**1. Introduction**

Ageing populations are a global phenomenon with important biopsychosocial and economic impacts that will affect all areas of our lives. The global population over 60 years of age will increase from 900 million in 2015 to 2000 million in 2050, according to the World Health Organization (WHO) [1,2]. From a musculoskeletal perspective, old age means a higher level of osteoporosis, a silent, asymptomatic disease that produces bone fragility and when it manifests as fractures it can put the health of sufferers at risk. Of the various osteoporotic fractures, hip fractures are the most likely to cause mortality: the increased mortality in patients after a hip fracture compared with controls varies between 8% and 36% per year [1,3–6]. Hip fracture in the elderly represents approximately 40% of traumatology admissions in the developed world [1]. Therefore, because of its prevalence and clinical significance, especially in terms of mortality, it is an especially important area in biomedical traumatology research [2]. In the case of an elderly patient, over 85–90 years of age, with a hip fracture, the question arises as to whether it is ethically acceptable to subject the patient to surgery, assuming the risks (anesthesia, blood loss, convalescence) as opposed to the conservative attitude of no surgical intervention. It should be borne in mind that the patient is often vulnerable, not only because their advanced age may prevent them from being self-sufficient when it comes to daily living activities (walking, reading, seeing, hearing, etc.), but also because on many occasions there is an associated deterioration in mental function that hinders both the doctor–patient relationship and the decision-making process, which may be encompassed within the principle of autonomy [7]. All these circumstances described determine that, in many cases, the admitted elderly

**Citation:** Herrera-Pérez, M.; González-Martín, D.; Sanz, E.J.; Pais-Brito, J.L. Ethical Dilemmas with Regard to Elderly Patients with Hip Fracture: The Problem of Nonagenarians and Centenarians. *J. Clin. Med.* **2022**, *11*, 1851. https:// doi.org/10.3390/jcm11071851

Academic Editor: Gianluca Testa

Received: 23 February 2022 Accepted: 24 March 2022 Published: 27 March 2022

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patient is considered ineligible to receive information, regardless of the assessment of their mental capacity to receive this, with the typical circumstance being arrived at where the family is informed before the patient, who should be the holder of the information. This is what many authors have called the tacit pact of silence or conspiracy of silence [8]. In this pact, the influence of ageism is crucial.

#### *1.1. Ageism*

This term was coined in 1968 by the gerontologist and psychiatrist Robert Butler, to refer to discrimination against older people, based on the terms sexism and racism [9,10]. Butler defined "ageism" as a combination of three connected elements. These include harmful attitudes towards older people, old age, and the ageing process; discriminatory practices against older people; and institutional practices and policies that perpetuate stereotypes about older people [11]. The fear of death and the fear of disability and dependency are the leading causes of ageism. In the social and health care system, ageism often manifests as ill-treatment, a lack of attention, and even the restriction of access to specific resources, as discussed later [9–11].
