Screening with the double surprise question to predict deterioration and death: an explorative study

The Surprise Question and clinician-predicted prognosis: systematic review and meta-analysis

BACKGROUND

The Surprise Question, 'Would you be surprised if this person died within the next year?' is a simple tool that can be used by clinicians to identify people within the last year of life. This review aimed to determine the accuracy of this assessment, across different healthcare settings, specialties, follow-up periods and respondents.

METHODS

Searches were conducted of Medline, Embase, AMED, PubMed and the Cochrane Central Register of Controlled Trials, from inception until 01 January 2024. Studies were included if they reported original data on the ability of the Surprise Question to predict survival. For each study (including subgroups), sensitivity, specificity, positive and negative predictive values and accuracy were determined.

RESULTS

Our dataset comprised 56 distinct cohorts, including 68 829 patients. In a pooled analysis, the sensitivity of the Surprise Question was 0.69 ((0.64 to 0.74) I2=97.2%), specificity 0.69 ((0.63 to 0.74) I2=99.7%), positive predictive value 0.40 ((0.35 to 0.45) I2=99.4%), negative predictive value 0.89 ((0.87 to 0.91) I2=99.7%) and accuracy 0.71 ((0.68 to 0.75) I2=99.3%). The prompt performed best in populations with high event rates, shorter timeframes and when posed to more experienced respondents.

CONCLUSIONS

The Surprise Question demonstrated modest accuracy with considerable heterogeneity across the population to which it was applied and to whom it was posed. Prospective studies should test whether the prompt can facilitate timely access to palliative care services, as originally envisioned.

PROSPERO REGISTRATION NUMBER

CRD32022298236.

Characteristics of timely integration of palliative care into oncology hospital care for patients with incurable cancer: results of a Delphi Study

PURPOSE

To identify elements of timely integration of palliative care (PC) into hospital oncology care from best practices. Thereafter, to assess the level of consensus among oncology and PC specialists and patient and relative representatives on the characteristics of timely integration of PC.

METHODS

A three-round modified Delphi study was conducted. The expert panel consisted of 83 healthcare professionals (HCPs) from 21 Dutch hospitals (43 physicians, 40 nurses), 6 patient and 2 relative representatives. In the first round, four elements of integrated PC were considered: (1) identification of potential PC needs, (2) advance care planning (ACP), (3) routine symptom monitoring and (4) involvement of the specialist palliative care team (SPCT). In subsequent rounds, the panellists assessed which characteristics were triggers for initiating an element. A priori consensus was set at ≥ 70%.

RESULTS

A total of 71 (78%) panellists completed the first questionnaire, 65 (71%) the second and 49 (54%) the third. Panellists agreed that all patients with incurable cancer should have their PC needs assessed (97%), symptoms monitored (91%) and ACP initiated (86%). The SPCT should be involved at the patient's request (86%) or when patients suffer from increased symptom burden on multiple dimensions (76%). Patients with a life expectancy of less than 3 months should be offered a consultation (71%).

CONCLUSION

The expert panel agreed that timely integration of PC into oncology is important for all patients with incurable cancer, using early identification, ACP and routine symptom monitoring. Involvement of the SPCT is particularly needed in patients with multidimensional symptom burden and in those nearing death.

[Palliative Care in patients with gastrointestinal cancer]

Comprehensive Cancer Care stands for a concept of broad care providing substantial benefits to cancer patients. Beside prevention of cancer as first pillar and curative therapy as second pillar, comprehensive care also encompasses palliative care representing a third pillar providing service for incurable cancer patients burdened with physical symptoms and psychological, social and spiritual needs. This article describes the integration of palliative medicine into comprehensive cancer care for patients with gastrointestinal cancer.

Study protocol of the OrkA project: orofacial and communicative activation in old age- a cluster randomized prevention study in long-term care facilities in Lower Saxony, Germany

BACKGROUND

The process of aging involves numerous changes in the body, influencing physical, mental, and emotional well-being. Age-related changes and degradation can impact various functions of the swallowing process and lead to delayed word retrieval. Individuals with limited linguistic stimulation may experience a more rapid decline in cognitive performance. Thus, this project explores a preventive training program targeting swallowing and linguistic-communicative skills, aimed at preserving the social participation of older individuals residing in nursing homes.

METHODS

A preventive intervention program, combining orofaciopharyngeal and linguistic-communicative components, will be offered twice weekly over 12 weeks in long-term care facilities in the greater Hanover area. The program will aim at: (a) activating sensitive and motor skills in the orofaciopharyngeal area to counter age-related swallowing disorders, and (b) enhancing communicative abilities through semantic-lexical activation. A cluster randomized controlled trial will be conducted to investigate whether the intervention program improves swallowing skills in older adults. Additionally, a secondary analysis will explore the impact on language skills and social participation, as well as program acceptance.

DISCUSSION

The results will provide valuable insight into the effectiveness of preventive measures addressing swallowing and speech issues in older individuals.

TRIAL REGISTRATION

The trial was registered with DRKS (German register for clinical trials) in June 2023 (study ID: DRKS00031594) and the WHO International Clinical Trail Registry Platform (secondary register).

Interrater agreement of multi-professional case review as reference standard for specialist palliative care need: a mixed-methods study

BACKGROUND

A wide variety of screening tools for the need for specialist palliative care (SPC) have been proposed for the use in oncology. However, as there is no established reference standard for SPC need to compare their results with, their sensitivity and specificity have not yet been determined. The aim of the study was to explore whether SPC need assessment by means of multi-professional case review has sufficient interrater agreement to be employed as a reference standard.

METHODS

Comprehensive case descriptions were prepared for 20 inpatients with advanced oncologic disease at the University Hospital Freiburg (Germany). All cases were presented to the palliative care teams of three different hospitals in independent, multi-professional case review sessions. The teams assessed whether patients had support needs in nine categories and subsequently concluded SPC need (yes / no). Interrater agreement regarding SPC need was determined by calculating Fleiss' Kappa.

RESULTS

In 17 out of 20 cases the three teams agreed regarding their appraisal of SPC need (substantial interrater agreement: Fleiss' Kappa κ = 0.80 (95% CI: 0.55-1.0; p < 0.001)). The number of support needs was significantly lower for patients who all teams agreed had no SPC need than for those with agreed SPC need.

CONCLUSIONS

The proposed expert case review process shows sufficient reliability to be used as a reference standard. Key elements of the case review process (e.g. clear definition of SPC need, standardized review of the patients' support needs) and possible modifications to simplify the process are discussed.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00021686, registered 17.12.2020.

Should the Surprise Question be Used as a Prognostic Tool for People With Life-limiting Illnesses?

The surprise question screening tool ("Would I be surprised if this person died within the next 12 months?") was initially developed to identify possible palliative care needs. One controversial topic regarding the surprise question is whether it should be used as a prognostic tool (predicting survival) for patients with life-limiting illnesses. In this "Controversies in Palliative Care" article, three groups of expert clinicians independently answered this question. All experts provide an overview of current literature, practical advice, and opportunities for future research. All experts reported on the inconsistency of the prognostic capabilities of the surprise question. Two of the three expert groups felt that the surprise question should not be used as a prognostic tool due to these inconsistencies. The third expert group felt that the surprise question should be used as a prognostic tool, particularly for shorter time frames. The experts all highlighted that the original rationale for the surprise question was to trigger a further conversation about future treatment and a potential shift in the focus of the care, identifying patients who many benefit from specialist palliative care or advance care planning; however, many clinicians find this discussion a difficult one to initiate. The experts agreed that the benefit of the surprise question comes from its simplicity: a one-question tool that requires no specific information about the patient's condition. More research is needed to better support the application of this tool in routine practice, particularly in noncancer populations.

External Validation and User Experiences of the ProPal-COPD Tool to Identify the Palliative Phase in COPD

Background

Difficulty predicting prognosis is a major barrier to timely palliative care provision for patients with COPD. The ProPal-COPD tool, combining six clinical indicators and the Surprise Question (SQ), aims to predict 1-year mortality as a proxy for palliative care needs. It appeared to be a promising tool for healthcare providers to identify patients with COPD who could benefit from palliative care.

Objective

To externally validate the ProPal-COPD tool and to assess user experiences.

Methods

Patients admitted with an acute exacerbation COPD were recruited across 10 hospitals. Demographics, clinical characteristics and survival status were collected. Sensitivity, specificity, positive and negative predictive values of the tool using two cut-off values were calculated. Also, predictive properties of the SQ were calculated. In monitoring meetings and interviews, healthcare providers shared their experiences with the tool. Transcripts were deductively coded using six user experience domains: Acceptability, Satisfaction, Credibility, Usability, User-reported adherence and Perceived impact.

Results

A total of 523 patients with COPD were included between May 2019 and August 2020, of whom 100 (19.1%) died within 12 months. The ProPal-COPD tool had an AUC of 0.68 and a low sensitivity (55%) and moderate specificity (74%) for predicting 1-year all-cause mortality. Using a lower cut-off value, sensitivity was higher (74%), but specificity lower (46%). Sensitivity and specificity of the SQ were 56% and 73%, respectively (AUC 0.65). However, healthcare providers generally appreciated using the tool because it increased awareness of the palliative phase and provided a shared understanding of prognosis, although they considered its outcome not always correct.

Conclusion

The accuracy of the ProPal-COPD tool to predict 1-year mortality is limited, although screening patients with its indicators increases healthcare providers' awareness of palliative care needs and encourages them to timely initiate appropriate care.

Identifying, exploring and integrating the spiritual dimension in proactive care planning: A mixed methods evaluation of a communication training intervention for multidisciplinary palliative care teams

BACKGROUND

Patients receiving palliative care value attention given to their spiritual needs. However, these needs often remain unexplored as healthcare professionals lack the skills to identify and explore them and to integrate this information into care plans.

AIM

To evaluate the effects of an interactive communication training intervention for palliative care teams in order to identify and explore the spiritual dimension and integrate it in patients' care plans.

DESIGN

A mixed methods pre-post study, including self-assessment questionnaires, evaluation of videos with simulated consultations (applied competence) and medical record review (implementation).

SETTING/PARTICIPANTS

Three palliative care teams including nurses (N = 21), physicians (N = 14) and spiritual caregivers (N = 3).

RESULTS

The questionnaires showed an improvement on 'Patient and family-centred communication' of the End-of-life professional caregiver survey (+0.37, p < 0.01; the 8-item S-EOLC (+0.54, p < 0.01) and regarding the Spiritual Care Competence Scale, on the three subscales used (+0.27, p < 0.01, +0.29, p < 0.01 and +0.32, p < 0.01). Video evaluations showed increased attention being paid to patient's aims and needs. The medical record review showed an increase in anticipation on the non-somatic dimension (OR: 2.2, 95% CI: 1.2-4.3, p < 0.05) and, using the Mount Vernon Cancer Network assessment tool, addressing spiritual issues (OR: 10.9, 95% CI: 3.7-39.5, p < 0.001).

CONCLUSIONS

Our training intervention resulted in increased palliative care professionals' competence in identifying and exploring patients' spiritual issues, and their integration in multidimensional proactive palliative care plans. The intervention directly addresses patients' spiritual concerns and adds value to their palliative care plans.

Development of a screening tool for the need of specialist palliative care in oncologic inpatients: study protocol for the ScreeningPALL Study

INTRODUCTION

A range of referral criteria and scores have been developed in recent years to help with screening for the need of specialist palliative care (SPC) in advanced, incurable cancer patients. However, referral criteria have not yet been widely implemented in oncology, as they usually need to be revised by physicians or nurses with limited time resources. To develop an easily applicable screening for the need for SPC in incurable cancer inpatients, we aim to (a) test inter-rater reliability of multiprofessional expert opinion as reference standard for SPC need (phase I) and (b) explore the diagnostic validity of selected patient-reported outcome measures (PROMs) and routine data for the need of SPC (phase II).

METHODS AND ANALYSIS

Inclusion criteria for patients are metastatic or locally advanced, incurable cancer, ≥18 years of age and informed consent by patient or proxy. (Exclusion criteria: malignant haematological disease as main diagnosis). In phase I, three palliative care consultation teams (PCTs) of three German university hospitals assess the SPC need of 20 patient cases. Fleiss' Kappa will be calculated for inter-rater reliability. In phase II, 208 patients are consecutively recruited in four inpatient oncology wards of Freiburg University Hospital. The PCT will provide assessment of SPC need. As potential referral criteria, patients complete PROMs and a selection of routine data on person, disease and treatment is documented. Logistic regression models and ROC analyses are employed to test their utility in screening for SPC need.

ETHICS AND DISSEMINATION

Our findings will be published in peer-reviewed journals and presented at national and international scientific meetings and congresses. Ethical approval was granted by the Ethics Committee of Albert-Ludwigs-University Freiburg, Germany (approval no. 20-1103).

TRIAL REGISTRATION NUMBER

German Clinical Trials Register, DRKS00021686, registered on 17 December 2020.

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.

Treatment goals and changes over time in older patients with non-curable cancer

PURPOSE

To investigate the treatment goals of older patients with non-curable cancer, whether those goals changed over time, and if so, what triggered those changes.

METHODS

We performed a descriptive and qualitative analysis using the Outcome Prioritization Tool (OPT) to assess patient goals across four conversations with general practitioners (GPs) over 6 months. Text entries from electronic patient records (hospital and general practice) were then analyzed qualitatively for this period.

RESULTS

Of the 29 included patients, 10 (34%) rated extending life and 9 (31%) rated maintaining independence as their most important goals. Patients in the last year before death (late phase) prioritized extending life less often (3 patients; 21%) than those in the early phase (7 patients; 47%). Goals changed for 16 patients during follow-up (12 in the late phase). Qualitative analysis revealed three themes that explained the baseline OPT scores (prioritizing a specific goal, rating a goal as unimportant, and treatment choices related to goals). Another three themes related to changes in OPT scores (symptoms, disease course, and life events) and stability of OPT scores (stable situation, disease-unrelated motivation, and stability despite symptoms).

CONCLUSION

Patients most often prioritized extending life as the most important goal. However, priorities differed in the late phase of the disease, leading to changed goals. Triggers for change related to both the disease (e.g., symptoms and course) and to other life events. We therefore recommend that goals should be discussed repeatedly, especially near the end of life.

TRIAL REGISTRATION

OPTion study: NTR5419.

Timely identification of patients in need of palliative care using the Double Surprise Question: A prospective study on outpatients with cancer

BACKGROUND

The Surprise Question ("Would I be surprised if this patient were to die within the next 12 months?") is widely used to identify palliative patients, though with low predictive value. To improve timely identification of palliative care needs, we propose an additional Surprise Question ("Would I be surprised if this patient is still alive after 12 months?") if the original Surprise Question is answered with "no." The combination of the two questions is called the Double Surprise Question.

AIM

To examine the prognostic accuracy of the Double Surprise Question in outpatients with cancer.

DESIGN

A prospective study.

PARTICIPANTS

Twelve medical oncologists completed the Double Surprise Question for 379 patients.

RESULTS

In group 1 (original Surprise Question "yes": surprised if dead) 92.1% (176/191) of the patients were still alive after 1 year, in group 2a (original and additional Surprise Question "no": not surprised if dead and not surprised if alive) 60.0% (63/105), and in group 2b (original Surprise Question "no," additional Surprise Question "yes": surprised if alive) 26.5% (22/83) (p < 0.0001). The positive predictive value increased by using the Double Surprise Question; 74% (61/83) vs 55% (103/188). Anticipatory palliative care provision and Advance Care Planning items were most often documented in group 2b.

CONCLUSIONS

The Double Surprise Question is a promising tool to more accurately identify outpatients with cancer at risk of dying within 1 year, and therefore, those in need of palliative care. Studies should reveal whether the implementation of the Double Surprise Question leads to more timely palliative care.

Where do GPs find patients with possible palliative care needs? A cross-sectional descriptive study

BACKGROUND

For GPs to implement early palliative care, the first step is to identify patients with palliative care needs. The surprise question (SQ) is a screening tool that aims to aid this identification; for example, a response of 'no' to the SQ - 'Would you be surprised if this patient would die within a year?' - would suggest palliative care may be needed.

AIM

To describe setting-specific screening results of patients eligible for early palliative care in family practices, which is defined as patients aged ≥45 years with GPs' responses of 'no' to the SQ.

DESIGN & SETTING

A secondary analysis was undertaken using a cross-sectional descriptive study in family practices in five areas in Belgium.

METHOD

GPs were recruited by targeted sampling. As a first part of an implementation research project, participating GPs provided demographic information about themselves and also provided a response to the SQ for all patients who came to the practice in 10 consecutive office days. A summary table describing the sex, age, location of contact (GP surgeries, patients' homes, or nursing homes) of the patients was provided by each GP.

RESULTS

Fifty-six GPs provided complete data for the practice summary tables. In total, 9150 patients were described (all ages, all settings), of which 506 patients (6%) had a GP response of 'no' to the SQ. The distribution of SQ-no-as-answer patients per setting was: 152/7659 (2%) patients seen in family practice surgeries; 139/998 (14%) patients seen in their homes; and 215/493 (44%) patients seen in nursing homes.

CONCLUSION

There was a large number of patients with SQ-no-as-answer, with possible palliative care needs. To enhance implementation of early palliative care, future research should compare results of SQ and other screening tools with palliative care symptoms assessments.