Thomas Nijdam

Palliative, Non-Operative Management (P-NOM)
Part 3 centers on the evaluation of newly introduced Palliative, Non-Operative Management (P-NOM) for hip fracture patients. P-NOM was introduced as an option through shared decision-making for geriatric hip fracture patients considered frail and with very limited life expectancy. Initially, patients were considered frail with one or more Frailty Criteria (Body Mass Index (BMI) of 18.5 kg/m2 or lower, Functional Ambulation Category (FAC) of 2 or lower pre-trauma, American Society of Anesthesiologists (ASA) score of 4 or 5) or on the indication of the physician when thought of limited life expectancy without meeting the frailty criteria. With P-NOM, specific attention is paid to analgesia and patient comfort without aiming the patient to regain mobility and start the active rehabilitation program. Since P-NOM is not curative management, patients are likely to die within weeks after hip fracture (median survival 11 days (IQR 4-26)). The renewed hip fracture pathway for geriatric patients is shown below. Since 2020, P-NOM is also discussed on indication of the surgeon or treating physician given the greater difficulty assessing frailty with only three objective markers BMI, FAC, and ASA. This allows patients with very limited life expectancy to consider P-NOM over operative management in case of a hip fracture without meeting the frailty criteria.

Figure. Pathway for geriatric hip fracture patients.
Chapter 5 initiates the first evaluation of Palliative Non-Operative Management (P-NOM) through semi-structured interviews to gather the earliest patients’ experiences concerning the non-operative alternative. Four recurring themes were identified in the interviews that were deemed most important to the proxies in the palliative process. The decision-making process, communication with the patients, pain and passing away showed great similarity with severe end-stage disease palliative care. With pain identified as the most important factor influencing comfort of the patient and their environment after hip fracture, novel analgesia methods are requested and already available. Subsequently, future studies are needed for evaluation of clinical applicability. Chapter 6 monitors and delineates the impact of P-NOM on surgically treated hip fracture patients, observing differences between pre-implementation and post-implementation cohorts in the surgical cohort. The integration of palliative, non-operative management for frail geriatric hip fracture patients did not show a direct significant decline in mortality rates or postoperative complications when compared to the surgically managed geriatric hip fracture group. However, there was a considerable decrease in ICU admissions in the post-implementation period, indicating that the decision for P-NOM by patients had an effect on the short-term outcomes requiring ICU admission.

Patient-centered approach
Part 4 describing the evaluation of P-NOM, yielding novel themes aimed at refining the method. These themes are further investigated to align with patient preferences. Chapter 7 clarified the goals of care for geriatric patients who sustain a hip fracture, showing ‘preserving cognitive function’, ‘being with family’, and ‘being with partner’ among the most important GOC. The most important GOC should at least be discussed when a patient is presented at the ED with a hip fracture enhancing shared decision-making for patient and physicians in acute setting. Chapter 8 examines patient preferences within this shared decision-making process, drawing on prior experiences in decision-making dialogues between medical professionals and hip fracture patients, specifically focusing on the choice between hip fracture surgery and (palliative) non-operative management. Important themes gathered requiring attention in the SDM process were; ‘reasons to consider either P-NOM or surgery’, ‘provision of information’, ‘expectation management’, ‘shared decision-making’ and ‘quality of life’. Finally, chapter 9 introduces a pilot study aimed at testing a novel immunology method. This method involves the assessment of the geriatric immune response in the Emergency Department through the evaluation of neutrophil activation subsequent to a hip fracture. Potential future markers to distinguish the frail patient were observed, supporting the possibility in future immune-based identification of geriatric hip fracture patients at risk for adverse outcome. 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.

General discussion, future perspectives, and conclusions

GENERAL DISCUSSION

The past (hopefully)
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. To provide adequate care, patients were operated for pain reduction through removal or stabilization of the fracture line, with the aim to optimize quality of life. With the vast 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. 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.

“Decisions are more important than incisions” (Dr. R.B. Salter)

Surgeons are notorious for their expertise in operative management and their ability to be very decisive in acute settings. However, studies also described accompanying hazardous attitudes as a common characteristic of the trauma- and orthopedic surgeons influencing the decision-making process negatively. Evidence raises that surgery provides little advantage over non-operative treatment in certain situations, indicating that surgeons might exhibit overly optimistic beliefs regarding the benefit of a surgical intervention when discussing treatment options with patients. Also, these patients do not always have a vote in the decision-making process. The quality of life and 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.

The frail patient
Frailty is a complex and evolving condition. Reversing or halt the frailty progression in geriatric patients is an exceptionally arduous task for current healthcare. 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.

Instead of pursuing optimistic treatment for geriatric hip fractures, a more patient-centered approach involves investing in early recognition of frailty, enhanced secondary prevention of osteoporotic fractures, further propagate advance care planning, and investing in adequate palliative hip fracture care programs. Even once frail patients are identified in the acute setting, the decision-making process remains significantly complex due to various factors. These include social and cultural issues, comorbidities, cognitive impairment, and other complicating medical or patient-specific challenges that can limit their decision-making capacity.

Shared decision-making
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. 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. These subjects show very important, new insights and causing accelerated changes in hip fracture management, both nationally and internationally. 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. 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.

Palliative hip fracture care
With the introduction of palliative care in hip fracture management, once again there is evidence of a misconception of what is best for the patient in one the most occurring common medical problems in patients aged 60 years and older at the emergency department. Evidence supports the preference of most people to die in the comfort of their homes. However, statistics indicate that over half of all deaths happen in hospitals worldwide, with overuse of aggressive care for dying patients and simultaneous underuse of appropriate palliative care as recurring themes. In cancer patients, several studies describe the increase of aggressive treatment, such as cardiopulmonary resuscitation, chemotherapy and intensive care utilization, performed near the end of life phase. In general, the prevailing pattern in hospitals tends to involve a frequent overuse of aggressive care and a simultaneous underutilization of palliative care for patients approaching the end of their lives.

Partly, solutions in overtreatment could be found in adequate and early Advance Care Planning (ACP). By utilizing ACP, the goals of care for hip fracture patients ideally can be assessed before fracture occurs, recognizing that patients and their families have already indicated their preference to avoid this conversation in acute setting. However, concerns continue to be expressed that end-of-life services are primarily focused on the needs of patients with cancer. In recent studies in the UK only 27% of all patients who died were included in the ACP register before death, of whom 77% had cancer, despite only 25% of UK deaths being from malignant disease. Conversations about end-of-life care with frail and older people who have no overriding diagnosis seems just as important for improving health care. Also, with this important information gathered upfront, a substantial enhancement in patient-centered decision-making can be offered for this population.

Advance care planning
It has been five decades since legal frameworks for ACP were initially incorporated into healthcare during the mid-1970s. Nonetheless, although there is a rising adoption of advance care planning at a smaller scope, the absence of comprehensive ACP programs on a national or global level remains evident. Transparency of patients’ information between healthcare professionals give insight in patients’ treatment preferences. Still the majority of geriatric patient with a hip fracture is not even aware of his own preferences when becoming acute ill, let alone shared them with their family, general physician or other healthcare workers. We stand against a growing problem with the community becoming older and older, increasing workload in our hospitals and political pressure to reduce healthcare costs. Overdiagnosing and overtreating our patients is a very common, preventable and harmful aspect in current healthcare. Therefore we advocate for investing in advance care planning programs to address patients preferences early in the process, so we start taking care of good appropriate health care: ‘’no more and no less than necessary”. This approach aligns with current political strategies to cope with strained, human and financial, resources. Currently, the Dutch healthcare system aims to be reorganized in such a manner that we provide the best fit of health care in terms of treatment, location and timing for patients (‘Juiste Zorg, Juiste Plek, Juiste Kosten’).

Since large ACP programs need huge funding and political backing, improvement on national scale is a long time coming and very time consuming. Therefore improving the process for hip fracture patients in acute setting is just as important, whenever ACP information is lacking. After evaluation of SDM with hip fracture patients at the emergency department, written information is highly recommended to support the treating physicians’ verbal information to aid patient and family in this precarious setting. The decision-making process consist of periods of extensive discussions interspersed with moments of retraction of family and patients. In these particular moments, guidance should be available by an appropriately composed decision aid. Also addressing this problem and make the physician familiar with this knowledge gap could give the SDM process additional depth corresponding to the patients’ preferences.

Future perspectives
Overall, we can state that Palliative Non-Operative Management (P-NOM) is well received by hip fracture patients and family providing a viable option for frail geriatric patients. Also, with growing both national and international awareness under surgeons, P-NOM experiences can further expand and evolve to an even more enhanced patient-centered approach. 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, advance care planning and the holistic approach) and will give direction for future P-NOM research.

First, the most common question obtained from physicians and other healthcare professionals evaluating P-NOM is: ‘How do we identify the frail geriatric patient, and which patients are eligible for the palliative, non-operative management after hip fracture?’. Identification of frailty remains challenging and is best complemented with the use of reliable frailty scales or indexes. However, these tools are time consuming and difficult to use in acute setting at the Emergency Department. With the introduction of the AQUIOS flow cytometer, the first step towards immune based decision making is set. This variable could be of great additional use in shared decision-making to deflect the patients’ immune system and their potential response to physical traumatic actions such as surgery or battling potential infections in the peri-operative phase.

Second, since surgeons priorly addressed operative management as an adequate treatment modality to reduce pain for very frail hip fracture patients, other successful pain therapy seems necessary to maintain quality of life for patients opting for P-NOM. Also, in our qualitative studies ‘pain’ numerously was implicated as the most important theme where still a lot to be gained for the P-NOM patient in the end-of-life phase. With the undesired side effects of systemic opioids, local hip analgesia recently was introduced, such as a Pericapsular Nerve Block (PENG), as a promising and relatively non-invasive alternative to reduce pain to a minimum after hip fracture. However, evaluation of this seemingly viable option is necessary. Involving the anesthesiologists, optimizing pain management is highly recommended for improving quality of life and therefore quality of dying for the P-NOM patients.

Third, addressed before in this thesis concerning advance care planning, urgent action on this matter is asked. With our growing geriatric population, still the majority is not familiar with its personal preferences regarding treatment when becoming acutely ill. With a limited life expectancy, addressing this subject in non-acute setting gives patient and family time and space to exchange thoughts about their preferences. Family of P-NOM patients clearly underlined the difficulty of the very unexpected turn after hip fracture. In order to avoid time pressured and unfavorable situations in the emergency department in case of a hip fracture, clinicians should realize that fractures in frail geriatric patients are not just a diagnosis in isolation, but a symptom of multifactorial pathology, and therefore ones frailty ideally is addressed and documented at an earlier stage.

Last, significant developments by super specialization have made major impact on the practice of surgery. While specialization is merely intended to improve the quality of care, excessive specialization resulting in separation into narrow areas can have a deleterious effect on the total care of the patient. Focusing solely on the fractured hip, the patient behind the fracture is sometimes neglected. Surgery can fix the fracture and regain its function, however the overall deterioration of the patients’ condition is most often irrevocable. The holistic approach in hip fracture care is ought to be mandatory to compose a comprehensive treatment plan through shared decision-making which is in harmony with the goals of care and preferences of the geriatric hip fracture patient.

“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”
The Hippocratic Oath: Modern Version