for age, sex, smoking status, preinjury living situation, Charlson Comorbidity Index, frailty, and body mass index, a greater thigh muscle diameter on anteroposterior radiographs was associated with lower odds of 1-year mortality (adjusted odds ratio 0.74, 95% confidence interval 0.56-0.97, p = 0.028). There was no significant association with thigh muscle diameter on lateral radiographs or with total soft tissue diameter on anteroposterior or lateral radiographs. The ICCs demonstrated good-to-excellent reliability for all radiographic measurements. Conclusion: Greater thigh muscle diameter measured on anteroposterior radiographs was independently associated with decreased 1-year mortality following hip fracture surgery, with each centimeter increase in diameter being associated with an average reduction in odds of 26%. This finding should be interpreted in the context of the limited sample size, homogenous patient population, and range of observed thigh muscle sizes. Overall, these results suggest that radiographic parameters may potentially serve to complement currently used modalities, such as frailty assessment, in supporting individualized care. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.