Background:  Clinicians have been encouraged to utilize the surprise question (SQ) — “Would I be surprised if this patient died within 12 months?” – to identify patients at high 1-year mortality risk.  When clinicians answer “No – I would NOT be surprised if this patient died within 12 months,” the SQ may help clinicians identify patients with unmet palliative care needs who could benefit from advance care planning discussions and/or a palliative care referral (1). This Fast Fact reviews the clinical utility of the SQ.

Rationale of the SQ:   As difficult as it is for clinicians to prognosticate accurately, multiple studies have shown that patients with incurable disease desire more prognostic information the sicker they get and prognosis is a major factor in preferences for rehospitalizations, life support, and CPR (2-4).  Although, patients and surrogates often want temporal prognostic predictions (the clinician’s estimated length of time he or she predicts the patient will live), clinicians are more accurate and willing to offer probabilistic predictions (the clinician’s estimate, often in a percentage, of the chance of death in a set time frame, such as 1 year) (4-6). The SQ was designed as a clinical tool that generalist clinicians would utilize willingly and routinely to identify patients at risk of death in a year and thereby lead to more appropriate advance care planning, goals of care discussions, symptom management, and hospice referrals.

Effectiveness of the SQ:  Although variations on the SQ have been described in the published literature including “Would I be surprised if this patient died this hospitalization?” or “Would I be surprised if this patient died in 3 months?”, the SQ most commonly referred is “Would I be surprised if this patient died within 12 months?” This SQ has been studied in diverse populations, including a general inpatient setting (7), high-risk primary care clinic (8), pediatric patients (9), advanced kidney disease (10-12), cancer (13,14), acute surgical patients (15), emergency department settings (1,16), and nursing home settings (17). In general, the SQ has performed modestly well in identifying patients with a prognosis of < 1 year across these various patient populations (18,19). Notable findings from these studies include:

• A meta-analysis of the SQ among 26 studies across these patient populations found that it had a pooled accuracy of 75%, a sensitivity of 67% and specificity of 80% (18).
• “Yes” answers appear to be much more accurate than “No” answers. The predictive value of a “Yes” answer was 93%, while only 37% for a “No” answer (18). This means that the SQ is likely better designed to identify patients who will live more than a year vs the patients who live less a year. It also suggests that there is “false positives” are relatively common when clinicians answer “No” to the SQ.
• The SQ may be slightly more accurate for cancer patients (pooled accuracy 79%) and renal patients (76%) vs other disease groups (72%) (18). This may reflect a more predictable illness trajectory in cancer and renal disease. See Fast Fact #326 for more information on illness trajectories.
• In most studies, the SQ was utilized as one aspect of a broad prognostic assessment which included clinician gestalt and/or other prognostic tools. Hence, used in isolation, its accuracy is unclear (18).

Implementing the SQ Into Clinical Practice:  The SQ can be helpful in identifying patients at risk of medical decline and death in a certain time frame when used as part of a larger prognostic assessment (19). Yet, considering the relatively high false positive rate of a “No” answer, it is not established if the SQ is a cost-effective tool nor an effective way to trigger a palliative care consultation on its own. A consensus panel of experts suggested that a “No” answer trigger generalist clinicians to perform a primary palliative care assessment or screening for unmet palliative care needs (20).  Sentinel medical events like hospitalization, decline in performance status, or disease progression are reasonable triggers to implement the SQ into clinical practice. Note templates, medical rounding tools, and electric medical record prompts are potential system-based approaches to accomplish this. Reasonable components of the primary palliative care assessment triggered by a “No” include (20):

• Assessment for distressing physical, psychological, social, or spiritual concerns.
• Identification of whether the patient completed an advance directive such as a health care power of attorney that is available in the medical records.
• Assessment of patient, family, and/or surrogate’s understanding of the underlying illness, treatment options, and prognostic trajectory. 
• Assessment of decision-making capacity.
• Engagement in honest conversations about prognosis and medical expectations.
• Elicitation of the patient’s care preferences and values. 
• Consideration of whether a hospice referral would be appropriate.
• Consideration of whether a palliative care consultation may be beneficial.

References:

1. Haydar SA, Almeder L, Michalakes L, Han PKJ, Strout TD. Using the surprise question to identify those with unmet palliative care needs in emergency and inpatient settings: what do clinicians think J Palliat Med. 2017 doi:10.1089/jpm2016.0403
2. Weeks JC, Cook EF, et al.  Relationship between cancer patients’ predictions of prognosis and their treatment preferences.  JAMA 1998;279(21):1709-1714.
3. Murphy DJ, Burrows D, et al.  The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation.  NEJM 1994; 330:545-549.
4. Gaston CM, Mitchell G.  Information giving and decision-making in patients with advanced cancer: a systematic review.  Soc Sci and Med 2005;61(10):2252-64.
5. Christakis NA, Lamont EB.  Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study.  BMJ 2000; 320;469-472.
6. Hagerty RG, Butow PN, et al.  Communicating prognosis in cancer care: a systematic review of the literature.  Ann of Onc 2005; 16(7):1005-53.
7. Downer J, Goldman R, Pinto R, Englesakis M, Adhikari NKJ.  The “surprise question” for predicting death in seriously ill patients: a systemic review and meta-analysis. CMAJ. 2017;189(13):484-93.
8. Larkin JR, Robinson MG, Bernacki RE, et al. Estimating 1-year mortality for high-risk primary care patients using the “surprise” question. JAMA Intern Med. 2016;176(12):1863-1865.
9. Burke K, Coombes LH, Menezes A, Anderson AK.  The ‘surprise question’ in paediatric palliative care: a prospective cohort study. Palliative Medicine 2018; 32(2):535-42.
10. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3(5):1379-84.
11. Pang WF, Kwan BC, Chow KM, Leung CB, Li PK, Szeto CC. Predicting 12-month mortality for peritoneal dialysis patients using the “surprise” question. Perit Dial Int. 2013;33(1):60-6.
12. Javier AD, Figueroa R, Siew ED, et al. Reliability and utility of the surprise question in CKD stages 4 to 5. Am J Kidney Dis. 2017 doi: 10.1053/j.ajkd.2016.11.025.
13. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-40.
14. Moroni M, Zocchi D, Bolognesi D, et al. The ‘surprise’ question in advanced cancer patients: a prospective study among general practitioners. Palliat Med. 2014;28(7):959-964.
15. Lilley EJ, Gemunden SA, Kristo G, et al. Utility of the “surprise” question in predicting survival among older patients with acute surgical conditions. J Palliat Med. 2017;20(4):420-23.
16. Ouchi K, Jambaulikar, et al.  The “surprise question” asked of emergency physicians may predict 12-month mortality among older emergency department patients. J Pall Med 2018; 21(2): 236-40.
17. Rice J, Hunter L, Hsu AT, Donskov M, Luciani T, Toal-Sullivan D, Welch V, Tanuseputro P. Using the ‘Surprise Question’ in Nursing Homes: A Prospective Mixed-Methods Study. J Palliat Care. 2018; 33(1):9-18.
18. White N, Kupeli N, Vickerstaff V, Stone P. How accurate is the ‘Surprise Question’ at identifying patients at the end of life? A Systematic review and meta-analysis. BMC Med. 2017; 15(1):139.
19. Romo RD and Lynn J. The utility and value of the “surprise question” for patients with serious illness. Canadian Medical Association Journal 2017; 189(33):E1072-1073.
20. Weissman DE, Meier DE.  Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 14(1):1-6.

Author Affiliations: 1University of Colorado School of Medicine, Aurora, CO, USA; 2Medical College of Wisconsin, Milwaukee, WI; 3Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA

Conflicts of Interest: None to report

Version History: First electronically published in July 2018.