'Surprise' Question Effective at Predicting End of Life

Roxanne Nelson

October 08, 2015

A simple question may be an effective means of helping clinicians to predict which patients with cancer are nearing the end of their life.

The question is "Would you be surprised if this patient died within the next year?"

In pondering the answer to that question, clinicians were able to predict which of their patients were at a high risk of dying within 1 year. In fact, the "surprise" question, as it's called, was more predictive than other clinical factors, such as cancer stage, patient age, and time from diagnosis, according to a new study.

In this study, clinicians responded with "Yes, I would be surprised" for about 85% of patients and "No, I would not be surprised," for about 15% of the patients.

Within the cohort of patients who did die within 12 months, a negative response to the question identified 60% of them.

"Our results showed that oncology clinicians' own judgment using the 'surprise' question identified about 60% of deceased patients," said study author Judith B. Vick, BA, a medical student at Johns Hopkins University School of Medicine, Baltimore, Maryland. She was speaking at a press briefing held by the American Society of Clinical Oncology (ASCO), in advance of the Palliative Care in Oncology Symposium (PCOS) 2015, which will take place October 9 and 10 in Boston.

However, of the patients who died with the year, the "surprise" question failed to identify about 40%.

"Given that 40% of deceased patients were not identified by the 'surprise' question, more research is needed to understand factors that contribute to nonrecognition of so many patients," Vick commented.

The "surprise" question tool was developed about 2 decades ago, back in the 1990s. But up until recently, there has been limited evidence of its utility in the cancer care setting.

"There is no generally accepted screening tool to identify patients who are at risk of dying," explained Vick. "Patients who are at high risk of dying will benefit from conversations that can help them clarify and articulate what matters most to them as they live the rest of their lives."

The findings reported by Vick are from an ongoing study of a patient-centered serious-illness care program that was developed by Ariadne Labs in Boston. The program is being evaluated in a randomized trial at the Dana-Farber Cancer Institute in Boston, and the "surprise" question is the first step of Ariadne Labs' comprehensive patient-centered Serious Illness Care Program.

Study Details

In this study, 81 oncology clinicians, including oncologists, nurse practitioners, and physician assistants at the Dana-Farber Cancer Institute, were enrolled from July 2012 to October 2014. The aim of the trial was to investigate the effect of a structured intervention to improve conversations about end-of-life goals.

The "surprise" question was presented to 76 clinicians with regard to 4779 patients who were in all stages of cancer and diagnosed with several different types of the disease, including breast, gastrointestinal, genitourinary, head and neck, and thoracic cancer; sarcoma; and lymphoma.

The propensity-adjusted 1-year survival for "yes" patients was 93% (95% confidence interval [CI], 91% - 96%) compared with 53% (95% CI, 46% - 60%) for the "no" patients (P < 0.0001). The authors found that the "surprise" question was more predictive of patient death than type of cancer, age, cancer stage, or time since diagnosis.

Sensitivity of the "no" response was 59% (95% CI, 49% - 68%) and specificity was 90% (95% CI, 86% - 93%), while the positive predictive value was 49% (95% C,I 45% - 54%) and negative predictive value was 93% (95% CI, 90% - 95%).

"This important work shows that one question that clinicians actually ask themselves may be more effective than the usual clinical and laboratory parameters to identify patients that have a high risk of dying within a year," commented ASCO expert and moderator of the press briefing, Don S. Dizon, MD.

"I think this is important, especially in an era where we are looking at values and preferences regarding current and future cancer care, and I look forward to future results of this multipronged intervention," added Dr Dizon, who is also clinical co-director of gynecologic oncology at Massachusetts General Hospital, Boston.

No funding source was disclosed for this study. Coauthor Atul Gawande, MD, MPH, reported "multiple publishers globally from whom I receive royalties for my writing on mortality and medicine," and coauthor Susan Block, MD, reports employment with UpToDate.

Palliative Care in Oncology Symposium (PCOS) 2015. Abstract 8. To be presented October 10, 2015

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