title: End-of-life Care Planning and Fragility Fractures of the Hip: Are We Missing a Valuable Opportunity?
abstract: BACKGROUND
  Approximately 20% of all geriatric patients who sustain low-energy hip fractures will die within 1 year of the injury, and approximately 3% will die during the initial inpatient hospital stay. Accordingly, the event of a geriatric hip fracture might be an apt prompt for discussing end-of-life care: in light of the risk of death after this injury, the topic of mortality certainly is germane. However, it is not clear to what degree physicians and patients engage in end-of-life planning even when faced with a hospital admission for this potentially life-threatening condition.
  
  
  OBJECTIVE
  We assessed the frequency with which end-of-life care discussions were documented among a sample of geriatric patients admitted for hip fracture surgery.
  
  
  METHODS
  We studied 150 adult patients, 70 years and older, admitted between September 2008 and July 2012 for the care of an isolated low-energy hip fracture, who did not have documented evidence of end-of-life care planning before the time of admission. For each patient, the medical record was scrutinized to identify documentation of end-of-life care discussions, an order changing "code status," or a progress note memorializing a conversation related to the topic of end-of-life care planning.
  
  
  RESULTS
  Of the 150 subjects who had no documented evidence of end-of-life care planning at the time of admission, 17 (11%) had their code status changed during the initial hospitalization for hip fracture, and an additional four patients (3%) had a documented conversation regarding end-of-life care planning without a subsequent change in code status. Accordingly, there were 129 (86%) patients who had no record of any attention to end-of-life care planning during the hospital stay for hip fracture surgery.
  
  
  CONCLUSIONS
  Our findings suggest that physicians may be missing a valuable opportunity to help patients and their families be better prepared for potential future health issues. End-of-life care planning respects patient autonomy and enhances the quality of care. Accordingly, we recommend that discussion of goals, expectations, and preferences should be initiated routinely when patients present with a fragility fracture of the hip.
  
  
  METHODS
  Level IV, therapeutic study.
authors.affiliation: Department of Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA, 19104, USA.
authors.forename: Robin H
authors.initials: RH
authors.lastname: Dunn
authors.affiliation: Department of Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA, 19104, USA.
authors.forename: Jaimo
authors.initials: J
authors.lastname: Ahn
authors.affiliation: Department of Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA, 19104, USA. Joseph.Bernstein@uphs.upenn.edu.
authors.forename: Joseph
authors.initials: J
authors.lastname: Bernstein
mesh_terms: D032722:Advance Care Planning; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000375:Aging; D003142:Communication; D005260:Female; D016330:Frail Elderly; D006620:Hip Fractures / Q000000981:diagnostic imaging / Q000401:mortality* / Q000628:therapy; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D008297:Male; D010414:Pennsylvania; D010817:Physician-Patient Relations; D012189:Retrospective Studies; D012307:Risk Factors; D013727:Terminal Care; D013997:Time Factors; D016896:Treatment Outcome