When 'No Surgery' Is Chosen: A Five-Domain Framework for Evaluating Ethical Consent in Non-Operative Hip Fracture Care.

BACKGROUND

Hip fracture in frail older adults is commonly managed surgically, but non-operative management may be appropriate for selected patients with extreme frailty, limited life expectancy, severe cognitive impairment, multimorbidity or limited expected benefit from surgery. However, when 'no surgery' is chosen, documentation of consent or refusal may complete a procedural requirement without ensuring ethically sufficient decision-making.

METHODS

A structured, literature-informed conceptual ethical analysis was conducted using PubMed and Scopus searches, citation tracking and synthesis guided by the four principles of biomedical ethics.

RESULTS

Four ethical gaps are identified: non-operative burdens are often naturalised, 'conservative treatment' may be mistaken for comfort care, family signatures may not fully represent patient values, and refusal of surgery does not end clinical responsibility. These recurring concerns are organised into a five-domain framework: Burden, Goal, Voice, Balance and Commitment.

CONCLUSIONS

Non-operative hip fracture care should move from procedural consent to ethical consent. The proposed framework may support balanced risk communication, goal clarification, patient-centred decision making and continued care planning when 'no surgery' is chosen.