Abstract
Optimal end-of-life care requires identifying patients that are near the end of life. The extent to which attending physicians and trainee physicians agree on the prognoses of their patients is unknown. We investigated agreement between attending and trainee physician on the surprise question: "Would you be surprised if this patient died in the next 12 months?", a question intended to assess mortality risk and unmet palliative care needs. This was a multicentre prospective cohort study of general internal medicine patients at 7 tertiary academic hospitals in Ontario, Canada. General internal medicine attending and senior trainee physician dyads were asked the surprise question for each of the patients for whom they were responsible. Surprise question response agreement was quantified by Cohen's kappa using Bayesian multilevel modeling to account for clustering by physician dyad. Mortality was recorded at 12 months. Surprise question responses encompassed 546 patients from 30 attending-trainee physician dyads on academic general internal medicine teams at 7 tertiary academic hospitals in Ontario, Canada. Patients had median age 75 years (IQR 60-85), 260 (48%) were female, and 138 (25%) were dependent for some or all activities of daily living. Trainee and attending physician responses agreed in 406 (75%) patients with adjusted Cohen's kappa of 0.54 (95% credible interval 0.41 to 0.66). Vital status was confirmed for 417 (76%) patients of whom 160 (38% of 417) had died. Using a response of "No" to predict 12-month mortality had positive likelihood ratios of 1.84 (95% CrI 1.55 to 2.22, trainee physicians) and 1.51 (95% CrI 1.30 to 1.72, attending physicians), and negative likelihood ratios of 0.31 (95% CrI 0.17 to 0.48, trainee physicians) and 0.25 (95% CrI 0.10 to 0.46, attending physicians). Trainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement. Physicians had similar discriminative accuracy; both groups had better accuracy predicting which patients would survive as opposed to which patients would die. Different opinions of a patient's prognosis may contribute to confusion for patients and missed opportunities for engagement with palliative care services.
Highlights
Provision of optimal end-of-life care requires reliable identification of patients likely to die in the near future
Trainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement
There is no mandatory requirement for specific palliative care clinical exposure in internal medicine training in Canada, residents may participate in clinical electives to gain exposure to this area and “care of the dying” is one of the objectives of training [28]
Summary
Provision of optimal end-of-life care requires reliable identification of patients likely to die in the near future. Few reliable bedside tools are available to identify patients who may benefit from goals-of-care discussions due to near-term risk of death [1,2]. The risk of death may not correlate with other important aspects of patient care such as uncontrolled symptoms or psychological distress [8,9]. Optimal end-of-life care requires identifying patients that are near the end of life. We investigated agreement between attending and trainee physician on the surprise question: “Would you be surprised if this patient died in the 12 months?”, a question intended to assess mortality risk and unmet palliative care needs
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