Surprise Question Research Articles

The Surprise Question in Hemodialysis, Frailty, Nutrition, Patient-reported Quality of Life, and All-Cause Mortality: The Osaka Dialysis Complication Study (ODCS)

Rationale & ObjectiveA response “no” (SQ-No) to the surprise question (SQ) of whether a clinician would be surprised if a dialysis patient died in the next 6 months is associated with a higher risk of all-cause death. It is uncertain what domains are intuitively assessed with SQ. We hypothesized that SQ would be assessing the patient’s frailty, malnutrition, or patient-perceived health-related quality of life in a cohort of patients on maintenance hemodialysis. Study DesignCohort study Setting & ParticipantsA multi-center study including 994 patients on maintenance hemodialysis in Japan Predictors1) SQ answered by nurses, 2) frailty by modified Cardiovascular Health Study criteria, 3) malnutrition as evaluated by Geriatric Nutritional Risk Index (GNRI), and 4) patient-perceived health-related quality of life examined by the 36 Item Short-Form Health Survey (SF-36) physical component summary (PCS). OutcomesAll-cause mortality Analytical ApproachCox proportional hazard models ResultsMedian age and dialysis vintage were 66 and 5.9 years, respectively, and 35.8% were female, and 39.6% had diabetic kidney disease. The prevalence of SQ-No and frailty was 19.7% and 45.9%. Medians GNRI and SF-36 PCS were 96.3 and 36.9, respectively. During follow-up for 5 years, 247 patients died. Each of SQ-No, being frail, a low GNRI, and a low SF-36 PCS was a significant predictor of a higher risk for mortality independent of potential confounders. SQ-No remained a significant predictor after further adjustment for frailty or GNRI, but SQ-No was no longer significant when adjusted for SF-36 PCS. LimitationsWe did not assess the agreement of responses to SQ between different raters. ConclusionsPredictive ability of SQ was closely related to SF-36 PCS in hemodialysis patients. SQ by nurses appears to assess the physical domain of patient-perceived health-related quality of life rather than objectively assessed frailty or malnutrition.

Determining What’s Next: Visual Analytics for Evaluating Human-Automation Coordination

As advanced automated systems become more complex, there is a greater need to analyze the difficulty of human-automation coordination. We developed a novel visual analytics tool to evaluate human-automation coordination by examining the relationship between projection, explanation (retrojection), and the understanding of current events through time. The What’s Next Diagram visualizes demands on human sensemaking as operators answer Wiener’s key automation surprise question: what will automation do next. The tool can assess whether operators can answer the question directly and quickly given the design and architecture of human-automation systems. It can be used as a model of multi-agent coordination, as a tool for post-mortem analysis, or an aid for design. We illustrate how the tool can be used to identify system requirements for anomaly response in the aviation domain.

Early Palliative Care in the Emergency Department: A Concept Clarification

Introduction: Healthcare advances have contributed to patients living longer with chronic illnesses and diseases with uncertain trajectories impacting quality of life (QOL). Palliative care (PC) is no longer only for dying oncology patients as many healthcare practitioners have adopted the PC concept in diverse care settings and the timing of PC implementation remains ambiguous. There is a need to develop an operational definition of early palliative care (EPC) by clarifying the phenomenon and bridging concepts with empirical data to develop and test possible interventions before integrating EPC into emergency care (EC). Methods: Norris’ concept clarification method was used as the philosophical framework to define, analyze, and clarify EPC. An electronic search of literature from 2000-2024, using CINAHL, PubMed, APA PsychINFO, and Psychology and Behavioral Sciences Collection databases and search terms "early palliative care" AND "emergency care" NOT "animals", and NOT "pediatrics" were screened for eligible articles. Results: Of the 826 articles identified; 22 articles were retained for review. Attributes included timing, palliative, and EC; antecedents included symptom burden, access to care, and cognitive awareness; consequences included QOL and resource utilization; an empirical referent used to screen patients is the highly accurate surprise question "Would I be surprised if this patient died within a year?" Conclusion: Clarifying the concept of EPC leading to an operational definition will advance the development of interventions that support the implementation of EPC in ED clinical practice.

Identification of Hospitalized Patients Who May Benefit from a Serious Illness Conversation Using the Readmission Risk Score Combined with the Surprise Question

Identification of Hospitalized Patients Who May Benefit from a Serious Illness Conversation Using the Readmission Risk Score Combined with the Surprise Question

The Surprise Question and clinician-predicted prognosis: systematic review and meta-analysis

BackgroundThe Surprise Question, ‘Would you be surprised if this person died within the next year?’ is a simple tool that can be used by clinicians to identify people within the...

How accurate is clinical prognostication by oncologists during routine practice in a general hospital and can it be improved by a specific prognosis training programme: a prospective interventional study

ObjectivesOncologists need competence in clinical prognostication to deliver appropriate care to patients with cancer. Most studies on prognostication have been restricted to patients in palliative care settings. This paper investigates...

#267 “Surprise question”, malnutrition, frailty, and health-related quality of life in predicting mortality in a cohort of haemodialysis patients

Abstract Background and Aims “Would I be surprised if this patient died in the next year (or six months)?” This question by a medical staff is called “surprise question” (SQ) and the answer “no” (SQ-No) was shown to predict a higher risk of mortality. However, it is unknown what is intuitively assessed by this question. We examined whether SQ is assessing the patient's malnutrition, frailty, or self-perceived health-related quality of life in haemodialysis patients. Method We analysed data from 994 patients on maintenance haemodialysis who participated in the Osaka Dialysis Complication Study (ODCS). Attending nurses answered to SQ. Malnutrition was evaluated by Geriatric Nutritional Risk Index (GNRI). Frailty was assessed by a modified CHS criteria. Patient-perceived health-related quality of life was examined by SF36 physical component summary (PCS). The associations of these exposures with 5-year all-cause mortality (ACM) were analysed by Cox proportional hazards model. Results Median of age and dialysis vintage was 66 and 5.9 years, 35.8% were female, and 39.6% had diabetic kidney disease. The prevalence of SQ-No and frailty was 19.7% and 46.2%. Medians of GNRI and SF36 PCS were 96.3 and 46.2, respectively. During follow-up, 250 patients died. Each of SQ-No, a low GNRI, being frail, and a low SF36 PCS was a significant predictor of a higher risk for ACM independent of potential confounders. SQ-No remained a significant predictor after further adjustment for GNRI or frailty, but SQ-No was no longer significant when adjusted for SF36 PCS. Conclusion Predictive ability of SQ was closely related to SF36 PCS in haemodialysis patients. SQ by nurses appears to assess patient-perceived health-related quality of life rather than objectively assessed malnutrition or frailty.

A cross-cultural analysis of the gestural pattern of surprise and surprise-disapproval questions

Abstract In this article, we address the issue concerning the gestural patterns in expressing surprise and disapproval across various languages and cultures. The results obtained so far point to an interesting, and in a sense rather surprising, uniformity. We consider two types of special questions: counter-expectational questions expressing surprise and surprise-disapproval questions, i.e., sentences expressing surprise with a negative orientation, and adopt an experimental design involving sentence repetition and spontaneous production. We focus on the realization of these sentences in Vietnamese, Korean and Japanese, which we compare with the results previously obtained for Italian and replicated for Neapolitan, Spanish and German. Our research is based on the Minimalist theoretical framework developed by Chomsky and scholars in the tradition of generative grammar.

TABOO AND SWEAR WORDS IN HEARTBREAK HIGH SERIES

This study aims to identify the types of taboo and swear words and analyze their realization by the main characters in the Heartbreak High Series. This study utilizes a descriptive qualitative method, extracting data from the series, in the form of utterances, dialogues, and conversations that contain taboo and swear words. The findings revealed that four types of taboo words found in the Heartbreak High series realized by the main characters: lavatory (28%), private parts of the body (11%), religion (9%), sexual activity (43%), with an additional (9%) that does not align with Swan’s theory (1995). Additionally, this study categorizes swear words in the series into two categories. First are strong swear words, and second is weak swear words. Strong swear words consist of exclamations of annoyance (17%), exclamations of surprise (8%), exclamations of unconcern (2%), insults (33%), insulting request to go away (9%), emphasize an emotion (25%), surprise question (5%) and violent refusal/rejection (1%). Weak swear words consist of exclamations of annoyance (18%), exclamations of surprise (46%), and exclamations of emotion (36%). The emotional conditions of the main characters while using the swear words are joy, surprise, sadness, anger, fear, and hatred.

The Surprise Question: Not Ready for Prime Time.

The Surprise Question: Not Ready for Prime Time.

The utility of the surprise question by nurses to identify hospitalised older patients nearing the end-of-life and promotion of advance care planning: An interventional study.

To assess the prognostic accuracy of the surprise question (SQ) when used by nurses working in hospital wards to determine 1-year mortality in acutely hospitalised older patients. The predictive accuracy of the SQ, when used by general nurses caring for older hospitalised patients, has not been comprehensively studied. A prospective cohort study. This cohort study recruited consecutive 10,139 older patients (aged ≥65 years) who were admitted to Taipei City Hospital and were evaluated for the needs of palliative care in 2015. All patients were followed up for 12 months or until their death. The c-statistic value was calculated to indicate the predictive accuracy of the SQ and Palliative Care Screening Tool (PCST). Of all participants, 18.8% and 18.6% had a SQ response of 'no' and a PCST score ≥4, respectively. After controlling for other covariates, an SQ response of 'no' (adjusted hazard ratio [aHR], 2.05; 95% confidence interval [CI], 1.83-2.31) and a PCST score ≥4 (AHR = 1.50; 95% CI: 1.29-1.75) were found to be the independent predictors for patients' 12-month mortality. The C-statistic values of the SQ and the PCST at recognising patients in their last year of life were .663 and .670, respectively. Moreover, there was moderate concordance (k = .44) between the SQ and the PCST in predicting 12-month mortality. SQ response of 'no' and a PCST score ≥4 were independent predictors of 12-month mortality in older patients. The SQ, when used by nurses working in hospital wards, is effective in identifying older patients nearing the end of life, as well as in providing advance care planning for patients. Patients' palliative care needs at admission were assessed by general nurses using the SQ and PCST.

Letter to the Editor: The Surprise Question in Palliative Care: Does It Have a Role in Predicting Mortality?

Letter to the Editor: The Surprise Question in Palliative Care: Does It Have a Role in Predicting Mortality?

Advancing screening tool for hospice needs and end-of-life decision-making process in the emergency department

BackgroundPredicting mortality in the emergency department (ED) is imperative to guide palliative care and end-of-life decisions. However, the clinical usefulness of utilizing the existing screening tools still leaves something to be desired.MethodsWe advanced the screening tool with the A-qCPR (Age, qSOFA (quick sepsis-related organ failure assessment), cancer, Performance Status Scale, and DNR (Do-Not-Resuscitate) risk score model for predicting one-year mortality in the emergency department of Taipei City Hospital of Taiwan with the potential of hospice need and evaluated its performance compared with the existing screening model. We adopted a large retrospective cohort in conjunction with in-time (the trained and the holdout validation cohort) for the development of the A-qCPR model and out-of-time validation sample for external validation and model robustness to variation with the calendar year.ResultsA total of 10,474 patients were enrolled in the training cohort and 33,182 patients for external validation. Significant risk scores included age (0.05 per year), qSOFA ≥ 2 (4), Cancer (5), Eastern Cooperative Oncology Group (ECOG) Performance Status score ≥ 2 (2), and DNR status (2). One-year mortality rates were 13.6% for low (score ≦ 3 points), 29.9% for medium (3 < Score ≦ 9 points), and 47.1% for high categories (Score > 9 points). The AUROC curve for the in-time validation sample was 0.76 (0.74–0.78). However, the corresponding figure was slightly shrunk to 0.69 (0.69–0.70) based on out-of-time validation. The accuracy with our newly developed A-qCPR model was better than those existing tools including 0.57 (0.56–0.57) by using SQ (surprise question), 0.54 (0.54–0.54) by using qSOFA, and 0.59 (0.59–0.59) by using ECOG performance status score. Applying the A-qCPR model to emergency departments since 2017 has led to a year-on-year increase in the proportion of patients or their families signing DNR documents, which had not been affected by the COVID-19 pandemic.ConclusionsThe A-qCPR model is not only effective in predicting one-year mortality but also in identifying hospice needs. Advancing the screening tool that has been widely used for hospice in various scenarios is particularly helpful for facilitating the end-of-life decision-making process in the ED.

The Physician Surprise Question in the Emergency Department: prospective cohort study

ObjectivesThis study aims to test the ability of the surprise question (SQ), when asked to emergency physicians (EPs), to predict in-hospital mortality among adults admitted to an emergency room (ER).MethodsThis...

Screening for End-of-Life in Acute Hospitals: A Cross-Sectional Survey.

Patients are frequently admitted to hospital in the last year of life. Actively recognising patients at this stage gives the opportunity to plan future care. We performed a cross-sectional survey of all acute medical and surgical inpatients at one tertiary hospital. Two simple screening tools, the indicators for a palliative approach and the surprise question identified a group of patients at greatly increased risk of dying over the next year. The one-year mortality of the study group was 27%, however was 52% and 65% for those identified at risk by the indicators for a palliative approach and surprise question tools. The surprise question had an area under the receiver operator curve value of .84. These screening tools could be used to help clinicians identify hospital inpatients that would benefit from advance care planning and a tailored approach to their care.

The Surprise Question and Health-Related Quality of Life in Patients on Hemodialysis: A Cross-Sectional Multicenter Study.

The Surprise Question (SQ) is a common method aimed at identifying frail patients who need serious illness conversations to integrate a palliative approach. However, little is known about whether the SQ identifies patients on hemodialysis who perceive that they are declining or have low health-related quality of life (HRQoL)-important aspects when considering the need for serious illness conversations. To explore how nurses and physicians' responses to the SQ are associated with patients' self-reported HRQoL. Cross-sectional study. In total, 282 patients on hemodialysis were included. One nurse and one physician responded to the SQ for each patient. The patient-reported HRQoL was measured with the RAND 36-Item Health Survey 1.0 (RAND-36) and the EuroQual vertical visual analogue scale (EQ-VAS) from the EuroQual-5 Dimension Questionnaire (EQ-5D). Nurses' responses "no, not surprised" to the SQ were associated with patient-reported worsened health compared to one year ago (RAND-36), and lower perceived overall health (EQ-VAS). Physicians' responses "no, not surprised" were associated with lower overall health and lower physical functioning. Patient-reported pain, general health, fatigue, and emotional and social aspects were not associated with responses to the SQ. The findings indicate that the SQ identifies patients on hemodialysis who report low overall health and low physical functioning. However, the SQ did not identify patients who reported pain, emotional problems, or fatigue, which are also important aspects to consider in identifying needs for serious illness conversations, symptom management, and to be able to integrate a palliative approach.

Evaluating the Utility of the Surprise Question Among General Physicians for Appropriate Palliative Care Indication in Brazil.

This study aimed to assess the agreement between established tools, such as the Palliative Performance Scale (PPS) and Brazilian version of the Supportive and Palliative Care Indicators Tool (SPICT-BR), and the subjective assessment of palliative care (PC) need using the Surprise Question (SQ) administered by resident physicians. This assessment was conducted among hospitalized patients, with and without cancer, to determine the efficacy of these tools in indicating the need for PC. A six-month cross-sectional study in 2019 of medical records of patients hospitalized in a single center in IAMSPE-Brazil. The SPICT-BR and PPS were applied to the medical record data, and the SQ was posed to each resident physician. Comparisons for categorical data were made using the chi-square test, with p < 0.05 considered statistically significant. Of 203 patients evaluated, 57.6% were male and 81.2% were older adults (≥60 years). The mean age was 67.40 ± 9.72 years. Chronic disease was nonneoplastic in 78.32% of patients, and 56.65% had not been hospitalized in the preceding year. The PPS score was <70% in 69.4% of patients, and 51.2% met at least one SPICT-BR criterion. Among patients with cancer, 40.9% had over two positive SPICT-BR criteria; 97.5% of these patients received NO responses to SQ by residents (p < 0.0001). Similarly, 90.6% of patients with one SPICT-BR criterion received NO responses to SQ, with no significant difference between groups. The SQ proved to be a valuable tool for PC indication, particularly when administered by untrained professionals. Consistent with SPICT-BR findings, our study highlights the SQ's role in facilitating early identification of patients in need of PC.

Accuracy of the "Surprise Question" in Predicting Long-Term Mortality Among Older Patients Admitted to the Emergency Department: Comparison Between Emergency Physicians and Nurses in a Multicenter Longitudinal Study.

The "surprise question" (SQ) ("Would you be surprised if this patient died in the next 12 months?") is the most frequently used screening tool in emergency departments (EDs) to identify patients with poor prognosis and potential unmet palliative needs. To test and compare the accuracy of the SQ between emergency nurses (ENs) and emergency physicians (EPs) in predicting long-term mortality among older patients (OP) in the ED. A prospective cohort study of OPs (≥75 years) conducted in two Belgian EDs. EPs and ENs answered the SQ for the patients they cared for. Positive SQ (SQ+) was defined as a "no" answer. One-year mortality was assessed by phone call. EPs and ENs both answered the SQ for 291 OPs (mean age 83.2 ± 5.4, males 42.6%). The SQ was positive in 43% and 40.6%, respectively. Predictive values were similar in both groups: sensitivity, specificity, c-statistics, negative predictive value, and positive predictive value were 0.79 (0.66-0.88), 0.68 (0.62-0.76), 0.69 (0.63-0.75), 0.92 (0.86-0.96), and 0.4 (0.31-0.50), respectively, for EPs and 0.71 (0.57-0.82), 0.69 (0.62-0.75), 0.69 (0.63-0.75), 0.89 (0.83-0.93), and 0.41 (0.31-0.51), respectively, for ENs. SQ + was associated with a higher mortality risk in both group (EPs hazard ratio: 3.2 [1.6-6.7], p = 0.002; ENs hazard ratio: 2.5 [1.3-4.8], p = 0.006). The survival probability was lower when both EPs and ENs agreed on the SQ+ (p < 0.001). The SQ is a simple tool to identify older ED patients at high mortality risk. Concordant responses from EPs and ENs are more predictive than either alone.

'It is important to feel invited': what patients require when using the Utrecht Symptom Diary - 4 Dimensional, a qualitative exploration.

In palliative care, the Utrecht Symptom Diary - 4 Dimensional (USD-4D), a Dutch-adapted and validated patient-reported outcome measure, supports multidimensional symptom management through identification and monitoring of, as well as dialogue on symptoms and needs. For the USD-4D to optimally support patients' autonomy, it is essential to know what patients need to use it. This study aims to identify what patients need when using the USD-4D in clinical palliative care. A generic qualitative design with primary and secondary analyses of semistructured interviews. Patients ⩾18 years with a life-limiting illness were purposefully recruited within hospice and home care settings if they were in their last year of life as identified by the surprise question. Patients had to be aware of their life-threatening condition. Patients were selected in two tranches. In the first tranche, patients had to have completed the USD-4D at least once. The second tranche consisted of patients who were not familiar with the USD-4D in clinical practice and were interviewed in a previous study on the content validity of the USD-4D. The interviews were transcribed verbatim and were subjected to thematic analysis. Twenty-five patients were included (14 men, ages 44-87). Patients' needs when using the USD-4D were summarized in three themes: (1) feeling invited, (2) being aware of the purpose and function of the USD-4D, and (3) experiencing a personal and nonjudgmental approach. For patients to optimally benefit from the USD-4D as a supportive measure of their autonomy in clinical palliative care, it is essential that they feel invited to use it. Healthcare providers are tasked with setting the right preconditions for patients to want and to be able to use the USD-4D. For patients, this means healthcare providers should always be attuned to their personal preferences when communicating the purpose and function of the USD-4D and when they enter into dialogue with them.

The Peritoneal Dialysis Surprise Question and Technique Survival: Are you surprised?

The Peritoneal Dialysis Surprise Question and Technique Survival: Are you surprised?