European geriatric medicine · 2025
Defining ceilings of treatment in hip fracture patients: prevalence, prognostic value, and the role of orthogeriatric co-management.
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Bastings Janneke J C, Vleeshouwers Karin, Poeze Martijn, van den Boogaart Mark, Janssen Daisy J A, Hendriks Jeroen M, Brouns Steffie, Spaetgens Bart
Аннотация
PURPOSE: Ceilings of treatment, including do-not-resuscitate (DNR), do-not-intubate (DNI), or decisions to forgo intensive care unit (ICU) admission, are increasingly recognised in frail older adults, but evidence in hip fracture care is scarce. We aimed to (1) describe the prevalence and predictors of treatment ceilings, (2) evaluate associations with mortality and length of stay, and (3) assess the association of orthogeriatric care (OGC) with ceilings and outcomes.
METHODS: This retrospective cohort study included 1,120 hip fracture patients admitted to Maastricht University Medical Centre + in 2017-2018 and 2021-2022. Treatment ceilings were classified as full (no limitations), limited (DNR, optional ICU/intubation), or completely limited (DNR/DNI/no ICU). Multinomial logistic regression identified predictors, and Cox models estimated associations with 1-year mortality.
RESULTS: The median age of the patients was 82 years (IQR 74-87); 66% were female, while 14% lived in nursing homes. Overall, 50% had a limited or completely limited order. These were more common in patients with higher age, comorbidity, care dependency, higher ASA classification, and nursing home residency. Compared with full treatment, limited (aHR 2.44, 95% CI 1.66-3.58) and completely limited orders (aHR 3.79 95% CI 2.79-5.16) were independently associated with higher 1-year mortality. OGC was not linked to more ceilings, but was associated with lower 1-year mortality across all categories (aHR 0.69, 95% CI 0.54-0.87).
CONCLUSION: Half of hip fracture patients had a documented ceiling of treatment, strongly predicting mortality. OGC was associated with improved survival regardless of ceiling status, underscoring the need for geriatric integration and standardised definitions of treatment ceilings in hip fracture care.
METHODS: This retrospective cohort study included 1,120 hip fracture patients admitted to Maastricht University Medical Centre + in 2017-2018 and 2021-2022. Treatment ceilings were classified as full (no limitations), limited (DNR, optional ICU/intubation), or completely limited (DNR/DNI/no ICU). Multinomial logistic regression identified predictors, and Cox models estimated associations with 1-year mortality.
RESULTS: The median age of the patients was 82 years (IQR 74-87); 66% were female, while 14% lived in nursing homes. Overall, 50% had a limited or completely limited order. These were more common in patients with higher age, comorbidity, care dependency, higher ASA classification, and nursing home residency. Compared with full treatment, limited (aHR 2.44, 95% CI 1.66-3.58) and completely limited orders (aHR 3.79 95% CI 2.79-5.16) were independently associated with higher 1-year mortality. OGC was not linked to more ceilings, but was associated with lower 1-year mortality across all categories (aHR 0.69, 95% CI 0.54-0.87).
CONCLUSION: Half of hip fracture patients had a documented ceiling of treatment, strongly predicting mortality. OGC was associated with improved survival regardless of ceiling status, underscoring the need for geriatric integration and standardised definitions of treatment ceilings in hip fracture care.