Project Abstract Our current project, “A Layered Examination of the Patient Experience to Elucidate the Role of Palliative Care in Surgical Care for Seriously Ill Adults” (R01 AG070252-01A1) has contributed insights into the role of palliative care for seriously ill older adults undergoing elective surgeries. However, quantitative data from this project reveals that more than half of major surgical procedures for seriously ill older adults are unplanned (i.e., urgent, emergent), rather than elective, and that hip fracture is one of the most common surgical conditions among this group. Furthermore, our prior work shows that most older adults with hip fracture have palliative care needs preceding injury. These findings highlight a key area of research, particularly for persons living with dementia (PLWD), as over 60% of surgery among PLWD is unplanned, and the risk of hip fracture in PLWD is 2.7 times greater than those without dementia. Specifically, we have identified critical knowledge gaps at the intersection of surgery and palliative care that would benefit from supplemental funding: 1) The frequency with which seriously ill older adults and PLWD receive palliative care and its association with long-term outcomes in the setting of unplanned surgical care is unexamined. 2) Contextual factors influencing palliative care delivery during inpatient care for hip fracture and, particularly for PLWD, are undescribed. 3) There is insufficient evidence about deliberations for surgery and outcomes among adults who do not have surgery to guide improvements in the caregiver experience or shared decision making. Building upon the methodologies, resources, and procedures utilized in our current project, this supplemental work examines the role of palliative care in unplanned surgical care for hip fracture among seriously ill older adults, with a specific focus on PLWD. Aim 1 will identify a retrospective cohort of older seriously ill adults (≥66) with hip fractures in a large regional health system and use natural language processing in electronic health data linked to Medicare Claims to identify inpatient palliative care processes (goals of care discussions, healthcare proxy documentation, caregiver assessments, specialty palliative care, hospice referrals). We will evaluate associations between inpatient palliative care and healthcare utilization within one-year post-discharge, and sub-analyses to assess this relationship among PLWD. Aim 2 uses ethnographic observations to obtain an in-depth understanding of contextual factors influencing palliative care delivery for older adults with serious illness and PWLD with hip fractures. Observations will focus on decisions for surgery, caregiver involvement, and transitions to post-acute care. Responding to the National Institutes of Health’s call for research related to experiences of PLWD, geriatric palliative care, and emergency care for older adults, findings from the proposed studies will guide surgical and...