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

Abstract

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.

Discrepancy in responses to the surprise question between hemodialysis nurses and physicians, with focus on patient clinical characteristics: A comparative study

“…Another strength of this study was that each patient was evaluated by one nurse and one physician involved in the care of the patient and familiar with the history, the patient's clinical trajectory, and the treatment. In other studies evaluating the SQ, one or few physicians and/or nurses have evaluated many, and sometimes all patients at one dialysis unit 28,43 which may introduce a risk of rater bias. 18,31 Limitations include that the nurses responded both to the SQ and to the performance status, and that the physicians in most cases responded both to the CCI and the SQ for their patients.…”

“…28,29 It has also been evaluated for predicting mortality, as well as to identify patients approaching the end of life and being in need of serious illness conversations. 28,29 In a recent review, 29 the SQ, as a single question or in combination with other variables, was found to be the most common way to identify patients for serious illness conversations. It has also been proposed to be used by different professions in foreseeing the need of serious illness conversations and end of life dialogs.…”

“…The surprise question (SQ) “would I be surprised if this patient died within twelve months” was originally developed to identify patients with palliative care needs 27 . It has thereafter been evaluated in different contexts and with different time frames 28,29 . It has also been evaluated for predicting mortality, as well as to identify patients approaching the end of life and being in need of serious illness conversations 28,29 .…”

“…In a recent review, 29 the SQ, as a single question or in combination with other variables, was found to be the most common way to identify patients for serious illness conversations. It has also been proposed to be used by different professions in foreseeing the need of serious illness conversations and end of life dialogs 28–30 . In the hemodialysis context the SQ has been evaluated regarding 6 31 and 12 months 23,32–34 emanating from both nurses and physicians' perspectives 31,32,35 .…”

Likelihood Ratios: An Important Concept for Palliative Physicians to Understand

“…A meta-analysis of the surprise question was recently published. 21 The below table is a modification of the article’s Table 1 with added positive likelihood ratios (PLRs) and negative likelihood ratios (NLRs) for the various patient subgroups. We believe that the addition of this interpretation will greatly enhance the understanding of trial results.…”