Adding a second surprise question triggers general practitioners to increase the thoroughness of palliative care planning: results of a pilot RCT with cage vignettes

Should the Surprise Question be Used as a Prognostic Tool for People With Life-limiting Illnesses?

The surprise question screening tool ("Would I be surprised if this person died within the next 12 months?") was initially developed to identify possible palliative care needs. One controversial topic regarding the surprise question is whether it should be used as a prognostic tool (predicting survival) for patients with life-limiting illnesses. In this "Controversies in Palliative Care" article, three groups of expert clinicians independently answered this question. All experts provide an overview of current literature, practical advice, and opportunities for future research. All experts reported on the inconsistency of the prognostic capabilities of the surprise question. Two of the three expert groups felt that the surprise question should not be used as a prognostic tool due to these inconsistencies. The third expert group felt that the surprise question should be used as a prognostic tool, particularly for shorter time frames. The experts all highlighted that the original rationale for the surprise question was to trigger a further conversation about future treatment and a potential shift in the focus of the care, identifying patients who many benefit from specialist palliative care or advance care planning; however, many clinicians find this discussion a difficult one to initiate. The experts agreed that the benefit of the surprise question comes from its simplicity: a one-question tool that requires no specific information about the patient's condition. More research is needed to better support the application of this tool in routine practice, particularly in noncancer populations.

Advance Care Planning in the Netherlands

The Dutch health care system fosters a strong public health sector offering accessible generalist care including generalist palliative care. General practitioners are well positioned to conduct ACP, for example, to continue or initiate conversations after hospitalization. However, research shows that ACP conversations are often ad hoc and in frail patients, ACP is often only initiated when admitted to a nursing home by elderly care physicians who are on the staff. Tools that raise awareness of triggers to initiate ACP, screening tools, information brochures, checklists and training have been developed and implemented with funding by national programs which currently focus on implementation projects rather than or in addition to, research. The programs commonly require educational deliverables, patient and public involvement and addressing diversity in patient groups. A major challenge is how to implement ACP systematically and continuously across sectors and disciplines in a way that supports a proactive yet person-centered approach rather than an approach with an exclusive focus on medical procedures. Digital solutions can support continuity of care and communication about care plans. Solutions should fit a culture that prefers trust-based, informal deliberative approaches. This may be supported by involving disciplines other than medicine, such as nursing and spiritual caregiving, and public health approaches.

Validation of the Surprise Question and the Development of a Multivariable Model

CONTEXT

The Surprise Question (SQ) (would you be surprised if this patient died within a year?) is a prognostic variable explored in chronic illnesses. Validation is limited to sensitivity, specificity, and predictive values.

OBJECTIVES

Our objective is to validate the SQ in cancer patients and develop a predictive model with additional variables.

METHODS

A prospective cohort study of adult (age>18) cancer patients seen between October 1, 2019, through March 31, 2021, undergoing systemic therapies had the SQ completed by oncologists prior to each change in systemic therapy. The primary outcome was survival for one year. Secondary outcomes were predictions of survival at three, six, and nine months. Patients were grouped into negative SQ (not surprised) and positive SQ (surprised). Sensitivity, specificity, predictive values, and likelihood ratios (LR) were calculated for the SQ. Additional prognostic variables were age, gender, cancer stage, line of therapy, Charleson Comorbid Index (CCI), palliative care consultation (prior to, after the SQ, or not at all), and healthcare utilization (outpatient, inpatient, and emergency department (ED). Logistic regression and receiver operating characteristics (ROC) were used for discrimination and modeling. Akaike information criterion (AIC) was used to compare the model fit as each predictor.

RESULTS

1366 patients had 1 SQ; 784 died within a year. The SQ predicted survival at one year (P = 0.008), with a positive LR of 1.459 (95%CI 1.316-1.602) and a c-statistic of 0.565 (95%CI 0.530-0.600). Additional variables increased the c-statistic to 0.648 (95% CI 0.608-0.686). The total model best predicted survival at three months, c-statistic of 0.663 (95% CI 0.616-0.706). However, the total model c-statistic remained <0.70.

CONCLUSIONS

The SQ, as a single factor, poorly predicts survival and should not be used to alter therapies. Adding additional objective variables improved prognostication, but further refinement and external validation are needed.

A Description of Persons With Alzheimer Disease and Related Dementias Receiving Home Health Care: A National Analysis

The end-of-life period of individuals with Alzheimer disease and related dementias receiving home health care (HHC) is understudied. We sought to describe characteristics of HHC patients with Alzheimer disease and related dementias at risk of death within a year, based on clinician assessment. We conducted a secondary data analysis of a 5% random sample of the Outcome and Assessment Information Set data set for the year 2017. We used Outcome and Assessment Information Set-C item M1034 to identify HHC patients with overall status of progressive condition leading to death within a year. Multivariable logistic regression model was used to examine the association between sociodemographic, functional, clinical, and caregiving factors and likelihood of decline leading to death within a year, as identified by HHC clinicians. Clinician perception of decline leading to death within a year was higher for Whites (vs Blacks or Hispanics) (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.69-0.80], and OR, 0.63 [95% CI, 0.57-0.69], respectively). Factors associated with increased odds of decline leading to death within a year included daily pain (OR, 1.11 [95% CI, 1.06-1.17]), anxiety daily or more often (OR, 1.58 [95% CI, 1.49-1.67]), shortness of breath (OR, 1.45 [95% CI, 1.34-1.57]), use of oxygen (OR, 1.60 [95% CI, 1.52-1.69]), disruptive behavior (OR, 1.26 [95% CI, 1.20-1.31]), and feeding difficulty (OR, 2.25 [95% CI, 2.09-2.43]). High symptom burden exists among HHC patients with Alzheimer disease and related dementias identified to have a status of decline leading to death within a year.

Added Value of Early Consultation of an Inpatient Palliative Care Team in Hospitalized Older Patients With High Symptom Burden: A Prospective Comparative Study

BACKGROUND

It is estimated that in 2050 one quarter of the population in Europe will be aged 65 years and older. Although the added value of a palliative care team is emphasized in the literature, the impact of the palliative care team on the symptom burden in older non-cancer patients is not yet well established.

OBJECTIVES

To structurally measure symptoms and to investigate whether proactive consultation with a palliative care team results in improvement of symptoms.

DESIGN

This study has a prospective comparative design.

SETTING/PARTICIPANTS

Older patients, admitted to a Dutch University Medical Centre for who a health care professional had a negative response to the Surprise Question, were selected.

MEASUREMENTS, RESULTS

In period one, 59 patients completed the Utrecht Symptom Diary (USD) at day one of admission and after 7 days. In period 2 (n = 60), the same procedure was followed; additionally, the palliative care team was consulted for patients with high USD-scores. Significant improvement on the USD Total Distress Score (TSDS) was observed in both groups without a difference between the 2 periods. This study showed an association between consultation of the palliative care team and improvement on USD TSDS (adjusted odds ratio: 4.9; 95% confidence interval: 1.816-13.198), despite low follow-up rate of advices (approximately 50%).

CONCLUSIONS

This study emphasizes the importance of creating awareness for consulting the palliative care team. Further research should focus on assessing the reason behind the low follow-up rate of the advice given and understanding the specific advices contributing to symptom improvement.

Timely identification of patients in need of palliative care using the Double Surprise Question: A prospective study on outpatients with cancer

BACKGROUND

The Surprise Question ("Would I be surprised if this patient were to die within the next 12 months?") is widely used to identify palliative patients, though with low predictive value. To improve timely identification of palliative care needs, we propose an additional Surprise Question ("Would I be surprised if this patient is still alive after 12 months?") if the original Surprise Question is answered with "no." The combination of the two questions is called the Double Surprise Question.

AIM

To examine the prognostic accuracy of the Double Surprise Question in outpatients with cancer.

DESIGN

A prospective study.

PARTICIPANTS

Twelve medical oncologists completed the Double Surprise Question for 379 patients.

RESULTS

In group 1 (original Surprise Question "yes": surprised if dead) 92.1% (176/191) of the patients were still alive after 1 year, in group 2a (original and additional Surprise Question "no": not surprised if dead and not surprised if alive) 60.0% (63/105), and in group 2b (original Surprise Question "no," additional Surprise Question "yes": surprised if alive) 26.5% (22/83) (p < 0.0001). The positive predictive value increased by using the Double Surprise Question; 74% (61/83) vs 55% (103/188). Anticipatory palliative care provision and Advance Care Planning items were most often documented in group 2b.

CONCLUSIONS

The Double Surprise Question is a promising tool to more accurately identify outpatients with cancer at risk of dying within 1 year, and therefore, those in need of palliative care. Studies should reveal whether the implementation of the Double Surprise Question leads to more timely palliative care.

Where do GPs find patients with possible palliative care needs? A cross-sectional descriptive study

BACKGROUND

For GPs to implement early palliative care, the first step is to identify patients with palliative care needs. The surprise question (SQ) is a screening tool that aims to aid this identification; for example, a response of 'no' to the SQ - 'Would you be surprised if this patient would die within a year?' - would suggest palliative care may be needed.

AIM

To describe setting-specific screening results of patients eligible for early palliative care in family practices, which is defined as patients aged ≥45 years with GPs' responses of 'no' to the SQ.

DESIGN & SETTING

A secondary analysis was undertaken using a cross-sectional descriptive study in family practices in five areas in Belgium.

METHOD

GPs were recruited by targeted sampling. As a first part of an implementation research project, participating GPs provided demographic information about themselves and also provided a response to the SQ for all patients who came to the practice in 10 consecutive office days. A summary table describing the sex, age, location of contact (GP surgeries, patients' homes, or nursing homes) of the patients was provided by each GP.

RESULTS

Fifty-six GPs provided complete data for the practice summary tables. In total, 9150 patients were described (all ages, all settings), of which 506 patients (6%) had a GP response of 'no' to the SQ. The distribution of SQ-no-as-answer patients per setting was: 152/7659 (2%) patients seen in family practice surgeries; 139/998 (14%) patients seen in their homes; and 215/493 (44%) patients seen in nursing homes.

CONCLUSION

There was a large number of patients with SQ-no-as-answer, with possible palliative care needs. To enhance implementation of early palliative care, future research should compare results of SQ and other screening tools with palliative care symptoms assessments.

Physicians' perspectives on estimating and communicating prognosis in palliative care: a cross-sectional survey

Background

Advance care planning (ACP) can help to enhance the care of patients with limited life expectancy. Despite physicians’ key role in ACP, the ways in which physicians estimate and communicate prognosis can be improved.

Aim

To determine how physicians in different care settings self-assess their performance in estimating and communicating prognosis to patients in palliative care, and how they perceive their communication with other physicians about patients’ poor prognosis.

Design & setting

A survey study was performed among a random sample of GPs, hospital physicians (HPs), and nursing home physicians (NHPs) in the southwest of the Netherlands (n = 2212).

Method

A questionnaire was developed that had three versions for GPs, HPs, and NHPs. Each specialism filled in an appropriate version.

Results

A total of 547 physicians participated: 259 GPs, 205 HPs, and 83 NHPs. In the study, 61.1% of physicians indicated being able to adequately estimate whether a patient will die within 1 year, which was associated with use of the Surprise Question (odds ratio [OR] = 1.65, P = 0.042). In the case of a prognosis of <1 year, 75.0% of physicians indicated that they communicate with patients about preferences regarding treatment and care, which was associated with physicians being trained in palliative care (OR = 2.02, P=0.007). In cases where patients with poor prognosis are discharged after hospital admission, 83.4% of HPs indicated that they inform GPs about these patients’ preferences compared with 29.0% of GPs, and 21.7% of NHPs, who indicated that they are usually adequately informed about the preferences.

Conclusion

The majority of physicians indicated that they believe they can adequately estimate patients’ limited life expectancy and that they discuss patients’ preferences for care. However, more physicians should be trained in communicating about patients’ poor prognosis and care preferences.

Identification of patients with potential palliative care needs: A systematic review of screening tools in primary care

BACKGROUND

Despite increasing evidence of the benefits of early access to palliative care, many patients do not receive palliative care in a timely manner. A systematic approach in primary care can facilitate earlier identification of patients with potential palliative care needs and prompt further assessment.

AIM

To identify existing screening tools for identification of patients with advanced progressive diseases who are likely to have palliative care needs in primary healthcare and evaluate their accuracy.

DESIGN

Systematic review (PROSPERO registration number CRD42019111568).

DATA SOURCES

Cochrane, MEDLINE, Embase and CINAHL were searched from inception to March 2019.

RESULTS

From 4,127 unique articles screened, 25 reported the use or development of 10 screening tools. Most tools use prediction of death and/or deterioration as a proxy for the identification of people with potential palliative care needs. The tools are based on a wide range of general and disease-specific indicators. The accuracy of five tools was assessed in eight studies; these tools differed significantly in their ability to identify patients with potential palliative care needs with sensitivity ranging from 3% to 94% and specificity ranging from 26% to 99%.

CONCLUSION

The ability of current screening tools to identify patients with advanced progressive diseases who are likely to have palliative care needs in primary care is limited. Further research is needed to identify standardised screening processes that are based not only on predicting mortality and deterioration but also on anticipating the palliative care needs and predicting the rate and course of functional decline. This would prompt a comprehensive assessment to identify and meet their needs on time.

Prognosticating for Adult Patients With Advanced Incurable Cancer: a Needed Oncologist Skill

Patients with advanced cancer and their families commonly seek information about prognosis to aid decision-making in medical (e.g. surrounding treatment), psychological (e.g. saying goodbye), and social (e.g. getting affairs in order) domains. Oncologists therefore have a responsibility to identify and address these requests by formulating and sensitively communicating information about prognosis. Current evidence suggests that clinician predictions are correlated with actual survival but tend to be overestimations. In an attempt to cultivate prognostic skills, it is recommended that clinicians practice formulating and recording subjective estimates of prognosis in advanced cancer patient’s medical notes. When possible, a multi-professional prognostic estimate should be sought as these may be more accurate than individual predictions alone. Clinicians may consider auditing the accuracy of their predictions periodically and using feedback from this process to improve their prognostic skills.

Clinicians may also consider using validated prognostic tools to complement their clinical judgements. However, there is currently only limited evidence about the comparative accuracy of different prognostic tools or the extent to which these measures are superior to clinical judgement. Oncologists and palliative care physicians should ensure that they receive adequate training in advanced communication skills, which builds upon their pre-existing skills, to sensitively deliver information on prognosis. In particular, clinicians should acknowledge their own prognostic uncertainty and should emphasise the supportive care that can continue to be provided after stopping cancer-directed therapies.

Screening with the double surprise question to predict deterioration and death: an explorative study

Background

Early identification of palliative patients is challenging. The Surprise Question (SQ1; Would I be surprised if this patient were to die within 12 months?) is widely used to identify palliative patients. However, its predictive value is low. Therefore, we added a second question (SQ2) to SQ1: ‘Would I be surprised if this patient is still alive after 12 months?’ We studied the accuracy of this double surprise question (DSQ) in a general practice.

Methods

We performed a prospective cohort study with retrospective medical record review in a general practice in the eastern part of the Netherlands. Two general practitioners (GPs) answered both questions for all 292 patients aged ≥75 years (mean age 84 years).

Primary outcome was 1-year death, secondary outcomes were aspects of palliative care.

Results

SQ1 was answered with ‘no‘ for 161/292 patients. Of these, SQ2 was answered with ‘yes’ in 22 patients. Within 12 months 26 patients died, of whom 24 had been identified with SQ1 (sensitivity: 92%, specificity: 49%). Ten of them were also identified with SQ2 (sensitivity: 42%, specificity: 91%). The latter group had more contacts with their GP and more palliative care aspects were discussed.

Conclusions

The DSQ appears a feasible and easy applicable screening tool in general practice. It is highly effective in predicting patients in high need for palliative care and using it helps to discriminate between patients with different life expectancies and palliative care needs. Further research is necessary to confirm the findings of this study.

Surprise Question and Performance Status Indicate Urgency of Palliative Care Needs in Patients with Advanced Cancer at the Emergency Department: An Observational Cohort Study

Background: The surprise question (SQ), "Would I be surprised if this patient died within one year?", is a simple instrument to identify patients with palliative care needs. The SQ-performance has not been evaluated in patients with advanced cancer visiting the emergency department (ED). Objective: To evaluate SQ's test characteristics and predictive value in patients with advanced cancer visiting the ED. Design: Observational cohort study. Setting: Patients >18 years with advanced cancer in the palliative phase visiting the ED of an academic medical center. Methods: Attending physicians answered the SQ (not surprised [NS] or surprised [S]) and estimated Eastern Cooperative Oncology Group (ECOG)-performance status. Disease, visit, and follow-up characteristics were retrospectively collected from charts. SQ's sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and Harrell's c-index were calculated. Prognostic values of SQ and other variables were assessed by using Cox proportional hazards models. Results: Two-hundred-and-forty-five patients were included (203 NS [83%] and 42 S [17%]), median age 62 years, 48% male. Follow-up on overall survival was updated until February 2019. At ED entry, NS-patients had worse ECOG-performance and more symptoms. At study closure, 233 patients had died (95%). Median survival was three months for NS-patients (interquartile [IQ]-range: 1-8); nine months for S-patients (IQ-range: 3-28) (p < 0.0001). SQ-performance for one-year mortality: sensitivity 89%, specificity 40%, PPV 85%, NPV 50%, c-index 0.56, and hazard ratio 2.1 for approaching death. ECOG 3-4 predicted death in NS-patients; addition to the SQ improved c-index (0.65); sensitivity (40%), specificity (92%), PPV (95%), and NPV (29%). Conclusions: At the ED, the SQ plus ECOG 3-4 helps identifying patients with advanced cancer and a limited life expectancy. Its use supports initiating appropriate care related to urgency of palliative care needs.

An online international comparison of thresholds for triggering a negative response to the "Surprise Question": a study protocol

BACKGROUND

The Surprise Question (SQ) "would I be surprised if this patient were to die in the next 12 months?" has been suggested to help clinicians, and especially General Practitioners (GPs), identify people who might benefit from palliative care. The prognostic accuracy of this approach is unclear and little is known about how GPs use this tool in practice. Are GPs consistent, individually and as a group? Are there international differences in the use of the tool? Does including the alternative Surprise Question ("Would I be surprised if the patient were still alive after 12 months?") alter the response? What is the impact on the treatment plan in response to the SQ? This study aims to address these questions.

METHODS

An online study will be completed by 600 (100 per country) registered GPs. They will be asked to review 20 hypothetical patient vignettes. For each vignette they will be asked to provide a response to the following four questions: (1) the SQ [Yes/No]; (2) the alternative SQ [Yes/No]; (3) the percentage probability of dying [0% no chance - 100% certain death]; and (4) the proposed treatment plan [multiple choice]. A "surprise threshold" for each participant will be calculated by comparing the responses to the SQ with the probability estimates of death. We will use linear regression to explore any differences in thresholds between countries and other clinician-related factors, such as years of experience. We will describe the actions taken by the clinicians and explore the differences between groups. We will also investigate the relationship between the alternative SQ and the other responses. Participants will receive a certificate of completion and the option to receive feedback on their performance.

DISCUSSION

This study explores the extent to which the SQ is consistently used at an individual, group, and national level. The findings of this study will help to understand the clinical value of using the SQ in routine practice.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03697213 (05/10/2018). Prospectively registered.

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

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.