Clinicians have been encouraged to utilize the surprise question (SQ), “Would I be surprised if this patient died within 12 months?”, to identify patients at high, one-year mortality risk.
When clinicians answer, “No – I would NOT be surprised if this patient died within 12 months,” the SQ may help clinicians identify patients who could benefit from a palliative care referral.

Patients with incurable disease desire prognostic information and prognosis is a major factor in preferences for rehospitalizations, life support, and CPR. Clinicians are more accurate and willing to offer probabilistic predictions (the clinician’s estimate, often expressed as a percentage, of the chance of death in a set time frame, such as one year).
The SQ was designed as a clinical tool that generalist clinicians would utilize willingly and routinely to identify patients at risk of death in a year and thereby lead to more appropriate care planning and goals-of-care discussions.

The SQ has been studied in diverse populations: general inpatient setting, high-risk primary care clinic, pediatric patients, advanced kidney disease, cancer, acute surgical patients, emergency department settings, and nursing home settings.
In general, the SQ has performed moderately well in identifying patients with a prognosis of < 1 year across these various patient populations.

Notable findings from these studies include the following.
• The SQ had a pooled accuracy of 75%, a sensitivity of 67%, and specificity of 80%.
• “Yes” answers appear to be much more accurate than “No” answers. The predictive value of a “Yes” answer was 93%, while only 37% for a “No” answer.
• The SQ may be slightly more accurate for cancer patients and renal patients vs. other disease groups (72%).
• The SQ was utilized as one aspect of a broad prognostic assessment; used in isolation, its accuracy is unclear.

A “No” answer triggers generalist clinicians to perform a primary palliative care assessment or screening for unmet palliative care needs. Main components of the valuation include:
• assessment for distressing physical, psychological, social, or spiritual concerns
• assessment of patient, family, and/or surrogate’s understanding of the underlying illness, treatment options, and prognostic trajectory
• assessment of decision-making capacity
• consideration of whether a palliative care consultation may be beneficial

See reference for more information.

Adapted from Jennings KS, Marks S, Lum HD. The surprise question as a prognostic tool. Palliative Care Network of Wisconsin. Fast facts and concepts #360. Internet. Accessed on December 27, 2018.