We congratulate Downar and colleagues1 for their systematic review of the sensitivity and specificity of the “surprise question,” a tool widely publicized to identify patients in the last year of life.
We recently completed a systematic search and analysis. We searched for “surprise question” in five electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library and CINAHL) and identified two additional full papers (Lilley and colleagues, and Gómez-Batiste and colleagues)2,3 with values of 82.2% and 93.7% for sensitivity, and 48.7% and 26.4% for specificity, respectively. Downar and colleagues1 included six published abstracts; we believe that these should be considered with caution, because results can change following peer (including statistical) review.
Critically though, we believe that there are errors in two of the original studies. In Downar and colleagues’ review,1 one has been corrected (Moroni and colleagues 2014)4 and the other is not corrected at the present date (Feyi and colleagues 2015).5 Having identified these, we had written to the authors for corrected data, which they provided. The former study had transposed sensitivity and specificity; for the latter, the corrected values are slightly higher: 72.7% (sensitivity) and 83.5% (specificity) rather than 66.7% and 77.9%.
Despite these differences, we support the conclusion of Downar and colleagues1 that the surprise question performs poorly to modestly, often with a high proportion of false positives. Before including such questions in clinical practice, tools to assess prognosis should be subject to appraisal as screening instruments. They are also likely to become unreliable over time as new treatments emerge, changing the disease trajectory. Those studying their results or conducting systematic reviews need to carefully ensure that sensitivity and specificity are correctly analyzed and reported. However, closeness to death is not the best indicator of need for palliative care. Patients can have severe problems or symptoms in earlier stages of illness,6,7 when much can be done to improve quality of life.8 Therefore, patient need, not prognosis, should be the driver for referral to palliative care.
Footnotes
Competing interests: None declared.
References
- 1.Downar J, Goldman R, Pinto R, et al. The “surprise question” for predicting death in seriously ill patients: a systematic review and meta-analysis. CMAJ 2017;189:E484–93. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Lilley EJ, Gemunden SA, Kristo G, et al. Utility of the “surprise” question in predicting survival among older patients with acute surgical conditions. J Palliat Med 2017;20:420–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Gómez-Batiste X, Martínez-Muñoz M, Blay C, et al. Utility of the NECPAL CCOMS-ICO© tool and the Surprise Question as screening tools for early palliative care and to predict mortality in patients with advanced chronic conditions: a cohort study. Palliat Med 2016. November 4 [Epub ahead of print] 10.1177/0269216316676647. [DOI] [PubMed] [Google Scholar]
- 4.Moroni M, Zocchi D, Bolognesi D, et al. The ‘surprise’ question in advanced cancer patients: a prospective study among general practitioners. Palliat Med 2014;28:959–64. [DOI] [PubMed] [Google Scholar]
- 5.Feyi K, Klinger S, Pharro G, et al. Predicting palliative care needs and mortality in end stage renal disease: use of an at-risk register. BMJ Support Palliat Care 2015;5:19–25. [DOI] [PubMed] [Google Scholar]
- 6.Higginson IJ, Gao W, Saleem TZ, et al. Symptoms and quality of life in late stage Parkinson syndromes: a longitudinal community study of predictive factors. PLoS One 2012;7:e46327. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Selman LE, Beattie JM, Murtagh FE, et al. Palliative care: based on neither diagnosis nor prognosis, but patient and family need. Commentary on Chattoo and Atkin. Soc Sci Med 2009;69:154–7, discussion 158–9. [DOI] [PubMed] [Google Scholar]
- 8.Murray SA, Kendall M, Mitchell G, et al. Palliative care from diagnosis to death. BMJ 2017;356:j878. [DOI] [PubMed] [Google Scholar]