Using the “Surprise Question” in Nursing Homes

Rice, Jill; Hunter, Linda; Hsu, Amy T; Donskov, Melissa; Luciani, Tracy; Toal-Sullivan, Darene; Welch, Vivian; Tanuseputro, Peter

doi:10.1177/0825859717745728

Cited by 17 publications

(10 citation statements)

References 36 publications

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“…The Surprise Question has been shown to be quick and efficient with reasonable accuracy in some studies when it came to identifying patients at high risk of death who may benefit from palliative care services. 21 –23 The Surprise Question has been used in primary care and long-term care settings to promote SICs 24,25 ; if the goal is not to accurately prognose patients, but to promote early SICs, the Surprise Question can be a quick and efficient tool. The Surprise Question has mostly been studied in oncology settings and usually with just doctors and nurses 21 –23 ; so this study will expand the Surprise Question to include the whole interdisciplinary team (doctors, nurses, and allied health) on an acute medicine unit.…”

Section: Introductionmentioning

confidence: 99%

The Surprise Question and Serious Illness Conversations: A pilot study

Le¹,

Lee

Desai

et al. 2021

Nurs Ethics

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Background: Serious Illness Conversations aim to discuss patient goals. However, on acute medicine units, seriously ill patients may undergo distressing interventions until death. Objectives: To investigate the feasibility of using the Surprise Question, “Would you be surprised if this patient died within the next year?” to identify patients who would benefit from early Serious Illness Conversations and study any changes in the interdisciplinary team’s beliefs, confidence, and engagement as a result of asking the Surprise Question. Design: A prospective cohort pilot study with two Plan-Do-Study-Act cycles. Participants/context: Fifty-eight healthcare professionals working on Acute Medicine Units participated in pre- and post-intervention questionnaires. The intervention involved asking participants the Surprise Question for each patient. Patient charts were reviewed for Serious Illness Conversation documentation. Ethical considerations: Ethical approval was granted by the institutions involved. Findings: Equivocal overall changes in the beliefs, confidence, and engagement of healthcare professionals were observed. Six out of 23 patients were indicated as needing a Serious Illness Conversation; chart review provided some evidence that these patients had more Serious Illness Conversation documentation compared with the 17 patients not flagged for a Serious Illness Conversation. Issues were identified in equating the Surprise Question to a Serious Illness Conversation. Discussion: Appropriate support for seriously ill patients is both a nursing professional and ethical duty. Flagging patients for conversations may act as a filtering process, allowing healthcare professionals to focus on conversations with patients who need them most. There are ethical and practical issues as to what constitutes a “serious illness” and if answering “no” to the Surprise Question always equates to a conversation. Conclusion: The barriers of time constraints and lack of training call for institutional change in order to prioritise the moral obligation of Serious Illness Conversations.

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Section: Introductionmentioning

confidence: 99%

The Surprise Question and Serious Illness Conversations: A pilot study

Le¹,

Lee

Desai

et al. 2021

Nurs Ethics

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“…Because people are considered to be approaching the end of life when they are likely to die within the next 12 months (General Medical Council, 2010), the palliative phase in this study was defined as having a maximum life expectancy of one year. The accuracy of the SQ in predicting survival or death in nursing homes varies, from 57% to 67%, depending on the specific timeframes used (3 months, 6 months, or seasonal) (Rice et al, 2018). However, no timeframe of one year has, to our knowledge, been tested with residential care facilities as the only context.…”

Section: Methodological Considerations and Study Limitationsmentioning

confidence: 99%

Residents' and family members' perceptions of care quality and self-determination in palliative phase in residential care

et al. 2019

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ObjectiveDependency on others can compromise self-determination for older persons in the palliative phase in residential care. Family members can support the residents' self-determination but may also jeopardize it. Quality of care (QoC) is linked to respecting the autonomy of the residents and providing opportunities to participate in decision-making. The aim of the study was to provide knowledge about residents' and family members' perceptions of QoC and self-determination and to detect possible differences between their experiences.MethodThis cross-sectional study used an abbreviated version of the questionnaire, Quality from the Patients' Perspective, with additional items about decision-making. Wilcoxon's signed rank test was used to analyze the perception of QoC and to detect differences between residents' and family members' perceptions.ResultQoC was perceived as lower than preferred in the majority of items and there was a high level of agreement between residents and family members. Lowest mean values in QoC were found in: support when feeling lonely; support when feeling worry, anxiety or fear; and staff's time to talk to the residents. Decision-making in everyday life and in life-changing situations showed that neither residents nor family members trusted staff to know about the residents' preferences.Significance of resultsBroad improvements are needed, especially in psychosocial care. Several of the negative outcomes on QoC and self-determination seem to derive from a focus on practical tasks and the lack of trustful relationships between residents and staff. An early implementation of palliative care, with a focus on what brings quality to each resident's life, could facilitate QoC and self-determination, in both everyday life and at the end of life.

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“…Significantly, the 12-SQ was not originally developed for an accurate prognosis in the prediction of death, but to identify patients in need of palliative care ( 1 – 19 ). In specialties such as neurorehabilitation the implementation of the 12-SQ in combination with a palliative care assessment into the clinical routine—as in our study—might help sensitize healthcare professionals toward palliative care issues like initiating conversation on advanced care planning or prognosis or integrating additional services like palliative and hospice care services if needed.…”

Section: Discussionmentioning

confidence: 99%

“…As the 12-SQ is a commonly used tool for estimation of prognosis—even if poor when used as the only instrument—and for initiating palliative care in cancer and non-cancer patients ( 1 – 19 ), we investigated whether adding further clinical characteristics to the 12-SQ would improve the overall predictive power. Again, our results indicate that age and dysphagia, as well as rehabilitation phase and overburdening of the family in combination with the 12-SQ have great prognostic value in estimating prognosis and thus identifying patients in need of palliative care.…”

Section: Discussionmentioning

confidence: 99%

“…The various disease entities to which the SQ has been applied thus far include cancer ( 1 – 5 ), chronic obstructive pulmonary disease (COPD) ( 6 ), nephrological diseases ( 7 – 13 ), as well as pediatric palliative care ( 14 ), intensive care ( 15 ), emergency care ( 16 , 17 ), and in elderly care ( 17 – 19 ). The SQ has yet to be applied to neurological care where patients are characterized by different disease trajectories compared to other disease entities, especially cancer patients.…”

Section: Introductionmentioning

confidence: 99%

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The “Surprise Question” in Neurorehabilitation—Prognosis Estimation by Neurologist and Palliative Care Physician; a Longitudinal, Prospective, Observational Study

et al. 2018

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Background: The 12-months “surprise” question (12-SQ) for estimating prognosis and the need for integrating palliative care (PC) services has not yet been investigated for neurological patients.Objective: Test the value of the 12-SQ on a sample of neurorehabilitation patients.Methods: All patients newly registered in the Department of Neurorehabilitation, Dr. Becker Rhein-Sieg-Clinic (8/2016-03/2017) were asked to participate. The treating neurorehabilitation physicians (NP) and an external consulting PC physician (PCP) independently estimated patients' prognosis using the 12-SQ; while symptom burden was independently assessed using the standardized palliative outcome measurement HOPE-SP-CL, a set of additional neurological issues, and ECOG. Follow-up with consenting patients 12 months later was via telephone. Descriptive and inferential statistics were utilized in data analysis.Results: Of 634 patients, 279 (44%) patients (male: 57.7%, female: 42.3%; mean age: 63 ± 14) (or, alternatively, their legal representative) consented and were assessed at baseline. Per patient NP and PCP both answered the 12-SQ with “Yes” (164), with “No” (42), or had different opinions (73). The “No” group displayed the highest symptom burden on all three measures for both disciplines. Overall, PCP scored higher (i.e., worse) than NP on all measures used. Follow-up was possible for 236 (drop-out: 15.4%) patients (deceased: 34 (14.4%), alive: 202 (85.6%)). Baseline scores on all measures were higher for deceased patients compared to those still living. Prognostic characteristics were: sensitivity: NP 50%, PCP 67.6%; specificity: NP 86.1%, PCP 70.3%, p < 0.001; positive predictive value: NP 37.8%, PCP 27.7%; negative predictive value: NP 91.1%, PCP 92.8%; area under the curve: NP 0.68, PCP 0.69; success rate: NP 80.9%, PCP 69.9%, p = 0.002. Regression analysis indicated that age, dysphagia and overburdening of family (NP answering the 12-SQ), dysphagia and rehabilitation phase (PCP answering the 12-SQ) were associated with increased likelihood of dying within 12 months. Without the 12-SQ as relevant predictor, age, dysphagia and ECOG were significant predictors (NP and PCP).Conclusion: Combining the 12-SQ with a measurement assessing PC and neurological issues could potentially improve the 12-SQ's predictive performance of 12-month survival and help to identify when to initiate the PC approach. Clinical experiences influence assessment and prognosis estimation.

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Using the “Surprise Question” in Nursing Homes

Cited by 17 publications

References 36 publications

The Surprise Question and Serious Illness Conversations: A pilot study

The Surprise Question and Serious Illness Conversations: A pilot study

Residents' and family members' perceptions of care quality and self-determination in palliative phase in residential care

The “Surprise Question” in Neurorehabilitation—Prognosis Estimation by Neurologist and Palliative Care Physician; a Longitudinal, Prospective, Observational Study

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