Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Care must be taken before assuming that elderly people do not want to live when they are in a state
- Michael M Rivlin (11 February 2000)
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Reducing the incidence of hip fractures will prevent significant reductions in quality of life
- Glenn Salkeld (13 February 2000)
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Data argue against "fair innings" contention
- Rowan H Harwood (21 February 2000)
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Quality of life related to fear of falling and hip fracture in older women
- Malcolm Paes (21 February 2000)
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And after the fall?
- Stephen Workman (29 February 2000)
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What older Americans choose
- Gerson T Lesser (17 March 2000)
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Re: Quality of life related to fear of falling and hip fracture in older women
- Lisa Machin (5 January 2002)
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Michael M Rivlin
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Editor, We must be careful what inferences we draw from the results of the survey conducted by Salkeld et al (1). I of course agree with the authors that hip fractures should be treated and that doing so will increase quality of life, but presumably we did not require a survey to tell us that. It should be emphasised that the survey was conducted on only a small number (203) of women. I am not a statistician but it seems to me dangerous to imply that any woman aged 75 or over with hip fracture would regard such a condition as being worse than death, "The findings of this study should be applicable to all frail older women who have sustained injury after a fall ..." In any case, there is evidence to show that very elderly people do value their lives even when they are in a state of ill health. (2) I am also concerned that by stating, "...they believed in the 'fair innings' arguments", Salkeld et al are leading us to think that this was the general view of those surveyed. The authors should not make such a statement without making it clear how many of those surveyed concurred with this view. Clarifying this is important because the authors use the statement to back up their conclusions. What concerns me is that in an era of finite resources where age-based rationing of health (ABR) care is common, the results of the survey on a very small number of patients could be used as ammunition by those who argue for meso and macro ABR policies on the basis that elderly people as a group have lost the will to live, especially after they become ill. Dr Michael M. Rivlin
REFERENCES: 1. Salkeld G, et al Quality of life related to fear of falling and hip fracture in older women: a time trade off study. BMJ 2000;320:241-6. 2. Tsevat J, Dawson NV, Wu AW, Lynn J, Soukup JR, Cook EF, et al. Health values of hospitalised patients 80 years and older. JAMA 1998;279:371-6. |
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Glenn Salkeld, Senior Lecturer University of Sydney, Australia
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We agree with Rivlin that we do not need a survey to tell us that hip fractures should be treated. Our paper (Salkeld et al) was not a survey regarding treatment of hip fractures but rather a study to estimate how older women valued quality of life after falls or hip fracture. We are not discussing whether to treat a hip fracture but rather we are putting forward an argument as to why it is important to prevent falls and hip fracture, and have effective surgical treatment and rehabilitation after hip fracture. As we state in the concluding sentence of the paper "a reduction in the incidence of hip fractures will not only save lives but will prevent a significant reduction in their quality of life". Our results are statistically robust. For a time trade-off study such as this, the sample size of 203 had sufficient power to detect a 10% difference in utility scores, (where a = 0.05, power=80%) between the three groups of women interviewed. It was unexpected and disturbing to find that 80% of women studied would rather be dead than suffer a 'bad hip fracture' and require nursing home placement. However we will not know what older women think about the prospect of a hip fracture and moving to a nursing home unless we ask them. Concern is also expressed at the 'fair innings' argument. Of the women who were prepared to trade-off all survival for quality of life, 61% made statements that were consistent with the fair innings argument. In our study the verbal comments during the interview did accord with the expressed preference. Rivlin's final point is that our results could be used for age-based rationing of health care. The paper should not be seen as an argument for age based rationing but rather an appeal for effective prevention of falls and hip fracture. We will strongly object if our findings are (mis)-used to deny patients preventive measures or treatments for hip fractures. |
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Rowan H Harwood
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Editor- Salkeld et al demonstrate that the prospect of poor recovery from a hip fracture requiring nursing home care is rated as poorly as death by most elderly women [1]. Similar findings have been reported for outcomes after stroke [2]. There are several cautions about such results which need emphasising. Contemplating the prospect of a bad hip fracture, especially in an "at risk" population in whom the risks may have been emphasised, could plausibly lead to less favourable ratings than the actuality once it has been experienced. A problem with measuring utilities directly in people in nursing homes is that the usual reason for requiring this level of care is a combination of severe physical and mental disabilities, making the measurement process untenable. Variation in opinions between individuals may also have important implications. Should we try to anticipate those who wouldn't mind nursing home life so much and treat them differently? Our ability to predict outcomes that precisely is notoriously poor. My main point of contention is introduction in the discussion section of the "fair innings" argument about resource allocation towards the end of life. Are they advocating euthanasia for patients fracturing their hips? If nothing else, operative fixation is excellent pain-relieving palliation. Our service provides excellent surgery and good access to prolonged rehabilitation if that is needed, and no more than 11% of hip fracture patients admitted from home are discharged to nursing homes. I agree that severe dependency after hip fracture is a bad outcome, but with optimal management that will only occur in a minority of cases. We might also try to do something to make life in nursing homes more tolerable, but that is another story. The message to take from this study, surely, is that investment in fracture prevention (falls and osteoporosis), and high quality rehabilitation is very important, and all the more necessary because the alternatives are rated so poorly. The data actually argue against the "fair innings" contention that resources should not be expended on health care for elderly people. 1. Salkeld G, Cameron ID, Cumming RG, Easter S, Seymour J, Kurrle SE, Quine S. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. BMJ 2000: 320: 241-6 2. Gage BF, Cardinalli AB, Owens DK. The effect of stroke and stroke prophylaxis with aspirin or warfarin on quality of life. Archives of Internal Medicine 1996;156:1829-36. Rowan H Harwood
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Malcolm Paes
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Dear Sir, I read with interest the study by Cumming et al (Ref 2) and the accompanying commentary (Ref 2). The finding that 80% of elderly women would prefer death to a hip fracture resulting in loss of independence and mobility with admission to a nursing home is alarming but understandable. In a case report cited in the British Journal of Anaesthesia (Ref3) Britain's oldest living person at the age of 113 years sustained a fractured hip and successfully underwent surgery and anaesthesia followed by admission to ITU for post-operative ventilation. She was discharged from hospital and survived a further nine months. The accompanying editorial (Ref 4) recommended speedy operation upon admission and aggressive perioperative care including, if necessary, ITU. With unlimited resources this is fine and represents our gold standard. Whilst the recommendation is sound in itself this would represent a large expenditure on scarce resources including ITU beds especially given the increasingly elderly population and hence expected dramatic rise in hip fractures. It is, however, inhumane to keep such patients in traction and the cost would be equally formidable. The institution of consultant led trauma lists has no doubt improved the quality of care meted out to these patients but expeditious operating is still a vexed issue due to limited staffing and operating time. As always, the solution must lie in prevention. Whilst most fractures occur in the community a significant number of falls some resulting in fractured hips occur in hospitals. Many cases are due to poor supervision by nursing staff or care assistants. Personal accountability for these negligent actions may help reduce their frequency as may stringent audit of all falls on wards. Perhaps, falls resulting in fractures should be treated as critical incidents. Prevention whether in the community or hospital ward will be expensive but so will be treatment but either way the consequences of inactivity are unacceptable. Malcolm Paes References 1)Cumming R G, Semour J, Quine S, Cameron I D, Easter S, Kurrle S E, Quality of life related to fear of falling and hip fracture in older women: a time trade off study. BMJ 2000, 320: 341-6. 2) Ameratunga S N, Brown P M. Older people's perspectives on life after hip fractures. BMJ 2000 320:346. 3) Oliver C D, White S A, Platt M W. Surgery for fractured neck of femur and elective ICU admission at 113 yr. of age. Br. J Anaesth. 2000; 84:260-2. 4)Sharrock N .E, Fractured femur in the elderly: intensive perioperative care is warranted. Br. J Anaesth2000, 84:139. |
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Stephen Workman, Dalhousie University Halifax Nova Scotia
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How do elderly patients who have broken their hips and lost their independence rate the quality of their life? |
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Gerson T Lesser
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To the Editor: Salkeld and co-workers' (1) study of choices of older patients in hypothetical illness scenarios is of particular pertinence to our nursing home population. We are struck by the contrasts in attitudes and expectations from the elderly patients with whom we are in daily contact. In our experience, most older Americans hold onto life very dearly, and usually opt for even noxious treatments, such as chemotherapy, in order to gain a few months or years of reduced-quality life. These attitudes are consistent with observations of elderly (>80 yr) hospitalized patients, many of them in poor health. When offered time-trade-off preferences of current health state or shorter life in excellent health, over two-thirds were unwilling to exchange even 10% of life expectancy for the benefit of "excellent health" (2). Basic expectations also appear to differ between Australian and U.S. elderly. While many would attest to having had a fair or good long life, we rarely hear any suggestion that one has lived overlong or "…on borrowed time at the expense of younger people." Patient choices are amenable to influence and alteration (3). Salkeld's subject's choices conformed to attitudes and opinions of the investigators, who note in several places that all subjects had already "…exceeded average life expectancy…". Certainly people are unwilling to lose independence of function or decision, but we cannot readily accept (even for Australians) that 80% would rather be dead than suffer a hip fracture and subsequent admission to a nursing home. (Is there any incidence of suicide or request for death when such events are actually faced?) This prompts further consideration that advance preferences/directives may not conform with those when crisis is at hand. In abstract discussion (or in living wills), tube feeding, respirator care, and even intravenous treatments are often abjured, but such prohibitions are rarely carried forward when the acute illness is faced. Attitudes of those already in nursing homes with hip fractures might be studied for comparison with Salkeld's subjects. Our very active rehabilitation department deals with over 80 recovering hip fracture patients annually; many remain for long term care. While some of the latter are depressed, the majority soon accommodate, adjust and have reasonable quality of life. References: 1. Salkeld G, Cameron ID, Cumming RG, Easter S, Seymour J, Kurrle SE, Quinne S. Quality of life related to fear of falling and hip fracture in older women: a time trade-off study. BMJ 2000;320:341-345. 2. Tsevat J, Dawson NV, Wu AW, Lynn J, Soukup JR, et al. Health values of hospitalized patients 80 years or older. JAMA 1998;279:371-375. 3. Malloy TR, Wigton RS, Meeske J, Tape G. The influence of treatment descriptions on advance medical directive decisions. J Am Geriatr Soc 1992;40:1255-1260. Randall McShine, M.D. Gerson T. Lesser, M.D.(corresponding
author)
Antonios Likourezos, M.A., M.P.H The Jewish Home and Hospital, 120 West 106th Street, New York, New York 10025, and Dept. of Geriatrics & Adult Development, Mount Sinai School of Medicine |
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Lisa Machin, clinical audit assistant Shropshire Community Trust, SY3 8DN
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Proper rehabilitation leads to patients extending their physical abilities and falls on the ward will be an inevitable part of rehab for many. Making the nurse personally accountable for these incidents will hardly lead to a culture of re-enablement. Perhaps you have missed the point-proper rehab takes time and adequate resources, including numbers of nurses and therapists-unfortunately rare. |
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