Is There a Role for Early Palliative Intervention in Frail Older Patients With a Neck of Femur Fracture?

BACKGROUND: Patients with a neck of femur fracture have a high mortality rate. National outcomes have improved significantly as the management of this patient group is prioritized. In 2016, however, 4398 (6.7%) patients died within 30 days of admission. OBJECTIVE: To investigate whether palliative care could be integrated early in the care plan for high-risk patients. METHODS: All cases of inpatient mortality following neck of femur fracture at North Bristol Major Trauma Centre over a 24-month period were reviewed. A comprehensive assessment of care was performed from the emergency department until death. All investigations, interventions, and management decisions were recorded. A consensus decision regarding expected mortality was made for each case at a multidisciplinary meeting which included surgical, orthogeriatric, nursing, and anesthetic team input. RESULTS: A total of 1033 patients were admitted following a neck of femur fracture. There were 74 inpatient deaths, and 82% were considered predictable at our multidisciplinary meeting. The mean length of stay was 18 days (range: 0-85, median 14). In 42% of cases, mortality was considered predictable on admission, and 40% were considered predictable following acute deterioration. These patients received on average 28 blood tests (range: 4-114) and 6.8 X-rays and computed tomographies (range: 2-20). Of this, 66% received end-of-life care; mean duration 2.3 days (range: 0-17). CONCLUSIONS: Mortality rates remain high in a subset of patients. This study demonstrates that intensive investigation and medical management frequently continues until death, including in patients with predictably poor outcomes. Early palliative care input has been integrated successfully into patient management in other specialties. We demonstrate that it is feasible to identify patients with hip fracture who may benefit from this expertise.