Connie B. Berthelsen, Copenhagen University Hospital Kirsten Frederiksen, University of Aarhus, Tove Lindhardt, Copenhagen University Hospital Abstract The aim of this study was to generate a grounded theory of older patients’ pattern of behavior in relation to their relatives’ involvement in fast-track programs during total joint replacement. Sixteen patients were recruited in orthopedic wards. Data collection included 11 interviews with patients and 15 non-participant observations of interactions between patients, relatives, and health professionals during scheduled meetings throughout the fast-track program. The constant comparative method was used for simultaneous data collection, data analysis, and coding. Safeguarding self-governance emerged in the analysis as the core category of our theory and pattern of behavior of the older patients in relation to their relatives. The older patients’ main concern was to complete the fast-track program while maintaining autonomy, which they resolved through four strategies of actions: embracing, shielding, distancing, and masking. Keywords: Fast-track program, grounded theory, older patients, relatives, total joint replacement. Introduction Relatives often support their older family members through fast-track programs by sharing concerns, making decisions, and supporting with both emotional and practical issues (Berthelsen, Lindhardt, & Frederiksen, 2014). Although the support of relatives might increase the patients’ abilities to recover, knowledge is needed about how older patients’ actually relate to the involvement of relatives and how their pattern of behavior is displayed through social interactions with relatives. Total hip or knee replacements are invasive surgical procedures performed in fast-track programs. Indications for replacements are often osteoarthritis accompanied by excessive pain and loss of mobility (Kehlet & Søballe, 2010). The orthopedic fast-track program begins with an initial pre-assessment visit at the outpatient facilities, and continues through admission to discharge 1-2 days after the surgery (Kehlet & Søballe, 2010). Fast-track surgery is defined as “the synergistic, beneficent effect on convalescence achieved by adding multimodal evidence-based care principles and combining these with optimized logistics” (Husted, Solgaard, Hansen, Søballe, & Kehlet, 2010, p. 1), which means that the core areas of treatment and care—such as information, surgical stress reduction, pain management, mobilization, and nutrition—have been applied with systematic and evidence-based optimization (Kehlet & Søballe, 2010). Since the mean age of patients undergoing knee or hip replacement is 70 years for women and 68 years for men, consistent from 1995-2012 (The Danish Hip Alloplasty Register, 2013), patients have a higher risk of functional limitation, and are naturally more in need of practical support from relatives. During admission, care is supported by the core areas and administrated following clinical guidelines and the patients are required to participate actively and to adhere to standardized daily regimes. However, older patients might not have the strength and knowledge about this requirement, in which case the support of relatives may be decisive for the patients. A measurable impact on quality, length of stay (Husted et al., 2010), and rehabilitation (Theiss, et al., 2011) was seen when relatives were involved before, during, and after total hip or knee replacement. A study consisting of 1722 observations in four American hospitals revealed a significant effect on the patients’ outcomes regarding social support of the relatives before, during, and after total hip or knee replacement (Theiss et al., 2011). The length of stay was measurably shorter for patients with high or very high levels of relative involvement and the percentage of patients achieving the transfer-out-of-bed-goal was significantly higher for patients with a high level of social support (Theiss et al., 2011). Norlyk and Harder (2011) explored the recovery of 16 patients after elective fast-track...