Lessons from two of the oldest old patients with hip fractures: Patient-centric approach versus the frustrating assessments resulting in cumulative exhaustion syndrome

The French composer Daniel Auber is attributed with having said, “Ageing seems to be the only available way to live a long life”.^[1] Both Time magazine and National Geographic have featured children on their covers with headlines suggesting they may live for more than 120 years.^[2,3] With increasing life expectancy, we face several healthcare challenges that are likely to evolve in ways we may not be prepared for.

For instance, we must unravel the finer points of frailty syndrome, currently defined as a decline in physiological reserve across multiple organ systems, leading to increased vulnerability to external stressors.^[4] By 2030, only 4 years away, Western societies anticipate that 20% of all surgical procedures will be performed in patients over 75 years of age.^[5]

Against this backdrop, my family recently faced a healthcare crisis of epic proportions. Two very close relatives, both among the “oldest old” (85 years and above), suffered hip fractures within 5 days of each other [Figure 1]. I realized how ill-prepared we were, despite my being a senior specialist physician with a keen interest in geriatrics and more than 40 years of academic experience, including service as professor and department head in teaching hospitals.^[6] Viewing the situation from the patient’s side of the table made me recognize how hollow many socalled “patientcentric” approaches truly are. They often seem designed by those who have never experienced care from the patient’s perspective, especially not for the oldest old.

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Figure 1: Tale of two oldest old (>85 years) patients with hip fractures.

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Both patients were over 91 years of age. They had been living reasonably independent lives, mobile and able to manage their activities of daily living (ADL) as well as instrumental ADL. One was admitted to the hospital within 6 h of the fall, diagnosed immediately with a fracture of the femoral neck, operated on the following day, and discharged on day 6. The other was admitted for neurological symptoms; the femoral neck fracture was diagnosed several days later, surgery was performed on day 13, and hospitalization lasted a total of 30 days. Given such contrasting clinical courses, one might expect starkly different patient and caregiver experiences. Some aspects indeed differed, but for this editorial, I will focus on one element that was identical in both cases.

Is there anything we, as doctors and healthcare professionals, do in the name of patient welfare that actually achieves the opposite?

Once admitted under the orthopedic surgeon, a parade of healthcare professionals began trooping in and out of the patients’ rooms, junior resident, senior resident, nurse, nutritionist, physiotherapist, orthopedic surgeon, anesthetist, and internal medicine physician. Each was polite, yet 90% of the questions asked were identical.

It is said that a healthy young adult (16 years and older) generally has an attention span of 32–50 min.^[7] This peaks at around 43 years of age and declines after 60.^[8] For healthy adults over 85, sustained attention drops dramatically to an average of only 1–5 min.^[9] Yet my relatives, suffering painful hip fractures and the shock of hospitalization, were subjected to repetitive questioning by wellmeaning professionals who seemed unaware of its implications. I saw little evidence of a truly patientcentric approach.

This is when I realized that a huge, unrecognized gap exists, one without a name, ICD code, documentation, or visibility. I coined the term frustrating assessments resulting in cumulative exhaustion (FARCE) syndrome. The name is deliberate. A “farce” implies a ridiculous, disorganized process that wastes everyone’s time, precisely what uncoordinated, redundant assessments inflict on patients. The word requires no explanation. Patients, clinicians, administrators, and policymakers will (hopefully) immediately grasp what is being described. That clarity of communication will be its greatest strength.

Although I recognized its importance in my oldest old relatives, I believe that FARCE syndrome has wider relevance across healthcare, with particular significance in geriatrics, oncology, pediatrics, and complex inpatient care. Now that it has been named, I trust that its definition, diagnostic criteria, grading, documentation in medical records, analysis, and remedial measures will follow. It should become a new yardstick for a truly meaningful, realworld patientcentric approach.

Let us look up from our case sheets, our screens, and our scoring tools, and pause to read existing medical records before entering the patient’s room.