A Surprise Question Can Help Predict Which Patients Are Near the End of Life

Judith Vick, BA

Judith Vick, BA

An important aspect of patient-centered care is ensuring that those with advanced cancers have their values respected and their goals for care met at the end of life. Researchers have found that asking these patients’ clinicians a single “surprise” question can help achieve this aim by identifying those who are at highest risk of dying within a year.

The study found oncology clinicians’ responses to the Surprise Question (SQ)—Would you be surprised if this patient died within the next year?—were able to identify nearly 60% of patients who died within that timeframe.

SQ responses proved to be a better predictor of the risk of death than such factors as the patient’s age, cancer type, stage, or the time since diagnosis. Armed with this knowledge, clinicians can better identify seriously ill patients who would benefit from conversations to clarify and articulate what matters most to them as they live the rest of their lives.

Findings were presented by lead author Judith B. Vick, BA, a medical student at Johns Hopkins School of Medicine during an October 5 presscast in advance of the 2015 Palliative Care in Oncology Symposium to be held October 9-10 in Boston.

“The surprise question is meant to be very useful because of its simplicity,” explained Vick. “It asks the oncologist to consider the whole patient when answering the question.” She added that the SQ’s potential value lies in its ease of implementation versus other more complicated prognostic indices, which are more difficult and more expensive.

Although the SQ was developed in the 1990s, limited evidence exists of its utility in cancer care, and currently there is no generally accepted screening tool to identify patients who are at risk of dying.

To help address this gap, the study enrolled a total of 76 oncologists, nurse practitioners, and physician assistants at the Dana-Farber Cancer Institute. The participants were asked to use their best clinical judgment to answer the SQ for 4779 patients with all stages and types of cancer, including breast, gastrointestinal, genitourinary, head and neck, sarcoma, thoracic, and lymphoma.

Among those patients for whom clinicians responded, “Yes, I would be surprised if this patient died with a year,” 95% were alive within the year, Vick reported. Sixty-two percent of patients for whom the SQ was answered “No” were alive at 1 year.

Of the patients who died within 1 year, the SQ was able to identify 59%, but the SQ failed to identify 41% of those who died within the year, a finding Vick said suggests a need for more research to understand factors that contribute to nonrecognition of so many patients.

“While [the nearly 60%] is a good number, it’s certainly not perfect,” concurred study coauthor Rachelle Bernacki, MD, MS, director of Quality Initiatives at Dana-Farber. “We would like to have better tools to identify all patients who are at risk.”

With that in mind, researchers involved in this ongoing study plan to investigate clinician characteristics that might affect how accurately they answer the SQ and to examine the characteristics of patients which the clinicians inaccurately forecast who either died or lived contrary to expectations.

“It can be challenging for clinicians to determine which patients they should begin discussions with about end-of-life preferences,” noted Don S. Dizon, MD, ASCO expert and moderator of the presscast, in a statement. “This study indicates that the answer to a single question can be an important indicator of prognosis.”

“Sometimes when we do see patients, we develop a gestalt of how we think the person is doing. There’s nothing that might be there in terms of the laboratory values, the CT scans, or vital signs, but we just get this sense that things are going well or not going well, and I think that’s what the surprise question is getting at,” Dizon continued.

“With this tool, physicians can harness their clinical impressions to plan the most appropriate care for each patient.”

Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl; abstr 8).