Advance Care Planning Prior to Death in Older Adults with Hip Fracture

Background
Although hip fractures in older adults are associated with a high degree of mortality and disability, the use of advance care planning (ACP) in this population is unknown.

Objective
To determine the prevalence of ACP and need for surrogate decision-making prior to death in older adults with hip fracture and to identify factors associated with ACP.

Design
Retrospective cohort study using Health and Retirement Study (HRS) interviews linked to Medicare fee-for-service claims data.

Participants
Six hundred six decedent participants aged 65 or older who sustained a hip fracture during HRS enrollment and had a proxy participate in the exit HRS survey.

Main Measures
Survey responses by proxies were used to determine ACP, defined by either advance directive completion or surrogate designation, and to assess decision-making at the end of life. Multivariate logistic regression was used to analyze correlates of ACP.

Key Results
Prior to death, 54.9% of all participants had an advance directive and 68.9% had designated a surrogate decision-maker; however, 24.5% had no ACP. Of the total cohort, 32.5% required decisions to be made about treatment at the end of life and lacked capacity to make these decisions themselves. In this subset, 19.9% had no ACP. In all participants, ACP was less likely in non-white individuals (adjusted odds ratio (aOR) 0.14, 95% CI 0.06–0.31), those with less than a high school education (aOR 0.58, 95% CI 0.35–0.97), and those with a net worth below the median of the cohort (aOR 0.49, 95% CI 0.26–0.72). No clinical factors were found to be associated with ACP completion prior to death.

Conclusions
A considerable number of older adults with hip fracture required surrogate decision-making at the end of life, of whom one fifth had no ACP prior to death. Clinicians providing care for these patients are uniquely poised to address ACP.