1. Gould, Kathleen Ahern PhD, RN

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Over the past few years, Dimensions of Critical Care Nursing has featured editorials highlighting the work of the Conversation Project. The goal was to introduce readers to new language and techniques developed to help providers begin difficult conversations with patients and families about serious illness and end-of-life decisions.1-3


Often, providers are hesitant to begin these conversations, and what matters to patients is not always communicated effectively. Publications such as Dying in America,4Being Mortal: Medicine and What Matters in the End,5 and continued research on this topic encourage patients, families, and providers to discuss care options more openly. Moreover, it has urged providers to ask patients what matters to them and include the patients' perspective during bedside rounds with multidisciplinary teams and in every consultation. This is certainly a new era for health care.


This new era for health care has brought us to consider how we approach difficult topics with patients and families. Berwick6 defines this new era as a moral era, one that is committed to fundamentals such as access, quality, and transparency with a focus on the patient experience. Berwick6 states that "a notable shift is seen as we move to collaboration and partnerships with many disciplines, all focused on the best outcomes for patients and families." In this new era, we have many opportunities to reframe the patient experience. To do this, we must often begin difficult discussion with our own colleagues. Interprofessional conversations about care decisions may be difficult for many reasons. Providers may overestimate a patient's prognosis or simply feel that they must offer additional care options. The surprise question (SQ) was introduced to help us begin this discussion.



The SQ was developed more than a decade ago and has been suggested as a simple test to identify patients who might benefit from hospice and/or palliative care. The basic assumption of the SQ, as a screening test, is that patients in their final year of life may have unmet palliative care needs. The question, poised as a simple reflection, may help caregivers identify patients who may benefit from a discussion about care choices. Since its inception, the reflective question has been adopted into many frameworks for assessing palliative care needs.


The "surprise question," "Would I (or you) be surprised if this patient died in the next 12 months?" has been recognized as an innovation to improve end-of-life care by identifying patients who have a poor prognosis and who are appropriate for palliative care.7,8 The question is a validated single-item method for identifying patients at high risk of dying within a year, originally used among advanced cancer and dialysis patients in a primary care population in the Franciscan Health System in Tacoma, Washington. In this study, the SQ was found to be effective in identifying sicker dialysis patients who had a high risk for early mortality and should be considered for palliative care interventions.8


Although the "surprise" question tool was developed approximately 2 decades ago, recent studies report continued interest. Dower et al conducted a meta-analysis of 16 studies with 17 distinct cohorts that examined the SQ as a tool to predict death in patients with serious illness. The finding concluded that the question performs only modestly as a predictive tool for death, with even poor performance in patients with noncancer diagnosis. Overall, pooled results suggest poor to modest accuracy of the SQ for predicting death at 12 months, with low sensitivity and positive predictive values for the studied populations.9 However, these results include only a preliminary report from a 2015 study in Boston, which later reported more impressive results.10,11


The study of a patient-centered Serious Illness Care Program, which was developed by Ariadne Labs in Boston, reported that 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 program, evaluated in a randomized trial at the Dana-Farber Cancer Institute in Boston, uses the "surprise" question as the first step of Ariadne Labs' comprehensive patient-centered Serious Illness Care Program.10,11 To identify eligible patients, the study used a "no" answer to the question, "Would you be surprised if this patient died in the next year?" The "surprise" question was presented to 76 clinicians with regard to 4779 patients who were in all stages of cancer. The propensity-adjusted 1-year survival for "yes" patients was 93% (95% confidence interval, 91%-96%) compared with 53% (95% confidence interval, 46%-60%) for the "no" patients (P < .0001). This 2015 study showed that the "surprise" question was more predictive of patient death than type of cancer, age, cancer stage, or time since diagnosis.10 This study concludes 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.


The SQ is intended to be a simple and feasible screening test to identify patients with hospice and palliative care needs. In some applications, it may be helpful as a stand-alone tool, or in combination with other methods, to trigger palliative care measures. It may also be quite effective when used as a reflective technique to begin a discussion between providers.


A Hastings report notes that some of the patients identified by the SQ will end up living for years in a fragile state, and some will die soon, but all typically need the services that are priorities in the last part of life: advance care planning, comfort measures, assistance for daily activities, and family support, for a number of weeks or even years. In these cases, the SQ may trigger the social planning and arrangement of services that are required. In this report, palliative care physician Lynn13 discusses a slight variation of what's come to be known as "the surprise question", "Would you be surprised if this patient died in the next year?" This technique has been promulgated by Lynn as a simple way of eligibility screening for palliative care. It has also been described in patient scenarios by Byock,14 an international leader in palliative care.


In her work, Lynne13 reminds us, "Not long ago, people got sick and died, all in one sentence, and often in a few days or weeks. The end of life had religious and cultural significance and paid health care services played a small part. Today, most Americans are supported through many episodes of illness and live with chronic conditions to enjoy or endure extends time." Lynn13 reinforces "that, although we often do not have the language to discuss care needs, time frames, or end of life plans, we must continue to test techniques for this type of discussion." Lynn13 considers this a great time for reform and states, "despite our cultural (and perhaps our universally human) distaste for the fact of finitude, American society is gradually learning to expect disability in old age and to accept that serious illness and death are inevitable. Thirty years ago, hospital staff attempted resuscitation on nearly every person whose heart stopped. Now, only a small minority of patients, mostly those with some real chance to benefit, undergoes resuscitation."


Our commitment to patients often requires a new type of social understanding that may be facilitated by using "what matters" questions when speaking to patients and perhaps a "surprise question" in our collegial discussions. Continued study and discussion may help to identifying patients that need help with decisions during serious illness and those with unmet palliative needs.




1. Gould KA. A conversation for the holidays: the conversation project. Dimens Crit Care Nurs. 2014;33(6):307-308. [Context Link]


2. Gould KA. A conversation for the holidays: part II "what matters to you." Dimens Crit Care Nurs. 2015;34(6):313-316. [Context Link]


3. Gould KA. Are you conversation ready? Dimens Crit Care Nurs. 2016;35(6):301-302. [Context Link]


4. IOM. Dying in America: improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press; 2015 The National Academies of Sciences Engineering Medicine Accessed July 22, 2017. [Context Link]


5. Gawande A. Being Mortal: Medicine and What Matters in the End. New York: McMillan Press; 2014. [Context Link]


6. Berwick DM. Era 3 for medicine and health care. JAMA. 2016;315(13):1329-1330. [Context Link]


7. Della Penna R. Asking the right question. J Palliat Med. 2001;4:245-248. [Context Link]


8. Lynn J, Schuster JL, Kabcenell A. Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians. Oxford: Oxford University Press; 2000. [Context Link]


9. Moss AH, Ganjoo J, Sharma S, et al. Utility of the "surprise" question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3(5):1379-1384. [Context Link]


10. James Downar J, Goldman R, Pinto R, Englesakis R, Adhikari N. The "surprise question" for predicting death in seriously ill patients: a systematic review and meta-analysis. CMAJ. 2017;189:E484-E493. [Context Link]


11. Bernacki R, Hutchings M, Vick J, et al. Development of the Serious Illness Care Program: a randomised controlled trial of a palliative care communication intervention. BMJ Open. 2015;5(10):e009032. [Context Link]


12. Nelson R. Surprise questions effective at predicting end of life. Medscape News from Palliative Care in Oncology Symposium (PCOS). 2015. Medscape Web site. Accessed July 29, 2017.


13. Lynn J. "Living long in fragile health: the new demographics shape end of life care," improving end of life care: why has it been so difficult? Hastings Center Report Special Report. 2005;35(6):S14-S18. [Context Link]


14. Byock I. The surprise question: would your doctor be shocked if you died? The Atlantic March. 2012;9. [Context Link]