Prognostic significance of the “surprise” question in cancer patients

Abstract

9588 Background: In patients with advanced cancer, failure to accurately estimate and communicate prognoses can lead to overly aggressive care at the end of life with less attention to important palliative care issues such as pain and symptom management and patients’ values and goals for care. The “surprise” question—would I be surprised if this patient died in the next year?—has been recognized as an innovation to improve end-of-life care in the primary care population by identifying patients with a poor prognosis who are appropriate for palliative care. It has not been previously tested in cancer patients. The purposes of this study were to determine the feasibility and outcomes of the use of the “surprise” question in a cancer center population. Methods: Between July and November 2007, oncologists prospectively classified consecutive breast, lung, and colon cancer patients being seen at the Mary Babb Randolph Cancer Center of West Virginia University into “Yes” and “No” groups based on the surprise question. Patients were followed and their status at the end of one year-alive or dead-was determined along with patient demographics, type of cancer, and stage at presentation. A multivariate Cox proportional hazards regression analysis was used to identify variables associated with patient death. Results: Oncologists classified 826 of 853 prospective patients (97%), with 131 (16%) classified into the “No” group and 695 (84%) into the “Yes” group. At the end of the year, 71 patients had died; 41% of the “No” patients compared to 3% of the “Yes” patients (P <.001). The surprise question ‘No‘ response was more predictive of patient death than stage of cancer, cancer type, or age (hazard ratio 7.53, P value <.001). The “Yes” patients lived longer than the “No” patients (359.8±32.8 days versus 270±131.5 days, P <.001). The sensitivity of the surprise question “No” response was 75% and the specificity was 90%. Conclusions: We conclude that the surprise question is a simple, feasible, and effective tool to identify cancer patients with the worst prognoses who should receive the highest priority for palliative care interventions, particularly advance care planning. No significant financial relationships to disclose.

A scoping review of research to assess the frequency, types, and reasons for end-of-life care setting transitions

“…As the shift to palliative care also often occurs near death, despite most deaths now not being sudden or unexpected [5, 7], and with chronic progressive diseases the leading cause of death worldwide [8], a timeframe of 1 year is recommended for future research and EOL care planning. This recommendation is in keeping with the ‘surprise’ question – would you be surprised if this person were alive a year from now [50, 51]? Although this question is commonly used in the United Kingdom [50, 51], the Medicare Hospice Benefit in the United States of America, which was initially designed for the last 6 months of life, now enables 12 months of publicly funded hospice care [52].…”

“…This recommendation is in keeping with the ‘surprise’ question – would you be surprised if this person were alive a year from now [50, 51]? Although this question is commonly used in the United Kingdom [50, 51], the Medicare Hospice Benefit in the United States of America, which was initially designed for the last 6 months of life, now enables 12 months of publicly funded hospice care [52].…”

Hospice assist at home: does the integration of hospice care in primary healthcare support patients to die in their preferred location – A retrospective cross-sectional evaluation study

“…Patients living at home, with a life expectancy of less than 1 year, were referred to the HaHo service by their GP or DN. The patients’ life expectancy was estimated by the GP, using the ‘surprise’ question: ‘Would I be surprised if this patient died in the next year?’ 11–13 All patients referred to HaHo from June 2012 to December 2014 were enrolled in the study from referral to death or until the end of the study.…”

Consensus document of the Italian Association of Medical Oncology and the Italian Society of Palliative Care on early palliative care

“…The SQ involves a clinician reflecting on the question “Would I be surprised if this patient dies in the next 12 months?” and it is a simple, feasible, and effective tool for identifying patients who have a greatly increased risk of 1-year mortality; its prognostic value for cancer patients has been shown in several empirical studies, 35 and in a recent review its accuracy was slightly better in cancer patients than in other disease groups. 36…”