Predicting 12-Month Mortality for Peritoneal Dialysis Patients Using the “Surprise” Question

Abstract

♦ Background: Studies in hemodialysis patients suggest that the "surprise" question can help to identify a group of patients with a high mortality risk who should receive priority for palliative care interventions. However, the same instrument has not been tested in peritoneal dialysis (PD) patients. ♦ Method: We studied 367 prevalent PD patients from a single dialysis center. Three clinicians independently answered the "surprise" question (Would I be surprised if this patient died within the next 12 months?) according to their clinical impression of the individual patient. Patients are then classified into "yes" (yes, surprised) and "no" (no, not surprised) groups. All patients were followed for 12 months. ♦ Results: In this cohort, 109 patients (29.7%) were allocated to the "no" group, and 258 (70.3%), to the "yes" group. Patients in the "no" group were older and had high prevalences of pre-existing ischemic heart disease, cerebrovascular disease, and peripheral vascular disease. The "no" group had a higher score on the Charlson comorbidity index and a higher malnutrition-inflammation score. At 12 months, 44 patients had died. Mortality was 24.8% in the "no" group and 6.6% in the "yes" group. Multivariate analysis showed that an opinion of "Not surprised if dies in the next 12 months" was an independent predictor of 12-month mortality, with an associated 3.594 excess mortality risk (95% confidence interval: 1.411 to 9.151; p = 0.007). The positive predictive value of this opinion was 24.8%, and its negative predictive value was 93.4%. ♦ Conclusions: The "surprise" question has the potential to help identify a group of PD patients with high short-term mortality. Its use may contribute to a decision to refer PD patients for early palliative care assessment.

How to Integrate Predictions in Outcomes in Planning Clinical Care

“…The Karnofsky Performance Status (69.7 ± 17.1 vs. 81.6 ± 15.8) and comorbidity score (CCI of 7.1 ± 2.3 vs. 5.8 ± 2.1) are independent predictors of death. Similar results were seen in a study from Hong Kong of peritoneal dialysis (PD) patients where an answer of ‘no' to the SQ question was associated with a HR for death of 3.594 compared with the ‘yes' group (95% CI 1.411-9.151) [36]. The SQ, combined with the actuarial measurements of albumin, presence of peripheral vascular disease (PVD), dementia, and age, has been shown to be predictive of 6-month mortality in hemodialysis patients (AUC = 0.77, 95% CI = 0.72-0.82) [35].…”

The “surprise question” for predicting death in seriously ill patients: a systematic review and meta-analysis

“…14,19 In 3 studies, the SQ was used only to predict 7-and/or 30-day mortality. 29,37,38 Sixteen remaining studies of SQ to predict death met inclusion criteria 1,[20][21][22][23][24][25][26][27][28][30][31][32][33][34][35] (Table 1) and were included in the meta-analysis. One study provided data for a derivation cohort in the manuscript.…”

“…34 The SQ was answered by physicians in 13 studies (including oncologists, 26,33,35 nephrologists, 20,22,[30][31][32] respirologists, 23 intensivists, 24 and general practitioners 21,25,34 ), specialist nurses in 1 study, 1 either a physician or a nurse in 1 study 28 and a multidisciplinary team of 2 physicians and a nurse in another study. 27 In each case, the assessors were familiar with the patient.…”

“…27 In 1 study of patients receiving hemodialysis, every physician and nurse working with that patient was asked the SQ independently; to be consistent, we considered that the patient was SQ+ if either of the 2 physicians attending in their unit responded "no" to the SQ. 30 One study of patients receiving peritoneal dialysis 22 asked the SQ to 3 nephrologists for each patient and reported slight to fair 39 agreement (κ 0.34-0.41). We assessed the methodologic quality of the included studies using the 6 domains of the Quality in Prognosis Studies tool 7 ( Table 2) and assigned an overall risk of bias for each study according to the highest risk score in any domain.…”

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“…The so-called "surprise question" ("Would I be surprised if this patient died in the next 12 months?" [59,60]) has proved helpful in estimating the 12-month survival probability of patients with oncological or nephrological diseases [59,60]. If this might be true also for neurological diseases still needs to be clarified.…”