“The surprise questions” using variable time frames in hospitalized patients with advanced cancer

Abstract

Objective Several studies supported the usefulness of “the surprise question” in terms of 1-year mortality of patients. “The surprise question” requires a “Yes” or “No” answer to the question “Would I be surprised if this patient died in [specific time frame].” However, the 1-year time frame is often too long for advanced cancer patients seen by palliative care personnel. “The surprise question” with shorter time frames is needed for decision making. We examined the accuracy of “the surprise question” for 7-day, 21-day, and 42-day survival in hospitalized patients admitted to palliative care units (PCUs). Method This was a prospective multicenter cohort study of 130 adult patients with advanced cancer admitted to 7 hospital-based PCUs in South Korea. The accuracy of “the surprise question” was compared with that of the temporal question for clinician's prediction of survival. Results We analyzed 130 inpatients who died in PCUs during the study period. The median survival was 21.0 days. The sensitivity, specificity, and overall accuracy for the 7-day “the surprise question” were 46.7, 88.7, and 83.9%, respectively. The sensitivity, specificity, and overall accuracy for the 7-day temporal question were 6.7, 98.3, and 87.7%, respectively. The c-indices of the 7-day “the surprise question” and 7-day temporal question were 0.662 (95% CI: 0.539–0.785) and 0.521 (95% CI: 0.464–0.579), respectively. The c-indices of the 42-day “the surprise question” and 42-day temporal question were 0.554 (95% CI: 0.509–0.599) and 0.616 (95% CI: 0.569–0.663), respectively. Significance of results Surprisingly, “the surprise questions” and temporal questions had similar accuracies. The high specificities for the 7-day “the surprise question” and 7- and 21-day temporal question suggest they may be useful to rule in death if positive.

Prospective Comparison of Medical Oncologists and a Machine Learning Model to Predict 3-Month Mortality in Patients With Metastatic Solid Tumors

“…The SQ has been used most commonly with a 1-year time frame but also with time frames between 1 week and 6 months with varying performance. 7,9,10,[24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] The SQ has performed better in oncology populations compared with heart failure, kidney failure, and all diagnoses examined in other studies, 7,9,10 albeit modestly, and further research in this area is needed.…”

“…A widely and easily implemented prognostic tool is the surprise question (SQ), which asks clinicians whether it would surprise them if a patient died within a particular time frame. The SQ has been used most commonly with a 1-year time frame but also with time frames between 1 week and 6 months with varying performance . The SQ has performed better in oncology populations compared with heart failure, kidney failure, and all diagnoses examined in other studies, albeit modestly, and further research in this area is needed.…”

Prognostication in palliative radiotherapy—ProPaRT: Accuracy of prognostic scores

“…Efforts have been made using different methods to improve CPS performance, e.g., in a temporal way, in a probabilistic way, and using the surprise question (28)(29)(30)(31). Nonetheless, CPS alone continues to show limited accuracy, often overestimating the survival lifespan.…”

Prognostication of the Last Days of Life

“…These findings indicate that both 3-day and 1-day SQs can be useful screening tools to identify patients facing impending death. In another study, Kim et al [ 29 ] examined the accuracy of 7-day SQ in 130 patients admitted to PCUs in South Korea, and reported a sensitivity of 47%, specificity of 89%, positive predictive value (PPV) of 35%, and NPV of 93%, with an overall accuracy of 84% (C-index 0.66).…”