Management of Traumatic Hip Fracture in the Palliative Care Unit

An 84-year-old man with a history of glioblastoma multiforme was admitted to a Toronto, Ontario hospital palliative care inpatient unit (PCU) for end-of-life care. There was no further active management possible for his disease, and his life expectancy was estimated to be 1 to 3 months based on his disease burden and Palliative Performance Scale (50%). ¹ His past medical history consisted of prostatic hypertrophy and dementia. His goals of care on admission to the unit were to receive symptomatic care for his disease and to remain as independent as possible. A family member was acting as his substitute decision-maker for complex decisions as he had cognitive impairment that was mild initially but progressed during his stay. The expectation of the patient and his family was that he would die in the PCU.

The patient was identified as being at high risk for falls early in his admission. He was ambulatory in his room and the hallway but observed to be unsteady. He was seen by the physiotherapist who recommended the use of a walker, which he refused to use. He had discussions with several care team members about strategies to reduce his risk of falls. He was encouraged to ask for help when ambulating but refused to do this. He had bed alarms in place so that staff could come to his assistance when he exited the bed. He had a comprehensive discussion about risk of falls with the attending physician on the second week of his admission. He indicated that he would rather die of a hip fracture than be forced to use a walker. At the time of that discussion, the physician felt he was competent to understand the implications of his decision. The physician discussed the fall risk with his family and all were in agreement with a plan to try to mitigate the risk of falls (through use of the bed alarm, physiotherapy, and having the walker available), but allowing the patient to walk as per his wishes for reasons of quality of life.

The patient had an unwitnessed fall from his own height post admission while attempting to stand at the bedside. An X-ray showed a right nondisplaced intertrochanteric hip fracture.

The team and family considered both operative and conservative management of the patient’s hip fracture. At the time of his fall, the patient’s revised prefracture life expectancy was thought to be 1 to 2 months. This was due to increasing difficulties with cognition, mobility, and agitation and an overall decline in function. At the time of his fall, he was incompetent to make both simple and complex decisions. After the fall, his Palliative Performance Scale was 30%, and he became increasingly delirious and was unable to meaningfully interact with visitors and staff. With or without surgery, the PCU physician estimated the postfracture life expectancy to be 2 to 4 weeks. This was because of the added disease burden of hip fracture, the possible complications of surgery, the patient’s diminished ability to participate in rehabilitation, and the obligate period of immobility (even if the surgery was corrective). ² His family was concerned about operative management due to the pain and discomfort of an acute care visit and the fact that surgery (and the following recovery period) would be sources of pain and anxiety in of themselves. This concern was balanced by a desire to have his pain controlled at the end of life. The family agreed to a transfer to acute care for orthopedic consultation as there were no acute care services available at the patient’s home hospital.

Three orthopedic surgeons in 3 separate teaching hospitals were consulted by phone (for administrative and resource availability reasons). All were in agreement that the sole indication for surgery would be pain relief. This was in keeping with the goals discussed with the PCU team and the family. It was felt that the likelihood of the patient becoming independently ambulatory given his disease burden, rehabilitation potential, and prognosis was remote. One surgeon indicated that he would not recommend surgery at all, the second surgeon saw surgery as the only viable option, and the third thought surgery should be considered only if the team thought that the patient’s life expectancy exceeded 1 month.

The patient was sent to the emergency department for an in-person consultation with the on-call orthopedic surgeon. He was sent back to the PCU by ambulance having been deemed not appropriate for surgery by the orthopedics service. The reasons cited were his comorbidities and poor prognosis. The recommendation was for symptomatic nonsurgical management.

Conservative treatment in the PCU included the use of rapidly titrated doses of hydromorphone and midazolam to control pain and anxiety. The patient was opiate naive and had limited benzodiazepine use previous to the fracture. One week postfracture, he was receiving 14 mg of hydromorphone and 20 mg of midazolam by subcutaneous infuser every 24 hours. He was maintained on those doses until his death. While at rest, the patient was noted to be calm and comfortable. There was no facial grimacing or calling out. He did experience significant pain with care, and this presented the greatest challenge to the team. Solutions were found by administering 100 µg of sublingual fentanyl prior to care and dexamethasone subcutaneously for adjuvant pain control. On the recommendation of the physiotherapist, his right lower limb was packed with sandbags to minimize movement. Nursing practice was adjusted to reduce his pain with movement. Procedures and care events were limited and grouped. Adapted 2 person transfers were used when movement was required. Patient reassurance and distraction during care were also noted to be helpful. With these adjustments, it was possible to deliver the necessary care with minimal patient discomfort. The patient died in the palliative care unit on the 11th day postfracture.