Background
The “Surprise Question” (SQ) asks, “Would you be surprised if this person died within the next year?” and is commonly used to identify patients who may be in their last year of life though originally meant to be a way to refer to palliative care in a timely manner. Its accuracy and utility can vary by setting, underlying disease, timeframe, and the person making the assessment in terms of overall mortality.
Design and Participants
Design. A systematic review and meta-analysis following PRISMA guidelines of prospective observational studies on the SQs performance for predicting survival with the need to be able to calculated Sn, Sp, PPV, NPV and accuracy.
Participants. 56 distinct cohorts (from 57 eligible studies) comprising 68,829 patients in diverse settings (primary care, outpatient, inpatient, emergency department, community).
Results
Commentary
This is an interesting study showing that there is overall moderate accuracy of the SQ. That said one of the major limitations of this study is the heterogeneity of populations included in the studies so it really is difficult to parse out when it is accurate. The SQ performed best in populations with high event (death) rates, over shorter timeframes, and when posed by more experienced respondents. In disease-specific subgroups, the SQ was particularly accurate in populations with predictable courses (certain oncologic settings) as well as pediatrics. False positives like predicting death in patients who ultimately survive may lead to over-classification based on mortality estimates. That said the original purpose of the question is about early engagement of PC and supportive measures that likely identify an at risk cohort that could benefit from PC regardless of the mortality implications and predictive ability of the question diagnostically. A more longitudinal approach may be appropriate as these groups that are overclassified as the SQ can prompt vital end-of-life discussions and earlier palliative care referrals with symptom management and complex psychosocial needs.
Bottom Line
The Surprise Question is a quick, easily administered prompt with modest predictive value regarding 1-year mortality. It is most useful in settings with higher mortality rates and when asked by experienced clinicians. While it should not serve as the sole determinant for care decisions, the SQ can help facilitate timely palliative care interventions and advance care planning.
Source
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