Palliative Care for Older Adults With Hip Fracture: An Explanatory Sequential Mixed-Methods Study.

Abstract

After hip fracture, older adults experience burdensome treatments and high mortality; they may therefore benefit from palliative care (PC). Best practices for PC integration during inpatient hip fracture care remain understudied. To determine frequency of inpatient PC process documentation for seriously ill older adults with hip fracture and explore clinicians' perspectives on observed documentation patterns. We used an explanatory sequential mixed-methods design. In a cohort of seriously ill adults ≥66 years old admitted for hip fracture from 2016 to 2019 at an academic health system, natural language processing was used to measure documentation of inpatient PC processes: healthcare proxy designations, code status limitations, goals of care conversations (GOCC), hospice discussions, and specialty PC. We then conducted semi-structured interviews (n = 10) with clinicians, exploring perspectives on documentation rates. Transcripts were coded thematically using a mixed deductive-inductive approach. Among 1433 hip fracture admissions, GOCC, hospice discussions, and specialty PC were documented in <25% each. Clinicians viewed these rates as reflective of under-documentation and under-delivery. Workflow barriers included lack of standardized processes and diffusion of responsibility across interdisciplinary teams. Emphasis on efficient perioperative optimization and minimizing prolonged hospitalizations competed with perceived time for delivery of GOCC and specialty PC. Clinicians described a rescue-oriented surgical culture in which the palliative value of surgical repair for hip fracture paradoxically limited surgeons' view on their role in GOCC. PC process documentation during hip fracture admissions was low. Limited standardization, role uncertainty, and cultural factors limited PC documentation and delivery, highlighting opportunities to strengthen PC integration in surgical care.