Identification Of Palliative Care Research Articles

Derivation and validation of a mortality risk prediction model in older adults needing home care: Updating the RESPECT (Risk Evaluation for Support: Predictions for Elder-Life in their Communities Tool) algorithm for use with data from the interRAI Home Care Assessment System

Background Despite an increasing number of risk prediction models being developed within the healthcare space, few have been widely adopted and evaluated in clinical practice. RESPECT, a mortality risk communication tool powered by a prediction algorithm, has been implemented in the home care setting in Ontario, Canada, to support the identification of palliative care needs among older adults. We sought to re-estimate and validate the RESPECT algorithm in contemporary data. Methods The study and derivation cohort comprised adults living in Ontario aged 50 years and older with at least 1 interRAI Home Care (interRAI HC) record between April 1, 2018 and September 30, 2019. Algorithm validation used 500 bootstrapped samples, each containing a 5% random selection from the total cohort. The primary outcome was mortality within 6 months following an interRAI HC assessment. We used proportional hazards regression with robust standard errors to account for clustering by the individual. Kaplan–Meier survival curves were estimated to derive the observed risk of death at 6 months for assessment of calibration and median survival. Finally, 61 risk groups were constructed based on incremental increases in the observed median survival. Results The study cohort included 247,377 adults and 35,497 deaths (14.3%). The mean predicted 6-month mortality risk was 18.0% and ranged from 1.5% (95% CI 1.0%–1.542%) in the lowest to 96.0 % (95% CI 95.8%–96.2%) in the highest risk group. Estimated median survival spanned from 36 days in the highest risk group to over 3.5 years in the lowest risk group. The algorithm had a c-statistic of 0.76 (95% CI 0.75-0.77) in our validation cohort. Conclusions RESPECT demonstrates good discrimination and calibration. The algorithm, which leverages routinely-collected information, may be useful in home care settings for earlier identification of individuals who might be nearing the end of life.

Development of the conversation tool "I-HARP for COPD" for early identification of palliative care needs in patients with chronic obstructive pulmonary disease.

This study aimed to develop the conversation tool "I-HARP for COPD" for timely identification of palliative care needs in Dutch patients with chronic obstructive pulmonary disease (COPD). An iterative and participatory research design was used to develop "I-HARP for COPD". There were 2 phases to the development of "I-HARP for COPD": content development and testing. A review of current literature, parallel focus groups, and a questionnaire among experts were used to develop the content of "I-HARP for COPD". "I-HARP for COPD" was then assessed by health-care professionals (HCPs) in clinical practice for understanding, difficulty, and relevance. A total of 46 HCPs, 6 patients, 1 informal caregiver, and 1 bereaved informal caregiver participated in this study. "I-HARP for COPD" included 14 screening questions, additional in-depth questions, and recommendations to address identified needs. The content of "I-HARP for COPD" was accepted by 86.2% of the HCPs. "I-HARP for COPD" was successfully developed for providing guidance in the palliative care of Dutch patients with COPD and their informal caregivers. By supporting HCPs with "I-HARP for COPD", they are better able to timely identify and direct palliative care needs.

Utilization of Hospice Resources in Adult Intensive Care Units: A Comparison Between Users and Non-Users

The application of palliative care is limited and challenging in intensive care units (ICUs) because of complex factors such as time constraints and unpredictable disease progression. Although research results and international consensus stress the early use of palliative care, utilization remains low, resulting in increased risks of ineffective medical care and poor quality of death. Improving this situation requires a comprehensive understanding of the palliative condition in ICUs. This study was designed to investigate the utilization of hospice resources in adult ICUs and to compare this utilization between users and non-users. This retrospective correlation study recruited cases from the adult ICU database of a medical center in northern Taiwan between June and July 2022. Descriptive statistics, independent t-test and chi-square were used to analyze the data. A total of 1,181 records were analyzed, including 458 (38.8%) females and 723 (61.2%) males. Two hundred and seventeen cases (18.4%) used hospice resources. Although 124 (10.4%) of the 1181 cases were identified as "in urgent need of hospice resources" (i.e., died within 30 days of ICU admission), 25 (20.2%) did not use these resources. Significant differences between the urgent-need cases who did and did not use hospice resources were found in terms of age, disease type, degree of frailty, cardiac arrest, infection, state of consciousness, intubation and tracheostomy status, inotropic and vasopressor medication, renal replacement, ECMO placement, delirium, and Acute Physiology and Chronic Health Evaluation III and Sequential Organ Failure Assessment Scores. The roughly 20% of ICU patients in urgent needs of palliative care who did not utilize palliative care resources highlight the needs for continued discussion to better assist patients on palliative care decision-making. The findings show multifaceted differences between those who did and did not access palliative care. Future studies should design and test strategies to facilitate the identification of palliative care needs and ensure the effective allocation of palliative care resources in ICUs.

Understanding patient views and experiences of the IDENTIfication of PALLiative care needs (IDENTI-PALL): a qualitative interview study.

Palliative care improves quality of life for people with life-threatening illnesses. There are longstanding inequalities in access to palliative care, with many people never identified as having palliative care needs, particularly frail older people, those with non-malignant disease, and people from ethnic minority backgrounds. Little is known about the process of identification of palliative care needs from a patient perspective. To provide new understanding into patient views and experiences of the process of identification of palliative care needs, and to explore the impact of identification on health care, if any, from a patient perspective. A qualitative interview study undertaken with patients and family carers in a major UK city. Semi-structured interviews were carried out with patients (and/or family carers) identified as being on general practice palliative care registers. An inductive thematic analysis was conducted to explore the data. Eleven participants were recruited: eight patients and three family carers. The following three interrelated themes were identified: 1) misconceptions about palliative care and unshared prognostic uncertainty hinder the identification of palliative care needs; 2) a compassionate, timely approach is required for identification of palliative care needs, with or without an identification tool; and 3) identification of palliative care needs is beneficial where it leads to proactive holistic care. A compassionate approach, sharing of prognostic uncertainty, and proactive primary care are key to timely, beneficial identification of palliative care needs. Future policy should ensure that identification is an adaptable, personalised process to meet the individual needs of people with advanced serious illnesses.

More older adults died at their preferred place after implementation of a transmural care pathway for older adults at the end of life: a before-after study

BackgroundTo improve transmural palliative care for older adults acutely admitted to hospital, the PalliSupport intervention, comprising an educational programme and transmural palliative care pathway, was developed. This care pathway involves timely identification of palliative care needs, advance care planning, multidisciplinary team meetings, warm handover, and follow-up home visits. With this study, we evaluate changes in patient-related outcomes and transmural collaboration after implementation of the care pathway.MethodsWe conducted a before-after study, in which we compared 1) unplanned hospital admission and death at place of preference and 2) transmural collaboration before implementation, up to six months, and six to 18 months after implementation. Data from palliative care team consultations were collected between February 2017 and February 2020 in a teaching hospital in the Netherlands.ResultsThe palliative care team held 711 first-time consultations. The number of consultation, as well as the number of consultations for patients with non-malignant diseases, and consultations for advance care planning increased after implementation. The implementation of the pathway had no statistically significant effect on unplanned hospitalization but associated positively with death at place of preference more than six months after implementation (during/shortly after adjusted OR: 2.12; 95% CI: 0.84–5.35; p-value: 0.11, long term after adjusted OR: 3.14; 95% CI: 1.49–6.62; p-value: 0.003). Effects on transmural collaboration showed that there were more warm handovers during/shortly after implementation, but not on long term. Primary care professionals attended multidisciplinary team meetings more often during and shortly after implementation, but did not more than six months after implementation.ConclusionsThe pathway did not affect unplanned hospital admissions, but more patients died at their place of preference after implementation. Implementation of the pathway increased attention to- and awareness for in-hospital palliative care, but did not improve transmural collaboration on long-term. For some patients, the hospital admissions might helped in facilitating death at place of preference.

Methods used to identify the prevalence of palliative care needs: An integrative review.

Early identification of palliative care (PC) needs is crucial to provide appropriate holistic care to patients. The objective of this integrative review is to synthesize the methods used to identify the prevalence of PC needs. An integrative review search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with full text, ProQuest, Wiley InterScience, ScienceDirect, Scopus, PubMed, and Web of Science with publications from 2010 to 2020 was carried out in English. Empirical studies examining the methods used to determine the prevalence of PC needs were included. The methods of data extraction of the included articles were categorized by data source, study setting, and data collector. Quality appraisal was performed using QualSyst. Of the 5,410 articles screened, 29 were included in this review. Two articles identified the prevalence of PC needs in a community that was supported by a network of volunteers, while 27 studies considered this at a continent, country, hospital, and/or primary care facility level as represented by physicians, nurses, and researchers. Various methods have been used to determine the prevalence of PC needs, and the outcomes are valuable for policymakers in developing PC services when allocating resources at the national and community levels. Future research to identify PC needs across health settings, especially primary care facilities, should consider providing PC across a spectrum of care settings.

Identification of palliative care needs and prognostic factors of survival in tailoring appropriate interventions in advanced oncological, renal and pulmonary diseases: a prospective observational protocol

IntroductionIt is estimated that of those who die in high-income countries, 69%–82% would benefit from palliative care with a high prevalence of advanced chronic conditions and limited life prognosis. A...

Assessing the implementation and effectiveness of early integrated palliative care in long-term care facilities in France: an interventional mixed-methods study protocol

BackgroundMajority of residents in long-term care facilities (LTCF) have limited and delayed access to palliative care even though many suffer from incurable chronic illnesses that will likely require the provision of palliative care. We present the study protocol of “PADI-Palli”, an intervention aims to advance early integrated palliative care into standard care delivered in LTCF. This study will assess the effectiveness of early integrated palliative care on palliative care accessibility for older persons in LTCF, and identify the key factors for the successful implementation of early integrated palliative care and its sustainability in the LTCF context.MethodsThis multicentre interventional study utilises a pragmatic research design with a convergent parallel mixed-methods approach. The qualitative study will use a case study design and the quantitative study will use a stepped wedge cluster randomised trial. In total, 21 participating LTCF from three French regions will be randomly allocated to one of seven clusters. The clusters will cross over from the usual care to the active intervention condition over the course of the study. The primary outcome relates to the accurate identification of palliative care needs and early access to palliative care for LTCF residents. Secondary outcomes are quality of care, quality of life for residents and their families, and quality of life at work for professionals. Measurements will be performed before and after the intervention. Implementation and evaluation of PADI-Palli intervention is grounded in the Consolidated Framework for Implementation Research.DiscussionExisting evidence demonstrates that early integrated palliative care in cancer care leads to a significant improvement in patient outcomes and processes of care. Little is known, however, about early integrated palliative care in the context of LTCF for older persons. This study has the potential to fill this gap in the literature by providing evidence on the effectiveness of early integrated palliative care for older persons in LTCF. Moreover, this study will provide a better understanding of the relevant contextual elements that facilitate or hinder early integrated palliative care implementation and transferability. If proven effective, this intervention can be scaled to other care settings in which older persons require palliative care.Trial registrationClinicalTrials.gov ID: NCT04708002; National registration: ID-RCB number: 2020-A01832-37.

Palliative Care across Settings: Perspectives from Inpatient, Primary Care, and Home Health Care Providers and Staff.

Early introduction of palliative care can improve patient-centered outcomes for older adults with complex medical conditions. However, identifying the need for and introducing palliative care with patients and caregivers is often difficult. We aim to identify how and why a multi-setting approach to palliative care discussions may improve the identification of palliative care needs and how to facilitate these conversations. Descriptive qualitative study to inform the development and future pilot testing of a model to improve recognition of, and support for, unmet palliative care needs in home health care (HHC). Thematic analysis of semi-structured interviews with providers across inpatient (n = 11), primary care (n = 17), and HHC settings (n = 10). Four key themes emerged: 1) providers across settings can identify palliative care needs using their unique perspectives of the patient's care, 2) identifying palliative care needs is challenging due to infrequent communication and lack of shared information between providers, 3) importance of identifying a clinical lead of patient care who will direct palliative care discussions (primary care provider), and 4) importance of identifying a care coordination lead (HHC) to bridge communication among multi-setting providers. These themes highlight a multi-setting approach that would improve the frequency and quality of palliative care discussions. A lack of structured communication across settings is a major barrier to introducing and providing palliative care. A novel model that improves communication and coordination of palliative care across HHC, inpatient and primary care providers may facilitate identifying and addressing palliative care needs in medically complex older adults.

Predicting Patient Mortality for Earlier Palliative Care Identification in Medicare Advantage Plans: Features of a Machine Learning Model

Background Machine learning (ML) can offer greater precision and sensitivity in predicting Medicare patient end of life and potential need for palliative services compared to provider recommendations alone. However, earlier ML research on older community dwelling Medicare beneficiaries has provided insufficient exploration of key model feature impacts and the role of the social determinants of health. Objective This study describes the development of a binary classification ML model predicting 1-year mortality among Medicare Advantage plan members aged ≥65 years (N=318,774) and further examines the top features of the predictive model. Methods A light gradient-boosted trees model configuration was selected based on 5-fold cross-validation. The model was trained with 80% of cases (n=255,020) using randomized feature generation periods, with 20% (n=63,754) reserved as a holdout for validation. The final algorithm used 907 feature inputs extracted primarily from claims and administrative data capturing patient diagnoses, service utilization, demographics, and census tract–based social determinants index measures. Results The total sample had an actual mortality prevalence of 3.9% in the 2018 outcome period. The final model correctly predicted 44.2% of patient expirations among the top 1% of highest risk members (AUC=0.84; 95% CI 0.83-0.85) versus 24.0% predicted by the model iteration using only age, gender, and select high-risk utilization features (AUC=0.74; 95% CI 0.73-0.74). The most important algorithm features included patient demographics, diagnoses, pharmacy utilization, mean costs, and certain social determinants of health. Conclusions The final ML model better predicts Medicare Advantage member end of life using a variety of routinely collected data and supports earlier patient identification for palliative care.

Facilitators and barriers to implementation of a patient and staff reported measure for screening of palliative concerns of patients with heart failure: a qualitative analysis using the Consolidated Framework for Implementation Research.

Screening patients with patient-reported outcome measures allows identification of palliative care concerns. The Integrated Palliative Care Outcome Scale (IPOS) was developed in the United Kingdom for this purpose. Tools developed in another setting might not be readily usable locally. We previously evaluated the validity and reliability of the IPOS in our cardiology setting. However, it remains uncertain what factors would influence the subsequent implementation of IPOS for routine screening of patients with advanced heart failure in future practice. This study aimed to identify the factors that could affect the IPOS implementation for patients with advanced heart failure. This was a qualitative study conducted at the National Heart Centre Singapore. Patients with advanced heart failure who participated in our previous IPOS validation study were purposively recruited for semi-structured interviews. Healthcare workers caring for these patients and involved in the testing of the IPOS tool were also invited for interviews. The interviews were analyzed thematically and mapped to the Consolidated Framework for Implementation Research (CFIR). Our analysis identified six potential facilitators and six potential barriers to implementation across five major domains of the CFIR (intervention characteristics, inner setting, outer setting, individual characteristics, and process). Facilitators include: (i) perception of utility, (ii) perception of minimal complexity, (iii) perception of relatability, (iv) conducive culture, (v) dedicated resources, and (vi) advocates for implementation. Barriers include: (i) need for adaptation, (ii) mindsets/role strains, (iii) resource constraints, (iv) cultural concerns, (v) individual needs, and (vi) change process. Institutions could focus on cultivating appropriate perceptions and conducive cultures, providing dedicated resources for implementation and introducing facilitators to advocate for implementation. Adaptation of IPOS to suit workflows and individual needs, consideration of change processes, and systemic changes to alleviate cultural, resource, and staff role strains would improve IPOS uptake during actual implementation in clinical services. Not applicable.

Building Palliative Care Capacity for Generalist Providers in the Community: Results From the Capaciti Pilot Education Program.

Objective: Primary care providers play an important role in providing early palliative care, however they often lack practical supports to operationalize this approach in practice. CAPACITI is a virtual training program aimed at providing practical tips, strategies, and action plans to help primary care providers offer an early palliative approach to care. The CAPACITI pilot program consisted of 10 facilitated, monthly training sessions, covering identification and assessment, communication, and engaging caregivers and specialists. We present the findings of an evaluation of the pilot program. Method: We conducted a single cohort study of primary care providers who participated in CAPACITI. Study outcomes were the change in the percentage of caseload reported as requiring palliative care and improved confidence in competencies measured on a 20-item, study-created survey. Pre and post survey data were analyzed using paired t-tests. Results: Twenty-two teams representing 127 care providers (including 36 physicians and 28 Nurse Practitioners) completed CAPACITI. Paired comparisons showed a moderate improvement in confidence across the competencies covered (.6 to 1.3 mean improvement across items using seven-point scales, all P < .05). Pre-CAPACITI, clinician prescribers (N = 32) identified a mean of 1.2% of their caseload requiring a palliative approach to care, which increased to 1.6% post-program (P = .02). Said differently, the total group of paired clinician prescribers identified 338 patients as requiring palliative care in their caseloads at baseline vs 482 patients following the intervention, for an overall increase of 144 patients in their collective caseloads. Conclusion: CAPACITI improved self-assessed palliative care identification and provider confidence in core competencies. The program demonstrated potential for building palliative care capacity in primary care teams.

Palliative and end-of-life care in the emergency department.

With current medical advances, the human population continues to age. This presents healthcare practitioners with the increasing complexity of providing care to elderly patients with multifactorial medical and personal needs. This is a particular challenge in the emergency department, where patients often present for care in the last months of their lives. Early identification of palliative care needs and initiation of comfort care can drastically improve patient care and quality of life. Although emergency physicians agree that palliative care is an important area of knowledge, there is a gap in palliative care training in emergency medicine residencies. It is increasingly important for emergency medicine providers to have the resources and training to provide palliative care and to understand end-of-life issues.

Using routinely collected data to develop and evaluate a clinical tool for early identification of palliative care needs in long-term care: The RESPECT Project.

ObjectivesPrognostication tools reporting personalized mortality risk and survival can improve advance care planning and discussions about end-of-life care. We developed, validated, and implemented a mortality risk algorithm for older adults with diverse care needs in long-term care (LTC) homes, called the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool for LTC (RESPECT-LTC).&#x0D; ApproachRESPECT-LTC was developed using routinely-collected health information on residents in LTC homes in Ontario, Canada. Model development used a cohort of LTC residents aged 50 years or older with at least 1 Resident Assessment Instrument—Minimum Data Set (RAI-MDS) record between January 2010 and December 2016. The primary outcome was mortality 6 months after a RAI-MDS assessment. We used proportional hazards regression with robust standard errors to account for clustering by the individual. We validated this algorithm, temporally, in a cohort of LTC residents who were assessed between January and December 2017. We constructed 37 risk bins based on incremental increases in estimated median survival of ~3 weeks among residents at high risk of death and 3 months among residents with lower mortality risk. We implemented and are evaluating the use of RESPECT-LTC for early identification of palliative care needs in LTC homes across Ontario.&#x0D; ResultsDevelopment and validation cohorts included 2,228,176 and 328,204 RAI-MDS assessments, respectively. Mean predicted 6-month mortality risk ranged from 1.38% (95% CI 0.63%-1.61%) in the lowest to 91.97% (95% CI 81.47%-99.9%) in the highest risk group. Estimated median survival spanned from 42 days (15 to 128 d at the 25th and 75th percentiles) in the highest risk group to over 8 years (2,066 to 3,428 d) in the lowest risk group. The algorithm had a c-statistic of 0.730 (95% CI 0.726–0.736) in our validation cohort.&#x0D; ConclusionRESPECT-LTC makes use of routinely-collected information to improve the identification of palliative and end-of-life care needs in LTC. Ongoing evaluation will assess its impact on referrals to palliative care, hospitalization at the end of life, and location of death.

Gift of time: learning together to embed a palliative approach to care in long-term care

BackgroundEmbedding a Palliative Approach to Care (EPAC) is a model that helps shift the culture in long-term care (LTC) so that residents who could benefit from palliative care are identified...

Understanding patient views and experiences of the IDENTIfication of PALLiative care needs (IDENTI-Pall): a qualitative interview study protocol

IntroductionMore people are living with multimorbidity, defined as two or more long-term physical or mental health conditions. Multimorbidity is associated with poor quality of life and high treatment burden. Palliative...

Primary care contacts, continuity, identification of palliative care needs, and hospital use: a population-based cohort study in people dying with dementia.

BackgroundReducing hospital admissions among people dying with dementia is a policy priority.AimTo explore associations between primary care contacts, continuity of primary care, identification of palliative care needs, and unplanned hospital admissions among people dying with dementia.Design and settingThis was a retrospective cohort study using the Clinical Practice Research Datalink linked with hospital records and Office for National Statistics data. Adults (>18 years) who died between 2009 and 2018 with a diagnosis of dementia were included in the study.MethodThe association between GP contacts, Herfindahl–Hirschman Index continuity of care score, palliative care needs identification before the last 90 days of life, and multiple unplanned hospital admissions in the last 90 days was evaluated using random-effects Poisson regression.ResultsIn total, 33 714 decedents with dementia were identified: 64.1% (n = 21 623) female, mean age 86.6 years (SD 8.1), mean comorbidities 2.2 (SD 1.6). Of these, 1894 (5.6%) had multiple hospital admissions in the last 90 days of life (increase from 4.9%, 95% confidence interval [CI] = 4.2 to 5.6 in 2009 to 7.1%, 95% CI = 5.7 to 8.4 in 2018). Participants with more GP contacts had higher risk of multiple hospital admissions (incidence risk ratio [IRR] 1.08, 95% CI = 1.05 to 1.11). Higher continuity of care scores (IRR 0.79, 95% CI = 0.68 to 0.92) and identification of palliative care needs (IRR 0.66, 95% CI = 0.56 to 0.78) were associated with lower frequency of these admissions.ConclusionMultiple hospital admissions among people dying with dementia are increasing. Higher continuity of care and identification of palliative care needs are associated with a lower risk of multiple hospital admissions in this population, and might help prevent these admissions at the end of life.

NECPAL Tool Aids Early Identification of Palliative Care Needs.

Background: A key issue in the development of population-based access to palliative care is identification of appropriate patients. Objective: To evaluate the NECPAL (NECesidades Paliativas) tool to identify unmet palliative care needs in the Czech Republic in regional hospitals of the Vysocina region. Methods: We used the End-of-Life care information system (ELFis) to evaluate prognostication to aid the identification of palliative care needs. The evaluation process was developed in cooperation with the regional government and central health care insurance agency as a step toward the development of a nation-wide palliative care program. Results: Our results demonstrate that the NECPAL tool successfully identified palliative care needs in specifically prepared clinical environment. An important part of this is a support of main stakeholders and an effective leadership. Conclusion: An unexpected finding was the role that leadership played in testing the tool, and very short time (10 months) needed for statistically visible changes in a regional system of care.

Identifying palliative care needs of patients with non-communicable diseases in Indonesia using the SPICT tool: a descriptive cross-sectional study

BackgroundIn Indonesia, Non-Communicable Diseases (NCD) are a contributing factor to mortality with most cases involving heart disease, cancer, chronic lung disease and diabetes. Accordingly, the identification of palliative care needs is very important as a first step in providing palliative care for these patients with NCD. However, currently there is no national standardized tool nor guidance system for identifying palliative care needs of NCD patients in Indonesia. The Supportive and Palliative Care Indicators Tool (SPICT) has been used worldwide for screening palliative care needs. This study aimed to identify palliative care needs in NCD patients using the SPICT tool.MethodsThis descriptive study used a cross-sectional design. Sampling technique used convenience sampling with a total sample of 124 adult patients with NCD in Dr. Sardjito Hospital Yogyakarta. Data collection used the Indonesian version of the SPICT. Data analyses used descriptive statistics and chi-square tests with p < 0,05 set as significant. Additionally, the prevalence of patients requiring palliative care was also calculated.ResultsThe patients with NCD requiring palliative care who were screened using the SPICT tool were 61.3%. The nurses identified only 17.7%, while the physicians identified only 9.7%. The overall agreement of the clinician’s assessments to the researchers was < 32%. Meanwhile, agreement with nurses was 31 and 25% with the physicians.ConclusionsThese results highlight that by using the SPICT tool, recognition of hospitalized patients with NCD needing palliative care increased from 10 to 18% to > 61%. The Indonesian version of the SPICT tool can help the clinicians to reach meet agreement in identifying hospitalized patients who need palliative care as the first step in addressing palliative interventions for patients with NCD. It can provide several benefits in screening patients with NCD from the beginning of diagnosis.

An online international comparison of palliative care identification in primary care using the Surprise Question

Background: The Surprise Question (‘Would I be surprised if this patient died within 12 months?’) identifies patients in the last year of life. It is unclear if ‘surprised’ means the same for each clinician, and whether their responses are internally consistent. Aim: To determine the consistency with which the Surprise Question is used. Design: A cross-sectional online study of participants located in Belgium, Germany, Italy, The Netherlands, Switzerland and UK. Participants completed 20 hypothetical patient summaries (‘vignettes’). Primary outcome measure: continuous estimate of probability of death within 12 months (0% [certain survival]–100% [certain death]). A threshold (probability estimate above which Surprise Question responses were consistently ‘no’) and an inconsistency range (range of probability estimates where respondents vacillated between responses) were calculated. Univariable and multivariable linear regression explored differences in consistency. Trial registration: NCT03697213. Setting/participants: Registered General Practitioners (GPs). Of the 307 GPs who started the study, 250 completed 15 or more vignettes. Results: Participants had a consistency threshold of 49.8% (SD 22.7) and inconsistency range of 17% (SD 22.4). Italy had a significantly higher threshold than other countries (p = 0.002). There was also a difference in threshold levels depending on age of clinician, for every yearly increase, participants had a higher threshold. There was no difference in inconsistency between countries (p = 0.53). Conclusions: There is variation between clinicians regarding the use of the Surprise Question. Over half of GPs were not internally consistent in their responses to the Surprise Question. Future research with standardised terms and real patients is warranted.