Table 1 A rationale for the authors’ approach to consent in the case of geriatric hip fracture

1. Start the clock. Ensure that the question of capacity is fully answered to allow treatment within the 36 h window of safety.

There is a strong association between delayed treatment and an increased risk of harm

2. Assess mental status closely.

Many patients with geriatric hip fracture may have a cognitive impairment

 a. Attempt to address the causes of cognitive impairment (via steps noted above), and reassess patient periodically to monitor effects of those efforts.

Many cases of cognitive impairment may be due to a reversible delirium

 b. Attempt to identify family members, caregivers, health proxies, etc. who can provide surrogate consent.

Surrogate consent is preferable to presumed consent

 c. Convene an ad hoc treatment committee to determine, absent patient-provided consent, the ideal treatment of the given patient’s fracture.

A committee comprising members with the relevant expertise in the medical, surgical, social and functional issues will be able to best select the treatment

4. Conduct the necessary pre-operative medical workup so that the patient is able to undergo surgery as soon as either consent is achieved or 36-h window closes.

Although many patients can be readied for surgery within 36 h, there may be necessary medical evaluations and interventions to assure safe care. Waiting for improved capacity or a surrogate decision maker need not be wasted time

5. By the 36th hour, if the patient is ready for surgery in all other ways, and if the patient cannot provide informed consent, and if substitute consent has not yet been employed, treat as suggested by an ad hoc committee under presumed consent.

The risk of waiting longer outweighs the potential gains, especially if steps 1–4 are taken