A Frail Path: Patient-centered care for frail older adults with hip fractures

Introduction
Very frail older adults with hip fractures often face a critical decision involving clinicians and proxies, balancing the potential benefits of surgery against its risks and the palliative alternative of non-operative care. This dissertation focuses on two aspects of this process: improvement of the decision-making process and improvement of pain relief in non-operative care.

Shared Decision Making and the Patient Decision Aid
In Chapter 2, a semi-structured interview study shows important themes in decision-making: a clear explanation of options, recognition of personal values, being involved in the decision and outcome explanations that match reality. This should be communicated in a sensitive manner that considers a patients personal situation.
The third chapter is a nationwide Dutch survey study among 146 clinicians. The majority agrees that patients and proxies should participate in shared decision making, though hindered by acute time pressure, cognitive impairment of the patient and the complexity of end-of-life choices. Most clinicians perceive that an appropriately applied digital Patient Decision Aid (PtDA) could benefit patients, families and clinicians.
A PtDA was developed and tested among 51 potential users in a concurrent mixed methods study with surveys and interviews in Chapter 4. Patients, family, healthy seniors and clinicians find the tool helpful and easy to use, though support is required for patients and time investments are required for clinicians.

Pain Relief in Non-Operative Care
The second part of this dissertation focuses on pain relief in non-operative hip fracture care. Chapter 5 evaluates experiences with phenol Pericapsular Nerve Group (PENG) block, an injection anesthesizes the anterior hip while preserving motor function. Proxies of treated patients participated in interviewd, and they indicate that pain relief from PENG block is only one part of care in the palliative context and offered varying pain relief. Interprofessional collaboration is essential to provide uninterrupted patient comfort with attention to dignity and personal autonomy.
In Chapter 6, a retrospective cohort study of 185 patients demonstrated that PENG block eased pain at rest and during care for the majority of patients with low pain scores and little morphine use. Mobility remained poor with a median survival of nine days.
Chapter 7 describes a cohort of 68 frail patients receiving the Spinal Phenol IN Glycerol (SPING) block, an analgesic treatment that numbs and paralyzes the affected leg. SPING was 93% successful, reduced pain scores to zero and enabled patients to sit after treatment with a median survival of 13 days.

Conclusion
This dissertation draws three conclusions. First, clinicians should prioritize the specific values and perspectives of patients and their proxies in decision-making. Second, shared decision-making should be facilitated even under acute time pressure, possibly supported by a PtDA. Third, targeted techniques, such as PENG and SPING, can be used for pain relief in non-operatively treated patients. The pallative context remains crucial. Care for frail older adults with hip fractures in the final phase of life should prioritize comfort and quality of life. This dissertation provides guidelines for person-centered, multidisciplinary care.