60 Can the ‘surprise question‘ be used to correctly identify people nearing the end of life?: a review

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It has been shown that clinicians are inaccurate at prognostication (White et al., 2016) and recognising dying patients (Neuberger et al., 2013). Patients who would benefit from palliative care may be missed because validated prognostic tools (Pirovano et al., 1999; Morita et al., 1999) are not routinely used, either due to the perceived complexity or inconvenience. The surprise question (SQ) (“Would you be surprised if this patient died within the next χ months?”) offers an alternative to standard prognostic estimates.


To evaluate the performance of the SQ in patients nearing the end of life.


We searched numerous databases, including: Medline, Embase, CINAHL, AMED. Studies were included if they reported the SQ and were written in English.


Out of the 357 studies identified, 22 were included in the review. In these studies, 25 718 estimates were reported. The results showed a wide variation in the reported accuracy of the SQ, with sensitivity ranging from 11.6% to 96.6% and specificity ranging from 13.9% to 78.6%. The AUROC score across the studies ranged from 0.512 to 0.822. Doctors appeared to be more accurate than nurses at recognising people in the last year of life (c-statistic=0.735 vs. 0.688).


The performance of the SQ varied greatly across the studies. Further work is required to understand the processes by which clinicians arrive at their prognostic estimates, to refine the accuracy of the SQ and to compare its performance against other more sophisticated prognostic tools, particularly in populations where a higher proportions of deaths occur.

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