The Surprise Question and Serious Illness Conversations: A pilot study

Abstract

Background: Serious Illness Conversations aim to discuss patient goals. However, on acute medicine units, seriously ill patients may undergo distressing interventions until death. Objectives: To investigate the feasibility of using the Surprise Question, “Would you be surprised if this patient died within the next year?” to identify patients who would benefit from early Serious Illness Conversations and study any changes in the interdisciplinary team’s beliefs, confidence, and engagement as a result of asking the Surprise Question. Design: A prospective cohort pilot study with two Plan-Do-Study-Act cycles. Participants/context: Fifty-eight healthcare professionals working on Acute Medicine Units participated in pre- and post-intervention questionnaires. The intervention involved asking participants the Surprise Question for each patient. Patient charts were reviewed for Serious Illness Conversation documentation. Ethical considerations: Ethical approval was granted by the institutions involved. Findings: Equivocal overall changes in the beliefs, confidence, and engagement of healthcare professionals were observed. Six out of 23 patients were indicated as needing a Serious Illness Conversation; chart review provided some evidence that these patients had more Serious Illness Conversation documentation compared with the 17 patients not flagged for a Serious Illness Conversation. Issues were identified in equating the Surprise Question to a Serious Illness Conversation. Discussion: Appropriate support for seriously ill patients is both a nursing professional and ethical duty. Flagging patients for conversations may act as a filtering process, allowing healthcare professionals to focus on conversations with patients who need them most. There are ethical and practical issues as to what constitutes a “serious illness” and if answering “no” to the Surprise Question always equates to a conversation. Conclusion: The barriers of time constraints and lack of training call for institutional change in order to prioritise the moral obligation of Serious Illness Conversations.

Organizational readiness to implement the Serious Illness Care Program in hospital settings in Sweden

“…Our study shows that different diagnoses, such as cancer and heart failure, could make it more challenging to identify patients in need of SIC. This was also shown in another study [33], in which they found that by using the surprise question, only six of 23 patients were identified. They also found issues with the feasibility of different prognoses and situations [33].…”

Patient Identification for Serious Illness Conversations: A Scoping Review

“…Billie and Letizia [ 39 ] wrote that there were ‘several situations in which a case manager evaluated the patient as appropriate for an SI [serious illness] conversation, although he or she did not meet the established SI criteria’ (p. 226). Other studies also indicated ambiguity surrounding eligibility criteria, for example, variation in the interpretation of clinical characteristics [ 34 ] and differences in understanding what constituted a ‘serious illness’ [ 50 ]. Uncertainty surrounding the ideal timing of the conversation, and lack of time to have the conversation, were also stated to be barriers to identification, as recruitment could be limited by patient number or urgency [ 12 , 52 ].…”

“…Furthermore, among larger, sicker patient groups, the SQ could be inadequate or difficult to operationalize [ 12 ]. It was suggested that relying solely on the SQ could overlook some patients who would benefit from a palliative approach [ 25 , 26 , 50 ]; similarly, replying ‘no’ to the SQ was not always thought to require a serious illness conversation [ 50 ]. Triggering criteria for a conversation did not guarantee that a conversation would be held, and without a structured tracking system it could be difficult for clinicians to know who had, or had not, completed serious illness conversations [ 35 , 43 ].…”

“…A major advantage of the SQ is that it encourages a level of closeness between the clinician and the patient, prompting active contemplation of the patient’s unique situation and care needs [ 26 ]. It is, however, important to note that the SQ has reported mixed sensitivity (low to reasonable/good), and responses to the question are said to be impacted by the clinician’s familiarity with both the question and the patient [ 50 , 55 , 56 , 57 ]. Furthermore, repeatedly asking oneself the SQ is not only time consuming but can be emotionally exhausting given the gravity of the overarching topic [ 12 , 58 ].…”

“… Staff = 2 Patients = 16 (67.8 y) 10 (62.5%) Implementation of the SICP resulted in increased rates of documentation, but the target number of conversations was not met. Le et al (2021) [ 50 ] Canada To investigate the feasibility of using the SQ to identify patients who would benefit from early SICs and study any changes in the interdisciplinary team’s beliefs, confidence, and engagement as a result of asking the SQ. Prospective cohort pilot study.…”