T he surprise question (SQ) was developed more than a decade ago and has been suggested as a simple test to identify patients who might benefit from hospice and palliative care (HPC).1 It involves a clinician reflecting on the question, "Would I be surprised if this patient died in the next 12 months?". It was thought that the SQ would correct for a physician's tendency to overestimate prognosis 2 by asking the physician to consider whether death in the coming year is possible rather than probable. The surprise question has been widely promoted 3,4 and adopted into frameworks for assessing hospice and palliative care needs. 5,6 In the past few years, several studies have reported on the accuracy of the SQ for a different purpose: as a prognostic test of intermediate-term death in different patient populations. These studies sought to determine whether an answer of "no" (hereafter SQ+) predicts intermediate-term death. We conducted a systematic review of the literature to determine the performance characteristics of the SQ in predicting death and the methodologic characteristics of these studies. Methods Search strategyWe searched MEDLINE (from 1946 to week 2 of October 2016), MEDLINE in process (to Oct. 19, 2016), Embase (1947 to Oct. 19, 2016 The surprise question -"Would I be surprised if this patient died in the next 12 months?" -has been used to identify patients at high risk of death who might benefit from palliative care services. Our objective was to systematically review the performance characteristics of the surprise question in predicting death.