Strategies to improve end-of-life decision-making and palliative care following hip fracture in frail older adults: a scoping review

Abstract

Background: Although surgery is the gold standard following a hip fracture, the potential for rehabilitation and survival rates are low in frail older patients. Some patients may derive more benefit from palliative care. The objectives of this review were to identify the available strategies to improve end-of-life decision-making and palliative care for frail patients with hip fractures and to synthetise their level of support.

Methods: We conducted a scoping review of the scientific and grey literature, searching seven databases and websites of associations. We included all study designs, expert opinion articles and clinical practice guidelines (CPGs). Data were synthetised according to the Approach to Patient with Limited Life Expectancy and Hip Fracture framework. The number of research items and their level of evidence were tabulated for each of the recommended strategies.

Results: Of the 10 591 items identified, 34 were eligible. The majority of included articles were original research studies (n = 15). Half of the articles and CPGs focused on intervention categories (55%) such as goals of care discussion and comfort care, followed by factors to consider in the end-of-life decision-making process (25%) and prognosis assessments (20%), mainly through the estimation of life expectancy. The level of evidence for these strategies remains low, given the limited number of prospective studies supporting them.

Conclusions: This scoping review highlighted that end-of-life care in frail older patients with a hip fracture remains understudied. The strategies identified could be prioritised for future research to improve the well-being of the target population while promoting sustainable resource management.

Keywords: decision-making; hip fracture; nonoperative management; older patients; older people; palliative care.

Figure 1

Flow diagram of included studies.

Figure 2

Years of publication of included items.

Figure 3

Evidence synthesis on end-of-life decision-making and palliative care strategies. *The level of evidence for each strategy was synthetised by classifying research items according to an adaptation of the Oxford Center for Evidence-based Medicine (OCEBM): RCTs or systematic reviews of RCTs (I), prospective studies or systematic reviews of RCTs and cohort studies (II), retrospective cohort studies, case–control studies, cross-sectional and case series studies (III) and expert consensus and others (e.g. case studies, editorials) and by calculating the number of items per adapted OCEBM category. NHFS, Nottingham Hip Fracture Score; PPS, Palliative Performance Scale.