1 Department of Medicine, University of Arizona College of Medicine , Tucson, Arizona.
2 Orthopedics and Rehabilitation, University of Vermont College of Medicine , Burlington, Vermont.
J Palliat Med. 2018 Aug;21(8):1069-1073. doi: 10.1089/jpm.2018.0029. Epub 2018 May 24.
Many older patients with a limited life expectancy experience fragility fracture of the hip, and this event is associated with increased risk of premature mortality, functional decline, and institutionalization. The treating team, in collaboration with patients and their families, must determine whether a surgical or conservative approach is in the patient's best interest when a patient has limited life expectancy.
Goals of care discussions appear to be rare in the setting of fragility fracture. The urgent nature of the problem makes such discussions challenging. We believe that many physicians have not considered goals of care discussions to be a standard component of fragility fracture management.
We propose that physicians caring for patients with limited life expectancy and fragility fracture of the hip should initiate a goals of care discussion to help determine whether operative repair will be the most patient-centered approach. Training on conducting goals of care discussions should be a standard part of surgical training programs. Goals of care discussions should include prognosis, patient values and preferences, pain, likelihood for functional recovery, and burdens and benefits of surgical versus nonsurgical management. Multidisciplinary input is required, and many patients will benefit from geriatric and/or palliative care team involvement.
许多预期寿命有限的老年患者会经历髋部脆性骨折，而这一事件会增加过早死亡、功能下降和住院的风险。当患者预期寿命有限时，治疗团队必须与患者及其家属合作，确定手术或保守治疗方法是否符合患者的最佳利益。
在脆性骨折的情况下，护理目标讨论似乎很少见。问题的紧迫性使得此类讨论具有挑战性。我们认为，许多医生并未将护理目标讨论视为脆性骨折管理的标准组成部分。
我们建议，照顾预期寿命有限且髋部脆性骨折的患者的医生应启动护理目标讨论，以帮助确定手术修复是否是最符合患者意愿的方法。关于进行护理目标讨论的培训应成为外科培训计划的标准部分。护理目标讨论应包括预后、患者的价值观和偏好、疼痛、功能恢复的可能性，以及手术与非手术管理的负担和益处。需要多学科的投入，许多患者将受益于老年病学和/或姑息治疗团队的参与。
