Utility of the "Surprise" Question in Predicting Survival among Older Patients with Acute Surgical Conditions

The Physician Surprise Question in the Emergency Department: prospective cohort study

OBJECTIVES

This study aims to test the ability of the surprise question (SQ), when asked to emergency physicians (EPs), to predict in-hospital mortality among adults admitted to an emergency room (ER).

METHODS

This prospective cohort study at an academic medical centre included consecutive patients 18 years or older who received care in the ER and were subsequently admitted to the hospital from 20 April 2018 to 20 October 2018. EPs were required to answer the SQ for all patients who were being admitted to hospital. The primary outcome was in-hospital mortality.

RESULTS

The cohort included 725 adults (mean (SD) age, 60 (17) years, 51% men) from 58 128 emergency department (ED) visits. The mortality rates were 20.6% for 30-day all-cause in-hospital mortality and 23.6% for in-hospital mortality. The diagnostic test characteristics of the SQ have a sensitivity of 53.7% and specificity of 87.1%, and a relative risk of 4.02 (95% CI 3.15 to 5.13), p<0.01). The positive and negative predictive values were 57% and 86%, respectively; the positive likelihood ratio was 4.1 and negative likelihood ratio was 0.53; and the accuracy was 79.2%.

CONCLUSIONS

We found that asking the SQ to EPs may be a useful tool to identify patients in the ED with a high risk of in-hospital mortality.

Involving people with lived experience of homelessness in palliative and end of life care research: key considerations from experts in the field

BACKGROUND

Co-production of research aims to include people with lived experience of a phenomena throughout the research process. People experiencing homelessness often experience advance ill-health at a young age, yet access palliative care services at a disparately low rate to the level of palliative care need. The voices of people experiencing homelessness are infrequently heard throughout palliative care research, despite the complexities and intricacies of the area.

AIM

To explore the experiences of experts in the field to identify key context considerations for involving people with lived experience of homelessness in palliative and end of life care research.

METHODS

Qualitative study comprising two data collection streams: interviews with professionals with experience of involving people experiencing homelessness in their work, and focus groups with people with lived experience (PWLE) of homelessness. Data were analysed using iterative, reflexive thematic analysis. Patient and Public Involvement contributors gave feedback on themes.

RESULTS

A total of 27 participants took part in semi-structured interviews (N = 16; professionals) or focus groups (N = 11; PWLE homelessness). Key considerations of involving people experiencing homelessness in palliative and end of life care research were developed into four key themes: complexity of lived experience of homelessness; representation of homelessness within experts by experience; professionalising lived experience; and methods for involvement.

CONCLUSIONS

Involvement of people with lived experience of homelessness is important in developing palliative care research. This paper begins to outline some contextual considerations for promoting involvement in a complex and intricate field of research.

Understanding aims, successes and challenges of palliative care and homelessness initiatives across the UK: an exploratory study

BACKGROUND

Due to the recognition that people experiencing homelessness (PEH) often die young and unsupported, a growing number of initiatives focusing on palliative care and homelessness are emerging across the UK. However, there has been no systematic exploration of the nature and landscape of this work.

AIMS

To understand the range, aims, successes and challenges of current initiatives within the field of palliative care and homelessness in the UK, by exploring existing projects and initiatives.

METHOD

An online survey was distributed to members of an Extension for Community Healthcare Outcomes network focusing on palliative care and homelessness for a mixed professional audience. The survey collated the aims, successes and challenges of initiatives aiming to improve palliative care for PEH. Responses were summarised using descriptive statistics, and free-text responses were analysed using thematic analysis.

RESULTS

162 professionals completed the survey. Of these, 62% reported involvement in at least one palliative care and homelessness initiative. Initiatives focused on service delivery (59%), training (28%) and research (28%). Themes for success included improved service engagement, relationship formation, housing provision, honouring end-of-life wishes, upskilling staff and enabling safe hospital discharge. The main challenges included stigma around substance misuse, securing funding, staff capacity, equipment and facilities, and engaging communities.

CONCLUSION

The number and scope of initiatives aiming to support PEH with advanced ill health and palliative care needs across the UK is growing, with a range of professionals engaging in the field. Future research may benefit from exploring initiatives in more detail to understand the specific drivers of impact on PEH and the staff and services supporting them.

Would you be surprised? Prospective multicenter study of the Surprise Question as a screening tool to predict mortality in trauma patients

BACKGROUND

The Surprise Question (SQ) ("Would I be surprised if the patient died within the next year?") is a validated tool used to identify patients with limited life expectancy. Because it may have potential to expedite palliative care interventions per American College of Surgeons Trauma Quality Improvement Program Palliative Care Best Practices Guidelines, we sought to determine if trauma team members could use the SQ to accurately predict 1-year mortality in trauma patients.

METHODS

A multicenter, prospective, cohort study collected data (August 2020 to February 2021) on trauma team members' responses to the SQ at 24 hours from admission. One-year mortality was obtained via social security death index records. Positive/negative predictive values and accuracy were calculated overall, by provider role and by patient age.

RESULTS

Ten Level I/II centers enrolled 1,172 patients (87.9% blunt). The median age was 57 years (interquartile range, 36-74 years), and the median Injury Severity Score was 10 (interquartile range, 5-14 years). Overall 1-year mortality was 13.3%. Positive predictive value was low (30.5%) regardless of role. Mortality prediction minimally improved as age increased (positive predictive value highest between 65 and 74 years old, 34.5%) but consistently trended to overprediction of death, even in younger patients.

CONCLUSION

Trauma team members' ability to forecast 1-year mortality using the SQ at 24 hours appears limited perhaps because of overestimation of injury effects, preinjury conditions, and/or team bias. This has implications for the Trauma Quality Improvement Program Guidelines and suggests that more research is needed to determine the optimal time to screen trauma patients with the SQ.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

A comparison of palliative care and rapid emergency screening (P-CaRES) tool, broad and narrow criteria, and surprise questions to predict survival of older emergency department patients

BACKGROUND

Palliative care is a form of medical care designed to enhance the quality of life of patients with life-threatening conditions. This study was conducted to compare the accuracy of predicted survival the 1 and 3-month survival rate of Broad and narrow criteria, Surprise questions (SQ), and Palliative Care and Rapid Emergency Screening (P-CaRES) after admission to the emergency department (ED).

METHODS

This prospective cohort study was conducted at an urban teaching hospital in Thailand. Patients aged ≥ 65 years admitted to the ED were classified according to their emergency severity index (ESI) (Level: 1-3). We collected data on SQ, P-CaRES, and broad and narrow criteria. A survival data of participants were collected at 1 and 3 months after admission to the ED. The survival rate was calculated using the Kaplan-Meier and log-rank tests.

RESULTS

A total of 269 patients completed the study. P-CaRES positive and P-CaRES negative patients had 1-month survival rates of 81% and 94.8%, respectively (P = 0.37), and at 3-month survival rates of 70.7% and 90.1%, respectively (P < 0.001). SQ (not surprised) had a 1-month survival rate of 79.3%, while SQ (surprised) had a 97% survival rate (P = 0.01), and SQ (not surprised) had a 75.4% survival rate at 3-months, while SQ (surprised) had a 96.3% survival rate (P = 0.01). Broad and narrow criteria that were positive and negative had 1-month survival rates of 88.1% and 92.5%, respectively (P = 0.71), while those that were positive and negative had 3-month survival rates of 78.6% and 87.2%, respectively (P = 0.19). The hazard ratio (HR) of SQ (not surprised) at 1 month was 3.22( 95%CI:1.16-8.89). The HR at 3 months of P-CaRES (positive) was 3.31 with a 95% confidence interval (CI): 1.74 - 6.27, while the HR for SQ (not surprise) was 7.33, 95% CI: 3.03-19.79; however, broad and narrow criteria had an HR of 1.78, 95% CI:0.84-3.77.

CONCLUSIONS

Among older adults who visited the ED, the SQ were good prognosis tools for predicting 1 and 3-month survival, and P-CaRES were good prognostic tools for predicting 3-month survival.

End of Life Care and Advance Care Planning for Outpatients with Inoperable Aortic Aneurysms

OBJECTIVE

A significant proportion of patients with abdominal and thoracic aortic aneurysms (AA) do not proceed to intervention after reaching treatment threshold diameter due to a combination of poor cardiovascular reserve, frailty and aortic morphology. This patient cohort has a high mortality, however, until this study, there exist no studies on the end of life care conservatively managed patients receive.

DESIGN

This is a retrospective multicentre cohort study of 220 conservatively managed AA patients referred to Leeds Vascular Institute (UK) and Maastricht University Medical Centre (Netherlands) for intervention between 2017 and 2021.

METHODS

Demographic details, mortality, cause of death, advance care planning and palliative care outcomes were analysed to examine predictors of palliative care referral and efficacy of palliative care consultation.

RESULTS

A total of 1506 AA patients were seen over this time period, giving a non-intervention rate of 15%. There was a 3-year mortality rate of 55%, a median survival of 364 days and rupture was the reported cause of death in 18% of the decedents. Median follow up was 34 months. Only 8% of all patients and 16% of decedents received palliative care consultation, which took place a median of 3.5 days before death. Patients over 81 years of age were more likely to have advance care planning. Only 5% and 23% of conservatively managed patients had documentation of preferred place of death and care priorities respectively. Patients with palliative care consultation were more likely to have these in place.

CONCLUSION

Only a small proportion of conservatively treated patients had advance care planning and this was far below international guidelines on end of life care for adults, which recommend it for each of these patients. Pathways and guidance should be implemented to ensure patients not offered AA intervention receive end of life care and advance care planning.

[DNVF Memorandum: Health Services Research in the Last Year of Life]

This memorandum outlines current issues concerning health services research on seriously ill and dying people in the last year of their lives as well as support available for their relatives. Patients in the last phase of life can belong to different disease groups, they may have special characteristics (e. g., people with cognitive and complex impairments, economic disadvantage or migration background) and be in certain phases of life (e. g., parents of minor children, (old) age). The need for a designated memorandum on health services research in the last year of life results from the special situation of those affected and from the special features of health services in this phase of life. With reference to these special features, this memorandum describes methodological and ethical specifics as well as current issues in health services research and how these can be adequately addressed using quantitative, qualitative and mixed methods. It has been developed by the palliative medicine section of the German Network for Health Services Research (DNVF) according to the guidelines for DNVF memoranda.

Palliative Care in Advanced Alzheimer's Disease Dementia: Evaluation of the Answers Given by Caregivers and Physicians to the Accuracy of Surprise Question, as a Prognostic Tool

Introduction: Alzheimer's disease (AD) dementia is the sixth leading cause of death in the United States. The surprise question (SQ) "Would you be surprised if this patient were to die within the next 12 months?" was used to identify death-risk patients, who could benefit from palliative care. Objective: To examine the prognostic accuracy of the SQ by physicians and caregivers in outpatients with AD dementia. Methods: This is a longitudinal and prospective study involving 101 patients along 1 year, applying the SAS 9.2 software and adopting a .05 P-value to assess the variables that influenced answers to the accuracy of SQ using the chi-square test. Results: 27 patients (26.7%) died during the follow-up. When caregivers answered the SQ, it presented a 51.8% sensitivity (CI 31.9 - 71.3), a 66.7% negative predictive value (20.7 - 63.6), a 56.2% specificity (CI 29.8 - 80.2), and a 40.9% positive predictive value of (CI 43.0 - 85.4) with a 53.4% accuracy (CI 38.5 - 68.4). When physicians answered, the SQ had an 88.8% sensitivity (CI 70.8 - 97.6), a 40% negative predictive value (CI 5.2 - 85.3), a 12.5% specificity (CI 1.5 - 38.3), a 63.1% positive predictive value (CI 45.9 - 78.1) with a 60.4% accuracy (CI 45.8 - 75). Conclusion: SQ remains a good tool with high sensitivity for the identification of patients with advanced AD dementia when presented to the attending physician for planning palliative advanced care with accuracy of 60.4% and caregivers' accuracy of 53.4%.

The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis

BACKGROUND

The surprise question is widely used to identify patients nearing the last phase of life. Potential differences in accuracy between timeframe, patient subgroups and type of healthcare professionals answering the surprise question have been suggested. Recent studies might give new insights.

AIM

To determine the accuracy of the surprise question in predicting death, differentiating by timeframe, patient subgroup and by type of healthcare professional.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Electronic databases PubMed, Embase, Cochrane Library, Scopus, Web of Science and CINAHL were searched from inception till 22nd January 2021. Studies were eligible if they used the surprise question prospectively and assessed mortality. Sensitivity, specificity, negative predictive value, positive predictive value and c-statistic were calculated.

RESULTS

Fifty-nine studies met the inclusion criteria, including 88.268 assessments. The meta-analysis resulted in an estimated sensitivity of 71.4% (95% CI [66.3-76.4]) and specificity of 74.0% (95% CI [69.3-78.6]). The negative predictive value varied from 98.0% (95% CI [97.7-98.3]) to 88.6% (95% CI [87.1-90.0]) with a mortality rate of 5% and 25% respectively. The positive predictive value varied from 12.6% (95% CI [11.0-14.2]) with a mortality rate of 5% to 47.8% (95% CI [44.2-51.3]) with a mortality rate of 25%. Seven studies provided detailed information on different healthcare professionals answering the surprise question.

CONCLUSION

We found overall reasonable test characteristics for the surprise question. Additionally, this study showed notable differences in performance within patient subgroups. However, we did not find an indication of notable differences between timeframe and healthcare professionals.

Prognostic value of the Surprise Question for one-year mortality in older patients: a prospective multicenter study in acute geriatric and cardiology units

OBJECTIVES

To determine the prognostic value of the Surprise Question (SQ) in older persons.

METHODS

A multicenter prospective study, including patients aged 75 years or older admitted to acute geriatric (AGU) or cardiology unit (CU). The SQ was answered by the treating physician. Patients or relatives were contacted after 1 year to determine 1-year survival. Logistic regression was used to explore parameters associated with SQ. Summary ROC curves were constructed to obtain the pooled values of sensitivity and specificity based on a bivariate model.

RESULTS

The SQ was positive (death within 1 year is no surprise) in 34.7% AGU and 33.3% CU patients (p = 0.773). Parameters associated with a positive SQ were more severe comorbidity, worse functionality, significant weight loss, refractory symptoms and the request for palliative care by patient or family. One-year mortality was, respectively, 24.9% and 20.2% for patients hospitalized on AGU and CU (p = 0.319). There was no difference in sensitivity or specificity, respectively, 64% and 77% (AUC 0.635) for AGU versus 63% and 76% (AUC 0.758) for CU (p = 0.870). A positive SQ is associated with a significant shorter time until death (HR 5.425 (95% CI 3.332-8.834), p < 0.001) independently from the ward.

CONCLUSION

The Surprise Question is moderately accurate to predict 1-year mortality in older persons hospitalized on acute geriatric and cardiologic units.

Using the "Surprise Question" to Predict Frailty and Healthcare Outcomes among Older Adults Attending the Emergency Department

The “surprise question” (SQ) predicts the need for palliative care. Its predictive validity for adverse healthcare outcomes and its association with frailty among older people attending the emergency department (ED) are unknown. We conducted a secondary analysis of a prospective study of consecutive patients aged ≥70 attending a university hospital’s ED. The SQ was scored by doctors before an independent comprehensive geriatric assessment (CGA). Outcomes included length of stay (LOS), frailty determined by CGA and one-year mortality. The SQ was available for 191 patients, whose median age was 79 ± 9. In all, 56/191 (29%) screened SQ positive. SQ positive patients were frailer; the median clinical frailty score was 6/9 (compared to 4/9, p < 0.001); they had longer LOS (p = 0.008); and they had higher mortality (p < 0.001). Being SQ positive was associated with 2.6 times greater odds of admission and 8.9 times odds of frailty. After adjustment for age, sex, frailty, co-morbidity and presenting complaint, patients who were SQ positive had significantly reduced survival times (hazard ratio 5.6; 95% CI: 1.39–22.3, p = 0.015). Almost one-third of older patients attending ED were identified as SQ positive. These were frailer and more likely to be admitted, have reduced survival times and have prolonged LOS. The SQ is useful to quickly stratify older patients likely to experience poor outcomes in ED.

Narrative review of palliative care in trauma and emergency general surgery

OBJECTIVE

The purpose of this article is to discuss the goals of palliative care with regards to acute care surgery patients and review the literature regarding administration and implementation of palliative programs.

BACKGROUND

For patients who experience unexpected and sometimes catastrophic life changes related to trauma or emergency general surgery, palliative care is a crucial adjunct that can help ensure the provision of optimal symptom management, communication, and goal-concordant care provided.

METHODS

Palliative care is medical specialty with a philosophy of care focused on improving the quality of life for patients with serious injury or illness and their loved ones. Palliative care provides significant benefit across the entire spectrum of illness and injury, regardless of prognosis. We will discuss palliative care topics related to trauma and emergency general surgery patients, including symptom management, goal setting, end of life care, communication strategies, addressing implicit/explicit bias, trauma-specific and emergency general surgery-specific considerations, and implementation strategies to reduce barriers for utilization of palliative care.

CONCLUSIONS

Unfortunately, palliative care is often underutilized in the trauma and emergency general surgery population. Acute care surgeons should be familiar with principles of primary palliative care, as well as understand the added benefits that be provided by consultant palliative care specialists.

Hidden lives and deaths: the last months of life of people with intellectual disabilities living in long-term, generic care settings in the UK

RATIONALE

This paper concerns mortality and needs for end-of-life care in a population of adults with ID living in generic care homes.

METHODS

Various sampling strategies were used to identify a difficult to find a population of people with ID in generic care homes. Demographic and health data were obtained for 132 people with ID. This included the Surprise Question. At T2, 12 months later, data were obtained on the survival of this sample.

FINDINGS

The average age was 68.6 years, and the majority were women (55.3%). Their health was typically rated as good or better. Responses to the Surprise Question indicated that 23.3% respondents might need EoLC. At T2, 18.0% of this population had died. The average of death was 72.2 years. The majority died within the care setting (62.9%).

IMPLICATIONS

The implications for end-of-life care and mortality research are discussed.

Non-Concordance between Patient and Clinician Estimates of Prognosis in Advanced Heart Failure

IMPORTANCE

Despite efforts to enhance serious illness communication, patients with advanced heart failure (HF) lack prognostic understanding.

OBJECTIVES

To determine rate of concordance between HF patients' estimation of their prognosis and their physician's estimate of the patient's prognosis, and to compare patient characteristics associated with concordance.

DESIGN

Cross-sectional analysis of a cluster randomized controlled trial with 24-month follow-up and analysis completed on 09/01/2020. Patients were enrolled in inpatient and outpatient settings between September 2011 to February 2016 and data collection continued until the last quarter of 2017.

SETTING

Six teaching hospitals in the U.S.

PARTICIPANTS

Patients with advanced HF and implantable cardioverter defibrillators (ICDs) at high risk of death. Of 537 patients in the parent study, 407 had complete data for this analysis.

INTERVENTION

A multi-component communication intervention on conversations between HF clinicians and their patients regarding ICD deactivation and advance care planning.

MAIN OUTCOME(S) AND MEASURE(S)

Patient self-report of prognosis and physician response to the "surprise question" of 12-month prognosis. Patient-physician prognostic concordance (PPPC) measured in percentage agreement and kappa. Bivariate analyses of characteristics of patients with and without PPPC.

RESULTS

Among 407 patients (mean age 62.1 years, 29.5% female, 42.4% non-white), 300 (73.7%) dyads had non-PPPC; of which 252 (84.0%) reported a prognosis >1 year when their physician estimated <1 year. Only 107 (26.3%) had PPPC with prognosis of ≤ 1 year (n=20 patients) or > 1 year (n=87 patients); (Κ = -0.20, p = 1.0). Of those with physician estimated prognosis of < 1 year, non-PPPC was more likely among patients with lower symptom burden- number and severity (both p ≤.001), without completed advance directive (p=.001). Among those with physician prognosis estimate > 1 year, no patient characteristic was associated with PPPC or non-PPPC.

CONCLUSIONS AND RELEVANCE

Non-PPPC between HF patients and their physicians is high. HF patients are more optimistic than clinicians in estimating life expectancy. These data demonstrate there are opportunities to improve the quality of prognosis disclosure between patients with advanced HF and their physicians. Interventions to improve PPPC might include serious illness communication training.

User-Centered Design of the consideRATE Questions, a Measure of People's Experiences When They Are Seriously Ill

CONTEXT

No brief patient-reported experience measure focuses on the most significant concerns of seriously ill individuals.

OBJECTIVES

The objective of the study was to develop the consideRATE questions.

METHODS

This user-centered design study had three phases. We reviewed the literature and consulted stakeholders, including caregivers, clinicians, and researchers, to identify the elements of care most important to patients (Phase 1). We refined items based on cognitive interviews with patients, families, and clinicians (Phase 2). We piloted the measure with patients and families (Phase 3).

RESULTS

Phase 1 resulted in seven questions addressing the following elements: 1) care team attention to patients' physical symptoms, 2) emotional symptoms, 3) environment of care, 4) respect for patients' priorities, 5) communication about future plans, 6) communication about financial and similar affairs, and 7) communication about illness trajectory. Phase 2 participants included eight patients, eight family members, and seven clinicians. We added an open-text comment option. We did not identify any other issues that were important enough to participants to include. Response choices ranged from one (very bad) to four (very good), with a not applicable option (does not apply). Phase 3 involved 15 patients and 16 family members and demonstrated the acceptability of the consideRATE questions. Most reported that the questions were not distressing, disruptive, or confusing. Completion time averaged 2.4 minutes (range 1-5).

CONCLUSION

Our brief patient-reported serious illness experience measure is based on what matters most to patients, families, and clinicians. It was acceptable to patients and families in a regional sample. It has promise for use in clinical settings.

Derivation and validation of a prognostic model to predict mortality in patients with advanced chronic kidney disease

BACKGROUND

Guiding patients with advanced chronic kidney disease (CKD) through advance care planning about future treatment obliges an assessment of prognosis. A patient-specific integrated model to predict mortality could inform shared decision-making for patients with CKD.

METHODS

Patients with Stages 4 and 5 CKD from Massachusetts (749) and West Virginia (437) were prospectively evaluated for clinical parameters, functional status [Karnofsky Performance Score (KPS)] and their provider's response to the Surprise Question (SQ). A predictive model for 12-month mortality was derived with the Massachusetts cohort and then validated externally on the West Virginia cohort. Logistic regression was used to create the model, and the c-statistic and Hosmer-Lemeshow statistic were used to assess model discrimination and calibration, respectively.

RESULTS

In the derivation cohort, the SQ, KPS and age were most predictive of 12-month mortality with odds ratios (ORs) [95% confidence interval (CI)] of 3.29 (1.87-5.78) for a 'No' response to the SQ, 2.09 (95% CI 1.19-3.66) for fair KPS and 1.41 (95% CI 1.15-1.74) per 10-year increase in age. The c-statistic for the 12-month mortality model for the derivation cohort was 0.80 (95% CI 0.75-0.84) and for the validation cohort was 0.74 (95% CI 0.66-0.83).

CONCLUSIONS

Our integrated prognostic model for 12-month mortality in patients with advanced CKD had good discrimination and calibration. This model provides prognostic information to aid nephrologists in identifying and counseling advanced CKD patients with poor prognosis who are facing the decision to initiate dialysis or pursue medical management without dialysis.

Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital

IMPORTANCE

The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making.

OBJECTIVE

To determine the association of the question, "Would you be surprised if your patient died in the next one month?" (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED).

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019.

EXPOSURES

Treating emergency clinicians were required to answer the surprise question, "Would you be surprised if your patient died in the next one month?" in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital.

MAIN OUTCOMES AND MEASURES

The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality.

RESULTS

The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]).

CONCLUSIONS AND RELEVANCE

This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen.

The Surprise Question Can Be Used to Identify Heart Failure Patients in the Emergency Department Who Would Benefit From Palliative Care

CONTEXT

Heart failure (HF) is associated with symptom exacerbations and risk of mortality after an emergency department (ED) visit. Although emergency physicians (EPs) treat symptoms of HF, often the opportunity to connect with palliative care is missed. The "surprise question" (SQ) "Would you be surprised if this patient died in the next 12 months?" is a simple tool to identify patients at risk for 12-month mortality.

OBJECTIVES

The objective of this study was to assess the accuracy of the SQ when used by EPs to assess patients with HF.

METHODS

We conducted a prospective cohort study in which clinicians applied the SQ to patients presenting to the ED with symptoms of HF. Chart review and review of death records were completed. The primary outcome was accuracy of the surprise question to predict 12-month mortality. A univariate analysis for potential predictors of 12-month mortality was performed.

RESULTS

During the study period, 199 patients were identified, and complete data were available for 97% of observations (n = 193). The one-year mortality was 29%. EPs reported that "they would not be surprised" if the patient died within the next 12 months in 53% of cases. 42.7% of these patients died within 12 months compared to 13.3% in the "would be surprised" group. There was a strong association with death in the "not surprised" group (odds ratio 4.85, 95% CI 2.34-9.98, P < 0.0001). The sensitivity, specificity, positive predictive value, and negative predictive value of the SQ were 78.6%, 56.9%, 42.7%, and 86.7%, respectively, with c-statistic = 0.68.

CONCLUSION

The SQ screening tool can assist ED providers in identifying HF patients that would benefit from early palliative care involvement.

The "Surprise Question" in Neurorehabilitation-Prognosis Estimation by Neurologist and Palliative Care Physician; a Longitudinal, Prospective, Observational Study

Background: The 12-months “surprise” question (12-SQ) for estimating prognosis and the need for integrating palliative care (PC) services has not yet been investigated for neurological patients.

Objective: Test the value of the 12-SQ on a sample of neurorehabilitation patients.

Methods: All patients newly registered in the Department of Neurorehabilitation, Dr. Becker Rhein-Sieg-Clinic (8/2016-03/2017) were asked to participate. The treating neurorehabilitation physicians (NP) and an external consulting PC physician (PCP) independently estimated patients' prognosis using the 12-SQ; while symptom burden was independently assessed using the standardized palliative outcome measurement HOPE-SP-CL, a set of additional neurological issues, and ECOG. Follow-up with consenting patients 12 months later was via telephone. Descriptive and inferential statistics were utilized in data analysis.

Results: Of 634 patients, 279 (44%) patients (male: 57.7%, female: 42.3%; mean age: 63 ± 14) (or, alternatively, their legal representative) consented and were assessed at baseline. Per patient NP and PCP both answered the 12-SQ with “Yes” (164), with “No” (42), or had different opinions (73). The “No” group displayed the highest symptom burden on all three measures for both disciplines. Overall, PCP scored higher (i.e., worse) than NP on all measures used. Follow-up was possible for 236 (drop-out: 15.4%) patients (deceased: 34 (14.4%), alive: 202 (85.6%)). Baseline scores on all measures were higher for deceased patients compared to those still living. Prognostic characteristics were: sensitivity: NP 50%, PCP 67.6%; specificity: NP 86.1%, PCP 70.3%, p < 0.001; positive predictive value: NP 37.8%, PCP 27.7%; negative predictive value: NP 91.1%, PCP 92.8%; area under the curve: NP 0.68, PCP 0.69; success rate: NP 80.9%, PCP 69.9%, p = 0.002. Regression analysis indicated that age, dysphagia and overburdening of family (NP answering the 12-SQ), dysphagia and rehabilitation phase (PCP answering the 12-SQ) were associated with increased likelihood of dying within 12 months. Without the 12-SQ as relevant predictor, age, dysphagia and ECOG were significant predictors (NP and PCP).

Conclusion: Combining the 12-SQ with a measurement assessing PC and neurological issues could potentially improve the 12-SQ's predictive performance of 12-month survival and help to identify when to initiate the PC approach. Clinical experiences influence assessment and prognosis estimation.

Derivation and Validation of a Prognostic Model to Predict 6-Month Mortality in an Intensive Care Unit Population

RATIONALE

Identification of terminally ill patients in the intensive care unit (ICU) would facilitate decision making and timely palliative care.

OBJECTIVES

To develop and validate a patient-specific integrated prognostic model to predict 6-month mortality in medical ICU patients.

METHODS

A longitudinal prospective cohort study of temporally split samples of 1,049 consecutive medical ICU patients in a tertiary care hospital was performed. For each patient, we collected demographic data, Acute Physiology and Chronic Health Evaluation III score, Charlson comorbidity index, intensivist response to a surprise question (SQ; "Would I be surprised if this patient died in the next 6 months?") on admission, and vital status at 6 months.

RESULTS

Between November 2013 and May 2015, derivation and validation cohorts of 500 and 549 consecutive patients were studied to develop a multivariate logistic regression model. In the multivariate logistic regression model, Charlson comorbidity index (P = 0.033), Acute Physiology and Chronic Health Evaluation III score (P < 0.001), and SQ response (P < 0.001) were predictors of vital status at 6 months. The odds of dying within 6 months were significantly higher when the SQ was answered "no" than when it was answered "yes" (odds ratio, 7.29; P < 0.001). The c-statistic for the derivation and validation cohorts were 0.832 (95% confidence interval, 0.795-0.870) and 0.84 (95% confidence interval, 0.806-0.875), respectively.

CONCLUSIONS

Our integrated prognostic model, which includes the SQ, has strong discrimination and calibration to predict 6-month mortality in medical ICU patients. This model can aid clinicians in identifying ICU patients who may benefit from the integration of palliative care into their treatment.

Usefulness of the Surprise Question on an Inpatient Oncology Service

BACKGROUND

Prognostication of survival in patients with advanced cancer has been challenging and contributes to poor illness understanding. Prognostic disagreement occurs even among providers and is a less studied phenomenon.

OBJECTIVE

We introduced the surprise question (SQ), "Would I be surprised if this patient died in the next 1 year, 6 months, and 1 month?," at multidisciplinary rounds to increase palliative care referrals through the introduction of this prognostic prompt.

DESIGN, SETTING, PATIENTS

This quality improvement project took place from March 2016 to May 2016 on the medical oncology service at a tertiary academic medical center. The question was asked 3 times a week at multidisciplinary rounds which are attended by the hospital medicine provider, palliative care provider, and consulting oncologist. Primary oncologists and bedside nurses were also asked the SQ.

MEASUREMENTS

Referral rates to outpatient palliative care clinic, community-based palliative care clinic, inpatient palliative care consults, and hospice 3 months prior to, during, and 5 months postintervention.

RESULTS

Regular discussion of prognosis of patients with cancer in an inpatient medical setting did not increase referrals to inpatient or outpatient palliative care or hospice. Increased clinical experience impacted hospital medicine providers and bedside nurses' estimation of prognosis differently than oncology providers. Medical oncologists were significantly more optimistic than hospital medicine providers.

End-of-life care for homeless people: A qualitative analysis exploring the challenges to access and provision of palliative care

BACKGROUND

Being homeless or vulnerably housed is associated with death at a young age, frequently related to medical problems complicated by drug or alcohol dependence. Homeless people experience high symptom burden at the end of life, yet palliative care service use is limited.

AIM

To explore the views and experiences of current and formerly homeless people, frontline homelessness staff (from hostels, day centres and outreach teams) and health- and social-care providers, regarding challenges to supporting homeless people with advanced ill health, and to make suggestions for improving care.

DESIGN

Thematic analysis of data collected using focus groups and interviews.

PARTICIPANTS

Single homeless people ( n = 28), formerly homeless people ( n = 10), health- and social-care providers ( n = 48), hostel staff ( n = 30) and outreach staff ( n = 10).

RESULTS

This research documents growing concern that many homeless people are dying in unsupported, unacceptable situations. It highlights the complexities of identifying who is palliative and lack of appropriate places of care for people who are homeless with high support needs, particularly in combination with substance misuse issues.

CONCLUSION

Due to the lack of alternatives, homeless people with advanced ill health often remain in hostels. Conflict between the recovery-focused nature of many services and the realities of health and illness for often young homeless people result in a lack of person-centred care. Greater multidisciplinary working, extended in-reach into hostels from health and social services and training for all professional groups along with more access to appropriate supported accommodation are required to improve care for homeless people with advanced ill health.

Performance of the Surprise Question Compared to Prediction Models in Hemodialysis Patients: A Prospective Study

BACKGROUND

The surprise question (SQ) ("Would you be surprised if this patient were still alive in 6 or 12 months?") is used as a mortality prognostication tool in hemodialysis (HD) patients. We compared the performance of the SQ with that of prediction models (PMs) for 6- and 12-month mortality prediction.

METHODS

Demographic, clinical, laboratory, and dialysis treatment indicators were used to model 6- and 12-month mortality probability in a HD patients training cohort (n = 6,633) using generalized linear models (GLMs). A total of 10 nephrologists from 5 HD clinics responded to the SQ in 215 patients followed prospectively for 12 months. The performance of PM was evaluated in the validation (n = 6,634) and SQ cohorts (n = 215) using the areas under receiver operating characteristics curves. We compared sensitivities and specificities of PM and SQ.

RESULTS

The PM and SQ cohorts comprised 13,267 (mean age 61 years, 55% men, 54% whites) and 215 (mean age 62 years, 59% men, 50% whites) patients, respectively. During the 12-month follow-up, 1,313 patients died in the prediction model cohort and 22 in the SQ cohort. For 6-month mortality prediction, the GLM had areas under the curve of 0.77 in the validation cohort and 0.77 in the SQ cohort. As for 12-month mortality, areas under the curve were 0.77 and 0.80 in the validation and SQ cohorts, respectively. The 6- and 12-month PMs had sensitivities of 0.62 (95% CI 0.35-0.88) and 0.75 (95% CI 0.56-0.94), respectively. The 6- and 12-month SQ sensitivities were 0.23 (95% CI 0.002-0.46) and 0.35 (95% CI 0.14-0.56), respectively.

CONCLUSION

PMs exhibit superior sensitivity compared to the SQ for mortality prognostication in HD patients.

The "Surprise Question" Asked of Emergency Physicians May Predict 12-Month Mortality among Older Emergency Department Patients

BACKGROUND

Identification of older adults with serious illness (life expectancy less than one year) who may benefit from serious illness conversations or other palliative care interventions in the emergency department (ED) is difficult.

OBJECTIVES

To assess the performance of the "surprise question (SQ)" asked of emergency physicians to predict 12-month mortality.

DESIGN

We asked attending emergency physician "Would you be surprised whether this patient died in the next 12 months?" regarding patients ≥65 years old that they had cared for that shift. We prospectively obtained death records from Massachusetts Department of Health Vital Records.

SETTING

An urban, university-affiliated ED.

MEASUREMENT

Twelve-month mortality.

RESULTS

We approached 38 physicians to answer the SQ, and 86% participated. The mean age of our cohort was 76 years, 51% were male, and 45% had at least one serious illness. Out of 207 patients, the physicians stated that they "would not be surprised" if the patient died in the next 12 months for 102 of the patients (49%); 44 of the 207 patients (21%) died within 12 months. The SQ demonstrated sensitivity of 77%, specificity of 56%, positive predictive value of 32%, and negative predictive value of 90%. When combined with other predictors, the model sorted the patient who lived from the patient who died correctly 72% of the time (c-statistic = 0.72).

CONCLUSION

Use of the SQ by emergency physicians may predict 12-month mortality in older ED patients and may help emergency physicians identify older adults in need of palliative care interventions.

How accurate is the 'Surprise Question' at identifying patients at the end of life? A systematic review and meta-analysis

BACKGROUND

Clinicians are inaccurate at predicting survival. The 'Surprise Question' (SQ) is a screening tool that aims to identify people nearing the end of life. Potentially, its routine use could help identify patients who might benefit from palliative care services. The objective was to assess the accuracy of the SQ by time scale, clinician, and speciality.

METHODS

Searches were completed on Medline, Embase, CINAHL, AMED, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Open Grey literature (all from inception to November 2016). Studies were included if they reported the SQ and were written in English. Quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 26 papers were included in the review, of which 22 reported a complete data set. There were 25,718 predictions of survival made in response to the SQ. The c-statistic of the SQ ranged from 0.512 to 0.822. In the meta-analysis, the pooled accuracy level was 74.8% (95% CI 68.6-80.5). There was a negligible difference in timescale of the SQ. Doctors appeared to be more accurate than nurses at recognising people in the last year of life (c-statistic = 0.735 vs. 0.688), and the SQ seemed more accurate in an oncology setting 76.1% (95% CI 69.7-86.3).

CONCLUSIONS

There was a wide degree of accuracy, from poor to reasonable, reported across studies using the SQ. Further work investigating how the SQ could be used alongside other prognostic tools to increase the identification of people who would benefit from palliative care is warranted.

TRIAL REGISTRATION

PROSPERO CRD42016046564 .