Effectiveness of interventions to increase the proportion of older adults admitted with fragility fracture with an advanced care

Introduction:
Advance care planning (ACP) supports discussions about future care preferences but remains underutilised among older adults. Older adults hospitalised with fragility fractures represent a high-risk population with significant unmet ACP needs. Hospital admission may provide an opportunity to initiate ACP discussions. This review evaluated ACP interventions for older adults hospitalised with fragility fractures and described intervention characteristics.

Methods:
A systematic search of MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL, Web of Science, and grey literature sources was conducted for studies published up to 19 January 2026. Studies evaluating ACP interventions for adults aged ≥65 years hospitalised with fragility fractures were included. Study selection and quality assessment were undertaken independently by two reviewers using CASP and ROBINS-I, and findings were synthesised narratively.

Results:
Fourteen studies published between 2012 and 2025 were included. Thirteen focused on hip fracture populations and one on a broader fragility fracture population. Several studies included frail populations, including care home residents (11%-100%) and people living with dementia (16%-90%). ACP interventions included ACP documentation, do-not-attempt resuscitation (DNAR) decision-making, palliative care involvement, goals-of-care discussions, and shared decision-making regarding treatment. Interventions were most commonly delivered by physicians or senior clinicians, although reporting was inconsistent and no study reported intervention frequency. Outcomes primarily focused on ACP documentation and end-of-life care processes, including advance directives, advance care plans, DNAR decisions, surrogate decision-making, ceilings of care, and palliative care involvement. Mortality was the most frequently reported clinical outcome. Patient- and proxy-reported outcomes included health-related quality of life, treatment satisfaction, and quality of dying.

Conclusion:
Evidence evaluating ACP interventions for older adults hospitalised with fragility fractures is limited. Existing studies primarily focus on documentation and end-of-life care processes rather than increasing ACP engagement. Multidisciplinary approaches that extend responsibility for ACP discussions beyond physicians may help increase uptake to ACP.