Clinical Faceoff: When Should Patients 65 Years of Age and Older Have Surgery for Hip Fractures, and When is it a Bad Idea?

Hip fractures in patients 65 years of age and older are common, but the variation in severity and type of these injuries results in a wide array of surgical and nonsurgical approaches being part of the conversation. As many as one in three patients will not survive a year after these injuries, and among those who do, some will experience substantial loss of independence in their living circumstances, implant breakage or cutout, deep vein thrombosis and pulmonary embolism, pneumonia, infection, bleeding, nonunion/malunion, cardiac or pulmonary complications, and anesthetic complications. Presumably, all of these risks factor into a thoughtful informed consent process that includes discussion of nonsurgical treatment.

But I wonder whether this really is the case. In particular, I’m concerned that the default position is surgery, that nonsurgical options seldom get discussed, and that sometimes comfort measures and nonsurgical care are the better choice. We all have treated older patients with hip fractures who present with cachexia and/or dementia; many may not even remember how they injured their hip or react with pain during a hip examination. Others may be cognizant and able to make their own decisions. They may say that they do not want surgery; end-of-life lines like “I am tired and ready to go” feature prominently in some of these conversations.

Given how common these injuries are and what a large event they represent in the lives of patients and families, getting this right seems important. I’ve invited two international experts to debate this topic.

Simon Mears MD, PhD is Professor of Orthopaedic Surgery at the College of Medicine at University of Arkansas for Medical Sciences. His special interests include total hip and knee replacement, hip fracture care, and geriatric orthopaedics. Carmen Quatman MD, PhD is one of a few surgeons in the country to complete a geriatric orthopaedic training fellowship. She is an Associate Professor at The Ohio State University as well as the Secretary of the International Geriatric Fracture Society

Lisa K. Cannada MD: Can you give me an example or two of patients with hip fractures whom you have cared for where the decision was a close call in terms of whether or not to operate, and what tipped you in one direction or the other?

Carmen Quatman MD, PhD: I treated a 76-year-old patient for a femoral neck fracture; at the time of the injury, she was in hospice for cardiac issues with severe aortic stenosis, right heart failure, and an ejection fraction of less than 5%. Despite the patient’s medical issues, she was living independently, ambulating without a gait aid, and her daughter was a nurse and a supportive caregiver. Although the patient was in pain, she was worried about the risk of death. After a long discussion about goals, she planned for nonoperative treatment. However, after 1 week, she came to the clinic and described debilitating pain that was diminishing her quality of life. At that point, she felt that she could not live comfortably without surgery and she was willing to accept the high risks of surgical treatment. We provided coordinated care and she did remarkably well.

In contrast, I recently treated an 80-year-old patient with coronavirus-2019 (COVID-19) who presented with symptomatic pneumonia, an elevated INR, and psoriasis over the fractured hip who ambulated with a walker at baseline. The patient had pain with transfers, but because of his rapidly declining lung function and high risk of clotting and congestive heart failure had we opted for rapid reversal of his warfarin, we elected for nonoperative management. There is mounting evidence demonstrating a high risk of death after surgery for patients with hip fractures who test positive for COVID [3, 8, 10, 11]. We have approached this as a multidisciplinary team to monitor symptoms daily and exhaust all measures of safe pain control to allow for mobilization; however, we may need to re-evaluate whether this patient’s quality-of-life goals remain impaired.

Simon Mears MD, PhD: I think this flexible approach is good, especially for patients with multiple comorbidities. We have been driven to a reflexive “fix them as soon as possible” attitude. While this is the correct attitude almost all the time, there still are patients who should have a delay in surgery or no surgery at all. For your first patient, the delay was caused by decision making. In the second, he was clearly not medically fit for surgery with COVID-19 and pneumonia. It may be that the patients’ respiratory status can be improved in the upcoming days. Hip fixation would help in mobilization, which should aid the pneumonia. If this patient survives those medical issues, surgery may improve their functional status.

Dr. Cannada: How do you speak with the patient (or his/her family) if you think surgery is the wrong option, and how does this conversation differ from one in which you recommend fracture surgery?

Dr. Quatman: I begin with a position of open mindedness, even though we know that most patients with hip fractures treated with surgery have better outcomes than those treated nonoperatively [1, 5]. I try to understand why a patient or family feels so strongly one way or the other about surgery. If the patients’ concerns are related to fear of death, or in direct conflict with previous healthcare goals, I try to engender trust and help them decide the best course. While surgery may put the patient at risk of death, if the pain is so severe that he or she cannot roll in bed or sit up, despite vigorous attempts at pain reduction, I review with the patient how this can impair quality of life. If I think surgery is not the best option, I will help the family and the patient exhaust all nonoperative methods for pain control for basic life needs. However, if I feel that surgery is the better choice, and the patient and family are nervous about proceeding, I offer the family an opportunity to have a second opinion to discuss the most essential patient care goals [13].

Ultimately, in my mind, this is not a right or wrong decision for the surgeon or family/patient. The best ethical approach to this is to align treatment with the patient’s quality-of-life goals. It is our job as surgeons to provide sound advice that respects a patient’s autonomy and goals of care. If you can take extra time to communicate with the patient and family and gain their trust, you can usually arrive at a treatment plan that is best for the patient.

Dr. Mears: I would agree with this strategy. Many families do not know that nonoperative care is a treatment option and that’s on us to do better. The care team should offer a detailed discussion reviewing all treatment options, but such discussions may be overlooked by the care team for several reasons. First, generally speaking, there is a bias toward surgical treatment for hip fractures and offering nonoperative treatment requires a change in tact from the “usual” hip fracture case. Second, there is a sense of urgency among the care team to surgically treat the hip fracture because decreasing time to surgery offers better outcomes for the patient [1, 5]. However, this rush may prevent adequate discussion with family members on nonsurgical options. This is particularly true now with the current visitation limitations for family members in hospitals due to the COVID-19 epidemic. Third, this discussion requires more time than usual and so conversations with the appropriate family member(s) must be planned and organized. Lastly, the surgical team may not be familiar with discussions about withholding care and/or palliative care. This topic may be difficult for a surgeon who is used to restoring function. Offering this option and giving them permission to not pursue a hopeless surgery is important and requires work from the surgeon and the team.

Dr. Cannada: How do you play it if you feel strongly that surgery is not the right option—perhaps posing a serious (> 50%) risk of death on the table or shortly thereafter and minimal to no hope for productive rehabilitation—but the patient cannot give consent, and the family wants “everything done”?

Dr. Mears: There is a clear role for nonoperative treatment in some patients with hip fracture. Decision making, gauging the risk of surgery, and selection for this treatment is difficult. There are many gray areas to consider including the wishes of the patient and family, rapid progression of dementia or other diseases, and other acute illnesses that may or may not improve with time. Patients often appear more ill at the time of their fractures than when in a home environment. Some comorbidities are worse than others; severe aortic stenosis and pulmonary hypertension, for example, carry an especially high risk of death after surgery. Risk calculators may be used to aid in decision making. Although there is some discrepancy regarding the reliability of these calculators [4, 7], the score for trauma triage in the geriatric and middle-aged tool (known as the STTGMA tool) may be useful in predicting mortality after hip fracture and has even been verified in the COVID-19 era [9].

I also consider what the patient will gain from surgical treatment. Ambulation at baseline is a critical factor. A patient who did not walk before his or her injury does not have as much to gain, as such a patient will not return to walking or even transfers. The goal then is in pain relief. Can this be managed medically? Can this patient’s pain (and transfers) be managed adequately without surgery?

My general approach is to determine these risk and benefit factors. If there is a high risk or little to gain then the surgeon needs to get help with decision making. Consultation from a geriatrician or palliative care team can be extremely worthwhile in these situations. A palliative care specialist can help determine the risk-benefit ratio of surgery and advise about other nonsurgical treatment options that may be available. It is a common misconception that palliative care is only for patients with cancer or those who are imminently dying [14]. In fact, these specialists can open up other resources for patients who may be near, but not at, the end of life [2]. They can assist with pain control and home care so that a patient with end-stage dementia can be cared for at home. They can help align the expectations of the family with realistic projections of prognosis as provided by the surgeon, and participate in meaningful family conversations about the benefits to the patient of nonoperative care [6]. The addition of the anesthesiologist to the family conversation can also be helpful, especially where risk assessment is concerned.

Often the most important point is to help the family understand that they can choose nonoperative care. Many feel that this means they are personally killing their loved one. They have to be made to understand that surgery is not a requirement and that this decision would be what their loved one would prefer. Sometimes, avoiding surgery and decision making can take much more time than surgical care, but this time is well worth the effort.

Dr. Quatman: It is rare that I feel a patient is not a good candidate for surgery. However, sometimes the surgeon does have to let the family know that “everything that can be done” is sometimes not surgery, especially if the goal for the family and patient is comfort. As surgeons, we have to advocate on the patient’s behalf. Sometimes, if desired by the family, we will even help start the process for hospice as this can help them achieve their end-of-life care goals. Most important, spending time to educate the family and patient if he or she is able to participate in care can often help resolve concerns around choosing a nonoperative route.

Dr. Cannada: What are the most important steps (medical, rehabilitative, social, for example) to take to give the patient the best chance for as full and comfortable of a recovery as possible if you plan not to operate?

Dr. Mears: When the decision has been made for nonoperative treatment, the most important steps are pain control, skin care, and mobilization. Pain control with narcotic medications may be necessary for a period of time. Early regional nerve block can be helpful with pain control efforts even with a catheter for a few days if needed. Skin care with frequent rolling and avoidance of bedsores is important. I would avoid tethers such as abduction pillows or Foley catheters that can lead to pressure points or urinary tract infections. Just because the hip is broken does not mean the patient cannot be mobilized. Bed-to-chair mobilization should be accomplished as soon as the patient is able. Analgesic dosing should be performed thoughtfully so as to allow for this. In patients who survive, results of nonoperative care are good in terms of pain control [12].

Dr. Quatman: I echo Dr. Mears’ responses for pain control, skin care, and mobilization, and I would add thoughtful approaches to nutrition. Understanding when to obtain a consult with palliative care is important as sometimes it can provide immense relief for family members to have hard conversations about end-of-life care goals. We also help families understand the difference between palliative care and hospice, and how each can provide the family or caregivers with support that may not be readily apparent. Often, families have never had these conversations, and these conversations can bring such a comfort to families and patients.

Hospice generally is considered for patients at a high risk of death within 6 months, and the goal is to provide comfort in ways that align with the goals of the patient (if he or she can express them) or the family. While palliative care is helpful for setting end-of-life goals and helping family members align care goals, it is important to communicate that this is not “giving up hope” or “throwing in the towel” as I have heard patients and family call it. Instead, it is truly about helping everyone understand what is most desirable from the patient’s point of view.

In the COVID-19 setting, more and more patients are worried about sending family members to nursing facilities but do not feel that they can provide the care at home. Hospice can provide a wonderful resource to help patients avoid placement in a skilled nursing facility while remaining safe, comfortable, and surrounded by family. In my practice, if nonoperative hip fracture care is chosen, I make sure we always have a discussion of hospice, as this really can be life-changing for patients in terms of facilitating quality time with family at the end of life.

It is hard to ever feel comfortable “living” with a decision that was ultimately not the patient’s choice. As I have grown more experienced in my own practice, I have become confident in leading palliative care discussions and have even done so with my own family members who had complex care decisions to make. Helping a family understand personal goals can be one of the best gifts a patient can give to his or her family. It helps tremendously in the healing process that accompanies bereavement.

I was once told by a palliative care doctor, it is never “too early” to have these conversations, and, ideally, they happen long before the patient ends up in the hospital. I like to remember that, and I discuss it often with patients and families when patients begin to show medical decline or increased frailty.