Goals of Care After Hip Fracture: Conversations That Matter

In this episode of Hipcast, we’re joined by Dr Linda Sheahan, palliative care physician and clinical ethics consultant, alongside Professor Jacqui Close, orthogeriatrician and geriatric medicine Co-Chair of the Australian and New Zealand Hip Fracture Registry.

Together, we explore the importance of goals of care discussions in the context of hip fracture - why they matter, when they should occur, and how they can support patients, families and clinicians during what is often a sudden and life-changing event.

Linda and Jacqui discuss the practical and ethical challenges of decision-making after hip fracture, including how to navigate uncertainty, align care with a person’s values and preferences, and approach conversations about surgery, recovery, frailty, prognosis and quality of life.

We also consider how goals of care discussions can be embedded into routine hip fracture care, and why these conversations are not about limiting care, but about ensuring that treatment decisions are informed, compassionate and person-centred.

Importantly, the conversation highlights that high-quality hip fracture care is not only about timely surgery and rehabilitation, but also about listening carefully to what matters most to the person at the centre of care.

You can find resources on Australian Advanced Care Planning resources here. 

🎙️ Hipcast is hosted by Dr Niamh Dove and produced by the Australian and New Zealand Hip Fracture Registry, dedicated to improving outcomes and experiences for people with hip fracture and those who care for them.

Transcript

SPEAKER_02 0:03

Hello and welcome to Hipcast, the podcast here to improve hip fracture care. I'm your host, Dr. Neve Dove. Join me today to welcome two guests. We have Professor Jacqueline Close, author geriatrician at Prince of Wales Hospital and co-chair of our Australian and New Zealand Hip Fracture Registry. We also have Dr. Linda Sheehan, Clinical Stream Director of Palliative and End-of-Life Care at the Southeast Sydney Health Service. And she's also the clinical ethics consultant and lead for the Clinical Ethics Support Service there. We at the Australian and New Zealand Hip Fracture Registry acknowledge the Gadigal people of the Euro Nation as the traditional custodians of the lands on which we meet today, and we pay our respects to elders past, present, and emerging. We extend that respect to the Aboriginal Torres Right Islander and Maori people joining us today and listening on the podcast. Welcome to you both. Thank you for joining today.

SPEAKER_00 0:56

Hi.

SPEAKER_02 0:57

Thanks, Dave. Thanks for having us. Jackie, to start, hip fracture represents a major turning point in a patient's overall health trajectory. From an orthogeriatric perspective, how often do hip fracture admissions trigger goal of care discussions? And what clinical cues make you start thinking about limits of treatment early?

SPEAKER_00 1:15

Thanks, Neve. I mean, the reality for most is that we start those conversations very early in the journey. The majority of people with a hip fracture will have surgery. So we're talking about 97% of hip fractures, they will undergo surgery. And if we are adhering to our national guidelines, we're talking about surgery within 36 hours. So you start them early, and there is a relatively short, small window to have those conversations. And when you're talking about goals of care, limits of care, ceilings of care, whichever way you're phrasing it, it's a routine conversation for us, and it is incredibly confronting for many people that you start to have those conversations with. So in the emergency department, which is where we see the majority of these people, they're vulnerable, they've fallen, they're lying in a bed, they're in pain. Yet we start these conversations. So we need to be incredibly sensitive about how we start the conversations. I will often start by saying, do you have an advanced care directive? Many, many people, particularly those from the community, still don't know what an advanced care directive is, and those conversations have never been started with families in terms of what somebody would or wouldn't want, or what's important in terms of what constitutes good quality of life. Residential aged care is a bit different these days. I think those conversations have often already been had, and people in the cold light of day have had the opportunity to say what isn't isn't important. I mean, you ask me what clinical clues I look for in terms of who is not likely to do well and where those conversations are really important early. It's always frailty, um, so uh severity of cognitive impairment and people's level of dependency. And they're the ones that we think physiologically have limited reserves to respond both to the insult from the trauma plus the surgical procedure. But but the reality is I would have the conversation with everyone, and there are very definitely people who, as clinicians, we don't see as frail or cognitively impaired, and they have very strong views on in terms of what's important to them. So I tend to have the same conversation with everyone. I may phrase it um differently, and there are certainly some who find the conversation too confronting and I'll abandon that conversation because I cannot afford to destroy a therapeutic relationship that needs to continue through that hip fracture um journey. So it's it's a challenge.

SPEAKER_02 4:04

Thanks, Jackie. It's definitely confronting a conversation I think for both patients and families, but also clinicians involved, you know, navigating such a fragile situation. And as you said, trying to strike that balance between not um sacrificing rapport with the patient when you're only just meeting them.

SPEAKER_01 4:20

Jackie, I'm so few, because it's so interesting, right, from a power care perspective, you're all they're already primed by the time we come in, right? By the time we come in, you know, we're allowed to open the box. Does that make sense in the consult center anyway? Whereas I can imagine with you guys by the bedside in ED, um, opening this, even with an 82-year-old who's independent living at home, must be a very different journey. When you sort of say people uh find it very confronting, what proportion really, really struggle enough for you guys to back off? Do you think?

SPEAKER_00 4:53

Um, possibly the fitter end of the spectrum who death or disability hasn't even crossed their mind. Um some of those get quite stressed about it. Um, and at that particular point in their trajectory, we would be offering them everything anyway. So it's very easy for that group to back off. Um there's a cultural component to some of those conversations as well. There are groups where it's everything at all cost, yeah, when clearly physiologically, that's just not realistic. Um, and that's I find that one very hard because we're encouraged to have these conversations with people, but at the end of the day, the decision to resuscitate or whatever is ultimately a medical decision. But but to have a conversation with somebody, they're telling you they want everything, and then say, well, actually, no, we're not going to do that though, because we don't need and of course we don't do that, but I find that part of it harder. Residential age care is usually um relatively straightforward, and most people and their families are on the same page, so it's a bit easier to say um full active measures whilst we're operating, and we will support them in the media 24 hours. There's no point in operating for not prepared to support them with blood pressure, etc. Um, but once they're back on the ward, most people um will want ward-level care only. They will not want to go to ICU, they will not want to be resuscitated, they will not want to be ventilated. So I'd say that's what the vast majority go for.

SPEAKER_01 6:24

Yeah, yeah, that sort of rings true. That's interesting. Just curious about what proportion pushback because I mean, obviously, all the literature in PowerCare is most people really want to have these conversations. Wanting to have them in the ED with a broken hip before you go wheeled off to theater is a whole different kind of piece to that, right? Absolutely.

SPEAKER_02 6:42

Linda, from an ethics perspective, what principles should guide clinicians when making time critical goals of care decisions in this setting?

SPEAKER_01 6:49

I suppose from the ethics perspective, pretty much all of these decisions are underpinned by values, right? And so it requires us to make values-based judgments in real time in order to discharge our clinical duties. Um, I guess understanding the obligations in emergent or time-critical settings just creates an extra layer of complexity to this, but the primary guiding principles, the things that are relevant, the things that are valuable or important, pretty much remain the same as they are in general clinical practice. We have this kind of primary professional obligation to sort of act in accordance with the best interests of our patients. Like best is by definition a values-based term, requires some sort of judgment, and getting in and under that individual person, their interests, their goals, their values in the specific clinical context can be hard, but it's really important. It's not a one-size-fits-all. We have to arrive at that kind of best interest call every single time we're having a clinical interaction. Um, ideally, that's iterative and kind of deliberative with the patient involved. Um, uh, but as Jackie's already flagged, people's readiness and engagement in that can be clunky, particularly in emergent settings. Um, but uh we always start with the person themselves. Who are they? What's important to them? What are their goals and values? How might that guide their wishes and preference in regard to the specific clinical circumstance they find themselves in, where they can't bring those uh those thoughts, those values. We look to a substitute decision maker to be that voice at the decision-making table. All of this kind of bundles in under the banner of kind of respect for persons or um broad concepts of autonomy, dignity. Um, but we start with that, and we've got to get some sense of that to be able to kind of start that process. And wrapped around it is our kind of clinical modus operandum. Somehow we have this uh obligation to proportionality, like treatments and interventions are contraindicated where we think they're gonna cause more harm than benefit, or more burden than benefit. Um, and starting with the patient, we wrap around this kind of beneficence, non-benficence juggle, the proportionality juggle, because we really only want to offer interventions where we really do think the harms and burdens will be outweighed by the potential benefits. And that's really a clinical deliberation and a responsibility that we kind of bring to the table. Um, and then we then we do the just shared decision-making bit. We kind of land on something that we think is best in the clinical context, um, and it's kind of scaffolded in on the justice stuff, you know, like what's available to us, what are the resources, what will it look like, are there any equity considerations, etc. So I suppose we do that kind of process every single time we're making a clinical decision or offering a particular intervention. It's just really, really much more time pressured and much more layered in emergency settings like this, where, as Jackie said, people are acutely unwell, haven't necessarily expected to be in this very critical situation, they're in pain, and things have got to be done quickly. Um, so the principles are the same. Uh, I guess we have to think more quickly and be more agile in how we apply them in an emergency setting. Um, and the other really important thing, I think, from the ethics perspective is just to remember that that deliberative thing means that it's sort of time, situation, and context specific. So different clinicians can sometimes land at different kinds of answers to the same values-based questions. So you might find different clinicians along the journey have different kinds of lenses on that. Um, and um, andor patients and families may have different kinds of lenses on those things. And so we've got to navigate that complexity as well in emergency settings like this. So recognising that people might have different recommendations and/or landing places on that best interest question is also, I think, a really important part, particularly in complex interdisciplinary care that's involved in things like hip fracture, um, and bringing kind of a consensus and/or bringing everybody together before we kind of try to confront patients and families with such a difficult decision-making process is really also a really important thing to keep in mind.

SPEAKER_02 11:08

Thank you. It's a good focus to remember we're all part of a bigger team when it comes to hip fracture care in particular. Linda, capacity care can be particularly challenging in hip fracture care with many patients presenting with dementia, delirium, and acute illness. How should clinicians approach assessing decision-making capacity? And what is the best pathway when the patient clearly lacks capacity?

SPEAKER_01 11:28

Yeah, I mean, capacity is really about part of this version of operationalizing respect for the person in the bed, trying to ensure we respect them as a person, they respect their dignity, align treatment decisions with their goals and values rather than our goals and values. And we've sort of got this mechanism of informed consent that's sort of enshrined in our thinking, but also in our legal frameworks that tries to create a very specific position for uh respecting people in decision making and healthcare. And as you know, capacity is kind of a core part of that. So you've got sort of the enabling things like capacity and voluntariness, and then you've got the informing things, you know, disclosure of the information and really kind of testing that people understand that um and integrate that information, and then you kind of have the final step, the authorization. Yes, go ahead, I give you permission to intervene on me in this way or do this particular intervention. Um, I think it's really important just to flag that you know, informed consent is a tool, but it's based on this respect obligation, and it means sometimes it can get kind of messy and we get kind of focused on the very black and white pieces like capacity and/or voluntariness. But where it gets messy, if we keep our eye on the ball around that respect piece and that respect for dignity and person's piece, it can help us sometimes get our way around and through the reeds, if you like. Um, I mean, obviously, ideally, the person themselves is that person involved in the decision-making process. Where a person lacks capacity or is unable to be involved in a decision-making process, we obviously have this mechanism whereby we look to another person to represent them with us in that shared process. Um, and that substitute decision maker or surrogate decision maker, you know, in New South Wales, it's delegated by the Guardianship Act, but most jurisdictions will have sort of a map as to who that person should be. But I think it's really important just to remember that the substitute decision maker is there to represent the person's voice, not their own voice. And they, like us, have obligations both to respect previously expressed wishes andor values, and also to act in the best interests of their loved one. So they don't have the same kind of rights in that process as the patient themselves would be. Um, and we really always benchmarking, are we both on the same, are we all on the same page and keeping our eye on the person in the bed? Because that's really the critical piece. And some of the kind of frequent ethical dilemmas is where we're not 100% sure where the SDM is sort of sitting, if you like, in terms of what interests are at play or what pressures might be on them in terms of advocating for their loved one and so on and so forth. So it's really important just to kind of frame up that the SDM is the substitute that we've built in for people without capacity, but it's got a lot more complications and nuance around it, and that's kind of the messier part of the decision making that is probably very common in the context of um hip fracture in the emergency department, for example. The only the only other thing I just want to to flag is that, you know, persons without capacity, their wish, their preference, their will is still ethically relevant. So if they, for example, are clearly without capacity but they don't want surgery, that should be an important ethical consideration in the context of that shared process of deciding the best way forward. Um, because it's still ethically weighty that they have a will or a preference that is not necessarily supportive of intervention. So just to kind of remember that. I guess in terms of assessment, my rule of thumb is just to ask myself: can this person understand and appreciate the significance and implications of accepting this particular surgical intervention andor proposal? Um, and remember that capacity is not like a global thing, it's time, situation, and decision specific. So we really try to maximize a person's involvement in the decision-making process as much as possible, and that's relevant, even where they lack capacity to bring them to the table so that we try to all land together on some sort of consensus.

SPEAKER_02 15:43

That's awesome. Thanks, Linda. I think you've really highlighted some great points to help keep the focus of the individual within our patient. You know, I think sometimes, as you said, it can get lost in the chaos of trying to make some of these big decisions. Jackie, considering surgery versus palliation, um, one of the most difficult scenarios is the very frail and unwell patient where surgery is not an appropriate option. How do you approach the conversations about whether surgery itself is appropriate rather than assuming it always is the default pathway?

SPEAKER_00 16:14

I think the reality in in this country is surgery is the default unless you've got a clear reason why that is not in the best interests of the patient. So as I said earlier, 97% of hip fractures in Australia and New Zealand undergo a procedure. But having said that, anytime you put anybody or to suggest that you put anybody through a procedure, you need to be clear in your head what you think the value of that procedure is going to bring to that individual. And for and for hip fracture, it's relatively straightforward. Alleviation of pain, it is by far the best way of addressing pain associated with a hip fracture. And for many people, it's restoration of function, not everybody. And certainly over my time practicing, surgeons and anaesthetists are now much more comfortable of the concept of a palliative surgical procedure. Because actually, alleviation of pain to allow nurses to be able to provide care to a patient, regardless of whether they're going to walk again or not. When they're managed in bed, they need to be turned to reduce the chances of a pressure injury. Turning somebody with a broken hip is incredibly painful, and it doesn't matter how much in the way of systemic opioid you offer, it is still a really uncomfortable mechanical pain that they experience. So the vast majority undergo a procedure, and I think we're pretty clear why we do it. But there are a small percentage whose life expectancy really is pretty short. And we're talking these days, probably about days, weeks, maybe, um, where actually it would be a futile um procedure. And then we alter our trajectory. It's still very much about a symptom-based approach to care, but actually we have a responsibility to make a death a good death, and we can do that even if we don't go down the route of surgical um intervention. I think we're getting better at that now as well. Um, so for example, the nerve blocks that we frequently use when people are coming into hospital to manage pain following their hip fracture. We can actually do nerve blocks for those not undergoing surgery, where we actually do neurolysis where we permanently um kill the nerve fibers. Um, but that allows for nurses to be able to turn patients in bed much, much more easily. Um, many of us will involve our palliative care um team in an end-of-life care um pathway as well. So it's a relatively small number. Mostly it's based on physiological reserve and our belief that we can get somebody safely through a procedure or not, and whether by doing so it will add value to their life. There'll there will be a small number of patients where you think they would benefit from a surgical um procedure, but they are very clear that they don't want a surgical procedure. Um and again, it's very much about good pain management, um, managing care in bed, nutrition, pressure injury, dbt um prophylaxis, etc. So it's a it's a small number, but they're an important number. Um and you can have a good to death without surgery.

SPEAKER_02 19:39

Thanks, Jackie. I think it's a small number that we don't always get insight into. So it's really interesting to hear about how you do manage those complex cases. Linda, sometimes the decision isn't about whether surgery occurs, but rather about how far escalation should go afterwards, as Jackie's kind of touched on. But for example, ICU admissions or intub intubation or aggressive life prolonging treatment. How should teams approach defining appropriate limits of care for patients with hip fracture?

SPEAKER_01 20:07

Yeah, I mean, Jackie's already kind of flagged this in in her answer to the previous question. I mean, again, it's keeping our eye on that big, big picture best interests decision-making process. Um, and and Jackie used the word futility. It's obviously a contested term in the ethics space, but the the idea, the functional definition of futility thinks about let's come to some kind of consensus about the achievable and valuable goals here, and then let's only offer treatments that really align with those goals. And I think in a setting that you've just described, you know, thinking about the post-doc care is just like that. What are their overall achievable goals here in the context of this person's values and priorities? And then how would those higher escalation treatments align with these or not? It may be in their interest to have their fractured hip pinned for symptom control reasons or to maximize quality of life goals or functionality, but not in their interest to have a prolonged stay in ICU post-operatively with all the sort of complications there with that come with that sort of escalation and burden of therapy. So, you know, as Jackie said, dying well and comfortably is also in people's interests. So thinking about where they are in their life cycle, their illness trajectory, and also kind of bringing in those ethically guiding things like goals and values will help you kind of formulate the appropriateness of escalation post-operatively should things get more complicated. I would say, sort of from the ethics perspective, ideally it's best to kind of frame that up before people get into theatre. Um, and that that is a little bit dependent on the receptiveness of the patient and and the family to sort of really map out those conversations, but it is part of the deliberation and the consent process to really understand and appreciate what may happen after and what thresholds we may want to bring in before we, you know, uh go into the theater so that it really is a shared journey to kind of land on those um ceilings of care or escalation points. Um, but given uh you know, really clarifying the goals really helps you do that because if you think about futile or disproportionate interventions in the context of consensus-based goals before you hit the rubber hits the road, you're in a much better place to make those difficult decisions and feel comfortable about them post-surgery, where things may get you know complicated or unstable, you feel confident that the goals have been clarified early and and previously. Um, and we should only really offer proportional interventions that go to those goals.

SPEAKER_02 22:54

For patients that are coming from home, what percentage of them have had these conversations or what percentage come in with an advanced care directive? Because I feel like it wouldn't be very many.

SPEAKER_01 23:04

Southeast would be 2%. Yeah. 2% have an ACD and EMR at least.

SPEAKER_00 23:11

We're a long way off the population understanding the importance of these conversations and and having the conversations in the cold light of the day, not waiting for a crisis to arise, because most of these conversations are still happening in the context of a crisis.

SPEAKER_01 23:27

Um I do think there's a huge community capacity building piece that's gotta get us over the line. We've been talking about advanced care planning for 30 years. There's government KPIs, funding attached to it, 500 million websites with resources, and we still have rates of 2% in Southeast Sydney. Like it's it's not the right, it's not the right framework. I don't think we need to rethink how to kind of approach conceptualizing these conversations and situating them in the kind of life journey. Um thinking about having them as part of good living, not just good dying or acute events.

SPEAKER_02 24:08

Jackie, utilising some of this wisdom that Linda has shared today, what's uh definition, what's one practical thing that clinicians involved in hip pressure care could do differently tomorrow to better approach goals of care decision making?