Reliability and Utility of the Surprise Question in CKD Stages 4 to 5

Abstract

Background Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question (“Would you be surprised if this patient died in the next 12 months?”) is a tool to assist in prognostication. However, it has not been studied in non–dialysis-dependent CKD and its reliability is unknown. Study Design Observational study Setting & Participants 388 patients at least 60 years of age, with non–dialysis-dependent CKD stages 4–5, who were seen at an outpatient nephrology clinic. Predictor Trinary (i.e., ‘Yes’, ‘Neutral’, ‘No’) and binary (‘Yes’, ‘No’) surprise question response. Outcomes Mortality, test-retest reliability, and blinded inter-rater reliability Measurements Baseline comorbidities, Charlson comorbidity index, cause of CKD, and baseline laboratory values (i.e., serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin). Results The median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded ‘Yes’, ‘Neutral’, and ‘No’ for 202 (52%), 80 (21%), 106 (27%) patients, respectively. About 5%, 15%, and 27% of ‘Yes’, ‘Neutral’, and ‘No’ patients died, respectively (p<0.001). The trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42–0.72) and the test-retest reliability was 0.63 (95% CI, 0.54–0.72). The trinary surprise question ‘No’ response had a sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had a sensitivity of 66% (95% CI, 49%-80%; p=0.3 vs trinary) but a lower specificity of 68% (95% CI, 63%-73%; p=0.02 vs trinary). Limitations Single center, small number of deaths. Conclusions The surprise question associates with mortality in CKD stages 4–5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non–dialysis-dependent CKD.

Health Outcome Priorities of Older Adults with Advanced CKD and Concordance with Their Nephrology Providers’ Perceptions

“…We approached older adults (age $60 years) with non-dialysisdependent CKD stages 4-5 who were seen in follow-up by a nephrology provider at an academic clinic in the southern United States from November of 2016 to January of 2018 to participate in research examining their health values and communication with their nephrology providers. As described in previous related studies, 19,22 we excluded patients with dialysis dependence, prior kidney transplant, and possible AKI, as well as patients on their initial visit with a particular nephrology provider. In this clinic, it is the standard of care to refer patients for education in CKD and renal replacement options when they reach CKD stage 4.…”

Tracking patients with advanced kidney disease in the last 12 months of life

“…and were cognitively sound and competent to give informed consent. The 'surprise question' demonstrates good reliability with CKD end of life prognostication (Javier et al 2017). Patients were excluded if they had extreme psychological or social distress that would prevent them from completing interviewer administered surveys (determined by clinical and/or research staff), died within 48 hours of qualifying for the study, or resided >2 hours' drive from the recruitment site.…”

A Tale of Two Failures: A Guide to Shared Decision-Making for Heart and Renal Failure

“…When providers caring for patients on dialysis were asked this question, 29.4% of patients for whom the provider would not have been surprised if the patient died in the next year had died at 1 year, compared with only 10% of other patients. 18 The surprise question has also been recently validated in the CKD stages 4 and 5 population with similar results, 19 suggesting that physicians should follow their clinical intuition. The surprise question has been validated in heart failure as a tool for triggering referral to palliative care.…”