Satisfaction and quality of dying with nonoperative end-of-life care for hospitalized and non-hospitalized frail older patients with (suspected) hip fractures: a combined cohort study

Background and purpose - For frail institutionalized hip fracture patients who opt for nonoperative management (NOM), the additional treatment benefits of hospital admission and in-hospital diagnostics are not well evaluated. We aimed to describe and compare treatment satisfaction and quality of dying for patients who refrained from hospitalization after a hip fracture and patients who were treated nonoperatively after a short period of hospitalization. Methods - Both cohorts included very frail institutionalized hip fracture patients. The first group directly started supportive care in their own nursing home after a suspected hip fracture. The second opted for NOM during shared decision-making after admission and diagnostics at the hospital. Primary outcomes were treatment satisfaction and quality of dying measured by the Quality of Dying and Death Questionnaire (QODD). Secondary outcomes included health- related quality of life (EuroQoL-5D-5L and Qualidem), pain, and medication. Results - 20 non-hospitalized and 88 hospitalized patients were included. Overall treatment satisfaction by proxies was high for both the non-hospitalized 9 (inter- quartile range [IQR] 8-10) and hospitalized patients 8 (IQR 4-9). Quality of dying was rated higher in the non-hospitalized group with QODD 8.3, IQR 6.9-8.6 versus 7.0, IQR 5.7-7.8, and median difference 1.0 (95% confidence interval [CI] 0.1-1.8). Health-related quality of life, measured by the EQ-5D-5L utility score, was low in both groups but higher in non-hospitalized patients (0.30, IQR 0.15-0.32) than in hospitalized patients (0.25, IQR 0.03-0.32, median difference: 0.03, CI -0.03 to 0.09). Both groups reported similar pain levels, but hospitalized patients used higher standardized daily doses of opiates (68 mg vs 39 mg, median difference 24 mg, CI 7-42). Conclusion - Proxies of hospitalized and non-hospitalized patients report high treatment satisfaction after opting for NOM. Non-hospitalization may have a beneficial effect on quality of dying in selected patients who have prerecorded do-not-hospitalize directives or shared decision- making after a suspected hip fracture.