Background Older patients admitted to hospital with traumatic hip fractures often have multiple co-morbidities and reported 30 day mortality of 8% and 12 month mortality of 25%.¹ This study aimed to investigate indicators of palliative care needs, frailty, referral to specialist palliative care and markers of quality end-of-life (EOL) care.

Methods Retrospective chart review of all patients aged >65 admitted to Monash Health with acute hip fracture between July 2022 and June 2023. Measures included demographics, Charlson Co-morbidity Index (CCI), Clinical Frailty Scale (CFS), Supportive and Palliative Care Indicators Tool (SPICT), advanced care directives and goals of care (GOC) documentation, referral to specialist palliative care and EOL care. Measures of quality of EOL care included appropriate GOC, prescribed pre-emptive medications and no inappropriate interventions. EOL medication doses (oral morphine equivalent dose [OMEDD] and midazolam) 2 days and 1 day prior to death were recorded.

Results 481 hip fracture admissions were reviewed. Patients had a median age of 83, 68% were female, 71% lived in private residence and 25% in residential aged care facilities (RACF) 77% spoke English as primary language. 26% were SPICT positive indicating palliative care needs, CFS mean was 4.9 (+1.6), indicating mild frailty and CCI mean was 5.4 (+2.2) indicating high risk for 1 year mortality. 13% had documented advanced care plans. Most patients (91%) had surgical management. Average length of stay was 10 days and majority were discharged to subacute (30%), rehabilitation (21%) or RACF (24%). 57% of those residing at home prior to admission returned home following subacute care. 30 day mortality was 7% and 12 month mortality at study end was 17%.

31 patients were referred to specialist care service, of whom 21 died and 6 were referred to a community palliative care service on discharge. Reasons for referral were EOL care (21%), symptom management (21%) and discharge planning (40%).

27 (5.6%) patients died during the acute admission and a further 5 (1%) died in subacute.

Of deaths in acute care the majority had palliative GOC (96%), families were informed (100%) and anticipatory medication prescribed (81%). Inappropriate interventions (antibiotics, ICU and blood products) were infrequent. Most died in acute ward (67%) and only 6 died in a palliative care unit. Mean doses of EOL medications 2 days before death were 56mg OMEDD and 11mg of midazolam. One day prior to death doses were 65mg OMEDD and 14mg midazolam. All families were informed of the death and GP’s were notified in 52%.

Discussion Older patients with hip fractures have frequent markers of palliative care needs and frailty. End-of-life care in hospital was high quality, excepting notification of GP’s. Few were referred to community palliative care post discharge, indicating needs may have been under recognised or unmet in the community. These results reflect challenges of accessing specialist palliative care in the aging frail population.

Reference

1. MTY Leung, et al. Hip fracture incidence and post-fracture mortality in Victoria, Australia: a state-wide cohort study. Arch Osteoporosis 2023;18(1):56.

Reference* Presenting author