Palliative care for hip fracture in elderly patients

Hip fracture in the elderly is a complex situation. High incidence in older patients with multiple comorbidities is associated with important complications and 18% 1-year mortality following surgery. The development of palliative care (i.e., non-surgical management with optimized pain control) for frail patients is a viable option, but which raises several questions. (1) What is the evidence in support of palliative care for these patients? - Growing literature, mainly from the Netherlands and Canada, confirms the need for palliative care in this population. (2) How do orthopedic surgeons consider this? - Although they understand the concept, there are many sociocultural, economic and logistic obstacles hindering implementation. (3) How can palliative treatment for hip fracture be defined? - It is an additional tool in our therapeutic toolbox and can be implemented either in dedicated or orthogeriatric units. It aims to relieve pain without seeking to extend life-expectancy unnecessarily and rapidly leads to death in most cases. 4) Who is concerned by palliative treatment for hip fracture, and what decision aids exist? - Elderly patients with severe cardiac comorbidity, moderate to severe neurocognitive disorder and low functional level prior to fracture can benefit from palliative care. New tools have been designed for patient selection and to enable validated and ethical decision-making between patient, family and care team. (5) What do we know about pain management in palliative treatment for hip fracture? - Pain control is effective, but challenging. Peripheral blocks, analgesia and co-analgesics and non-pharmaceutical strategies are used. (6) What are the functional results? - In well-selected patients, palliative care shows similar mortality to surgery but with significantly fewer complications. Palliative treatment for hip fracture in the elderly is a viable and ethical option for well-selected patients. New tools are available to aid clinicians and patients in decision-making. Some obstacles still need to be overcome to enable widespread use, improving quality of life in this population. LEVEL OF EVIDENCE: V, expert opinion.