Periprosthetic Fracture Management

Introduction to Surrogate Decision-Making

Patients with advanced dementia and lack of decision-making capacity should have a surrogate decision-maker, with the decision based on the patient's best interests and previously expressed wishes, as recommended by the American Geriatrics Society 1, 2, 3

Non-intervention for periprosthetic fractures carries risks including increased pain, loss of mobility, potential for pressure injuries, higher mortality risk, and complications from immobility 2
Surgical intervention for periprosthetic fractures offers benefits including pain control and potential for improved function 2

Proper documentation of the informed refusal process, including the surrogate's understanding of risks and consequences, is essential for protecting patient autonomy and provider legal position, and should include current functional status, pain assessment, and vital signs 1, 2
The care plan should include pain management, positioning and pressure injury prevention measures, mobility restrictions, monitoring parameters for potential complications, and circumstances prompting hospital transfer reconsideration 2

Medical decision-making should avoid age-based discrimination, ensuring decisions are based on the patient's best interests and previously expressed wishes, as recommended by the American Geriatrics Society and other organizations 3
Patients who refuse medical interventions should continue to receive appropriate care, with implementation of best possible conservative management and regular condition reassessment 2, 3
Healthcare organizations should implement clinical decision support systems to ensure appropriate test ordering, with moderate strength of evidence, as recommended by the American College of Physicians 4
Patients must be informed about a test's purpose, risks, benefits, and alternatives, and provide informed consent before any medical procedure, with high strength of evidence, as recommended by the American Medical Association 4

Adult patients with capacity have the right to refuse medical treatment, including surgery, a principle established in medical ethics and law, supported by the Association of Anaesthetists, American Society of Anesthesiologists, American Medical Association, and American College of Surgeons 5
A competent adult patient's refusal of medical treatment must be respected, and a family member cannot provide consent on behalf of a competent adult, as recommended by the American Medical Association and the American College of Surgeons 5
Informed consent must be obtained in writing prior to any medical procedure, explaining the nature, reason, benefits, risks, and alternatives, with high strength of evidence, as recommended by the British Society of Gastroenterology guidelines and other authorities 6, 7

A physician must evaluate a patient to determine if a test is medically necessary, with high strength of evidence, as recommended by the American Medical Association 4
Proper test authorization should follow a pathway including patient evaluation, medical necessity documentation, informed consent, and authorization, with moderate strength of evidence, as recommended by the American Academy of Family Physicians 4
Standardized protocols for test authorization should be implemented to prevent inappropriate practices, with moderate strength of evidence, as recommended by the American College of Physicians 4

Patients who refuse medical interventions should not be dismissed from care, and clinicians should continue to provide care in other areas, avoiding making the patient feel judged, as highlighted by the ESPEN guidelines and the Centers for Disease Control and Prevention 8, 9
Documenting the patient's explicit refusal, noting their reasons for declining treatment, and explaining potential consequences is crucial in respecting patient autonomy and avoiding legal vulnerability, as advised by the American Academy of Medical Ethics and other guidelines 10, 11, 12

For asymptomatic hernias in elderly patients, guidelines suggest against elective surgery when there are no symptoms or complications, with careful evaluation of the risk-benefit ratio, especially in elderly patients where surgical mortality increases with age, as stated by the World Journal of Emergency Surgery and the American College of Surgeons 13
Surgeons are not obligated to perform procedures they believe are non-beneficial or potentially harmful, and referral to another surgeon for a second opinion preserves the doctor-patient relationship while maintaining professional integrity, as suggested by the guidelines 13