Using the Surprise Question To Identify Those with Unmet Palliative Care Needs in Emergency and Inpatient Settings: What Do Clinicians Think?

Abstract

Background:

The surprise question (SQ), “Would you be surprised if this patient died within the next year?” is effective in identifying end-stage renal disease and cancer patients at high risk of death and therefore potentially unmet palliative care needs. Following implementation of the SQ in our acute care setting, we sought to explore hospital-based providers' perceptions of the tool.

Objectives:

To evaluate (1) providers' perceptions regarding the feasibility of SQ use in emergency and inpatient settings, (2) clinician perceptions regarding the utility of the SQ, and (3) barriers to SQ use.

Design:

A cross-sectional survey of medical providers following addition of the SQ to the electronic record for all patients admitted to a tertiary care hospital.

Results:

A total of 111/203 (55%) providers participated: 48/57 (84%) emergency physicians (EPs) and 63/146 (43%) inpatient providers (IPs). Most reported no difficulty using the SQ. Modest numbers in both groups reported that the SQ influenced care delivery (EPs 37%, IPs 42%) as well as goals of care (EPs 45%, IPs 52%). At least some advance care planning discussions were prompted by the SQ (EPs 45%, IPs 58%). Team discussions were influenced by SQ use for more than half of each group. Most respondents (55%) expressed some concern that their SQ responses could be inaccurate.

Conclusions:

In this setting, clinicians indicated that use of the SQ is feasible, acceptable, and useful in facilitating advance care planning discussions among teams, patients, and families. Many reported that SQ use influenced goals of care, but concern regarding accuracy was a barrier. Additional research examining SQ accuracy and predictive ability is warranted.

Introduction

Palliative care (PC) seeks to improve patients' quality of life by alleviating suffering through treatment to improve physical symptoms, spiritual, and psychosocial well-being.¹ Research supports the incorporation of PC in a patient's disease trajectory, concurrent with the delivery of curative therapies.^2,3 PC improves patient and provider satisfaction, quality of life, physical symptoms, and mood. It has also been shown to decrease hospital and intensive care lengths of stay and healthcare costs.^4–14 Despite this, clinicians' reluctance to incorporate PC into practice is well documented in the literature across a wide range of specialties.^15–18

Clinicians' failure to identify and refer patients to PC in the inpatient setting may be due, in part, to the lack of currently available screening tools to identify patients with potentially unmet PC needs.¹⁹ The surprise question (SQ), “Would you be surprised if this patient died within the next year?” is one screening tool that has been demonstrated to be effective in identifying end-stage renal disease and cancer patients with an increased risk of death in the outpatient setting.^20–22 While increased risk of mortality is only one indicator of the possible need for PC services, identifying these patients may be a useful way to begin incorporating palliative approaches into hospital-based care and move clinician thinking from a palliative care = hospice care mindset to a much broader perspective. However, while the SQ may be useful with specific populations in need of PC services, general acceptance and utilization of the surprise question have not been extensively evaluated.

In an effort to improve the identification and care of patients with unmet PC needs, we developed and implemented screening processes for newly admitted hospitalized patients in two different acute care settings, utilizing two versions of the surprise question (SQ). The first process was undertaken in the general medicine inpatient setting, utilizing the standard SQ, while the second process was undertaken in the emergency department (ED) utilizing a modified version of the surprise question (Modified ED Surprise Question [MESQ]), “Would you be surprised if this patient died in the next 30 days?”

For both processes and settings, the SQ was incorporated within the standard admission order sets used for all newly admitted patients (Supplementary Appendix I; Supplementary Data are available online at www.liebertpub.com/jpm). While we have found the MESQ to be a reliable predictor of inpatient mortality, intensive care utilization, and PC consultation, we lacked understanding of medical providers' perceptions of the traditional and modified surprise question tools.^23,24 Therefore, we sought in this study to evaluate (1) providers' perceptions regarding the feasibility of surprise question use in the emergency and inpatient settings, (2) clinician perceptions regarding the utility of the surprise question, and (3) barriers to surprise question use.

Methods

Study design

We utilized an observational cross-sectional design to address our study objectives. Data were collected using an electronic survey during a one-month period. The Maine Medical Center Institutional Review Board reviewed and approved the study as exempt. While the requirement for written informed consent was waived, a modified consent document explaining participants' rights and responsibilities, but not requiring signatures, was used.

Setting and participants

The study was conducted at Maine Medical Center (MMC), a 606-bed academic tertiary care center located in Portland, Maine. MMC currently houses 12 residency training programs, 8 fellowships, and a palliative medicine consult service. At the time of the study, improving the delivery of end-of-life and PC services was institutional priority and included within the institution's formal focus areas for the year.

All medical providers accessing the SQ through use of electronic order sets for admitted patients were invited to participate in the study. Providers included resident, fellow, and attending physicians, as well as physician assistants and nurse practitioners. In addition, attending and resident emergency physicians (EPs) and other prescribing clinicians were also invited to participate in the study as emergency clinicians were required to respond to a modified version of the SQ with each hospital admission through the use of an electronic record hard stop.

Recruitment and data collection

During the month of June, 2014, we used the Qualtrics (Qualtrics, LLC, Provo, UT) web-based survey platform to distribute our survey to 203 clinicians practicing within MMC. We used survey methods described by Dillman et al. to optimize the response rate.²⁵ Data were automatically collected and entered into a Microsoft Excel (Microsoft, Inc., Redmond, WA) spreadsheet program by the Qualtrics platform. The survey was conducted approximately six months after implementation of the SQ at our Institution.

Survey development

We designed our survey instrument to elicit data in three domains: feasibility of SQ use in emergency and inpatient settings, clinician perceptions regarding the utility of the SQ, and barriers to SQ use. Through group discussion and review of the existing literature in this area, a pool of potential survey items was developed. Two draft surveys, one for emergency clinicians and one for inpatient clinicians, were pilot tested using a group comprising both emergency and nonemergency medicine hospital-based physicians. Items were edited, added, or removed based upon their feedback using a consensus-based process. The final survey for emergency clinicians consisted of 23 items, while the final inpatient survey consisted of 21 items. The survey administered to emergency clinicians included two items focused on the usefulness of the SQ tool in the ED environment. The survey tools are available as Supplementary Appendix II.

Data analysis

All data were analyzed using SPSS for Windows, version 22.0 (SPSS, Inc., Chicago, IL). We report response frequencies using numbers and percentages.

Results

Table 1 describes the demographic characteristics of the respondents. In sum, 111/203 clinicians participated in the study for an overall response rate of 55%. Of those, 48/57 emergency clinicians (84%) and 63/146 inpatient clinicians (43%) chose to complete surveys. While the majority of emergency medicine respondents were males (n = 33, 69%), most inpatient clinician respondents were females (n = 35, 56%), reflecting the characteristics of the Institution overall.

Table 1.

Demographic Characteristics of the Study Participants

Characteristic	All, N (%)	ED, n (%)	Inpatient, n (%)
Professional role
Resident physician	56 (50)	21 (44)	35 (56)
Fellow	1 (1)	1 (2)	0 (0)
Attending physician	42 (38)	25 (52)	17 (27)
Advance practice provider	12 (11)	1 (2)	11 (17)
Postgraduate year
PGY-1	4 (24)	2 (10)	2 (6)
PGY-2	7 (41)	3 (14)	4 (11)
PGY-3	6 (35)	2 (10)	4 (11)
PGY-4	0 (0)	0 (0)	0 (0)
PGY-5+	0 (0)	0 (0)	0 (0)
Sex
Male	61 (55)	33 (69)	28 (44)
Female	50 (45)	15 (31)	35 (56)
Age group, years
20–30	34 (31)	13 (27)	21 (33)
31–40	47 (42)	22 (46)	25 (40)
41–50	19 (17)	8 (17)	11 (17)
51–60	10 (9)	4 (8)	6 (10)
>60	1 (1)	1 (2)	0 (0)
Post-training years of practice (mean, 95% CI)	8.5 (5.6–11.4)	12 (7.6–15.8)	3.3 (1.1–5.4)
Primary clinical practice
Emergency medicine	48 (43)	48 (100)	—
Family medicine	14 (13)	—	14 (23)
Hospital medicine	21 (19)	—	21 (34)
Internal medicine	29 (26)	—	29 (48)

CI, confidence interval; ED, emergency department.

Surprise question feasibility

To assess the overall feasibility of surprise question in the acute care setting, clinicians were asked two questions: (1) In general, how difficult has it been for you to answer the surprise question while admitting a patient? and (2) How often did your use of the surprise question decrease your efficiency in caring for your patients? As displayed in Table 2, 78% (n = 35) of emergency clinicians and 65% (n = 39) of inpatient clinicians reported no difficulty in responding to the SQ. In addition, the majority of both groups (84% [n = 38] of EPs and 92% [n = 54] of inpatient clinicians) reported that responding to the surprise question did not decrease their efficiency while caring for patients.

Table 2.

Clinician Beliefs Regarding Surprise Question Feasibility and Efficiency

	Response options
How difficult is it to use the SQ?	Not difficult at all	Somewhat difficult	Very difficult	Extremely difficult
Emergency, n (%)	35 (78)	7 (16)	3 (7)	0 (0)
In-hospital, n (%)	39 (65)	21 (35)	0 (0)	0 (0)

How often did SQ use decrease your efficiency?	Never	Sometimes	Often	Always
Emergency, n (%)	38 (84)	6 (13)	0 (0)	1 (2)
In-hospital, n (%)	54 (92)	5 (9)	0 (0)	0 (0)

The SQ is not the right tool for the ED.	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
Emergency, n (%)	5 (11)	18 (40)	17 (38)	4 (9)	1 (2)

SQ, surprise question.

Approximately half (51%, n = 23) of emergency providers agreed that the surprise question is an appropriate tool for the emergency setting (Table 2). Fifty-seven percent (n = 25) of EPs endorsed the statement that the SQ is helpful in the ED.

Despite responding to the surprise question on a daily basis, the majority of emergency and inpatient clinicians (84% and 81%, respectively) reported never communicating the results of their response to the question to an oncoming care provider during a care transition. In addition, 91% of emergency clinicians and 84% of inpatient providers (IPs) responded that they never received SQ response information while receiving sign-out from another provider.

Surprise question utility

Table 3 describes clinician assessments regarding the utility of the surprise question. Four questions were asked of all survey participants regarding the utility of the surprise question in the acute care setting. These included assessments of the degrees to which use of the question influenced the care provided to the respondent's patients, to which it influenced goals of care, to which responding to the question prompted advance care planning discussion with patients, and to which responding to the question led to healthcare provider team discussions regarding advance care planning. Thirty-seven percent (n = 17) of emergency clinicians and 42% (n = 25) of IPs reported that use of the SQ influenced the care they provided to their patients sometimes or often. Forty-two percent of EPs (n = 19) and 52% (n = 31) of IPs responded that goals of care for their patients were influenced by use of the question sometimes or often. Advance care planning discussions were prompted at least sometimes for 45% (n = 20) of emergency clinicians and for 58% (n = 34) of IPs. In addition, 53% (n = 24) of emergency and 52% (n = 31) of inpatient clinicians reported that use of the SQ led to advance care planning discussions among the team of care providers sometimes or often.

Table 3.

Clinician Beliefs Regarding Surprise Question Utility

	Never	Sometimes	Often	Always
How often did the SQ prompt an ACP discussion with the patient? n (%)
Emergency	25 (56)	16 (36)	4 (9)	0 (0)
In-hospital	25 (42)	30 (51)	3 (5)	1 (2)
How often did the SQ influence goals of care? n (%)
Emergency	26 (58)	14 (31)	5 (11)	0 (0)
In-hospital	27 (46)	26 (44)	5 (8)	1 (2)
How often did the SQ influence care delivery? n (%)
Emergency	28 (62)	15 (33)	42 (4)	0 (0)
In-hospital	34 (58)	22 (37)	3 (5)	0 (0)
How often did the SQ prompt team discussion? n (%)
Emergency	21 (47)	22 (49)	2 (4)	0 (0)
In-hospital	28 (47)	26 (44)	5 (8)	0 (0)

Barriers to surprise question use

Survey participants responded to six items regarding potential barriers to use of the surprise question in clinical practice. Ninety-three percent (n = 55) of inpatient clinicians and 98% of emergency providers (n = 38) reported that use of the question had never had a negative effect on patient care. As displayed in Table 4, the vast majority of respondents were not at all concerned that use of the surprise question might have negative effects on patient care (100% of EPs, 95% of inpatient clinicians) or could cause physicians to give up on patients too early (96% of EPs, 92% of IPs). Most respondents felt that use of the SQ would be acceptable to patients and families (EPs: 80%, n = 36; inpatient clinicians: 75%, n = 44). Forty percent (n = 18) of emergency providers and 46% of inpatient clinicians (n = 27) reported being somewhat to extremely concerned that they might not know enough about their patients to respond to the SQ. In addition, 53% of emergency (n = 24) and 63% of inpatient respondents (n = 37) reported that they were at least somewhat concerned that their responses to the question could be inaccurate.

Table 4.

Clinician-Reported Barriers to Surprise Question Use

	Not at all concerned	Somewhat concerned	Very concerned	Extremely concerned
I don't know enough about my patients to answer the surprise question, n (%)
Emergency	27 (60)	13 (29)	3 (7)	2 (4)
In-hospital	32 (54)	26 (44)	1 (2)	0 (0)
Patients and/or families would not want physicians to use the surprise question, n (%)
Emergency	36 (80)	9 (20)	0 (0)	0 (0)
In-hospital	44 (75)	14 (24)	1 (2)	0 (0)
Use of the surprise question could have a negative effect on patient care, n (%)
Emergency	45 (100)	0 (0)	0 (0)	0 (0)
In-hospital	56 (95)	3 (5)	0 (0)	0 (0)
Use of the surprise question could cause physicians to give up on patients too early, n (%)
Emergency	43 (96)	2 (4)	0 (0)	0 (0)
In-hospital	54 (92)	5 (8)	0 (0)	0 (0)
My answers to the surprise question could be inaccurate, n (%)
Emergency	21 (47)	17 (38)	3 (7)	4 (8)
In-hospital	22 (37)	36 (61)	1 (2)	0 (0)

Discussion

While there has been increasing recognition of the importance of incorporating PC into the acute setting, the majority of patients who might benefit from PC services are not identified during their hospitalizations and do not receive such care.^19,26–28 The reasons for this limited uptake of PC services may be complex and multifactorial, and clinician beliefs and attitudes toward the use of screening tools for unmet PC needs may be influential. To our knowledge, the current study is the first to describe emergency and acute care physicians' beliefs and attitudes toward the use of the SQ as a PC-needs screening tool.

Many ED patients have PC needs that (if left unidentified) are either ignored or not adequately addressed early enough in the admission process to have a significant impact.^29,30 Patients who require hospital admission commonly have burdensome symptoms that include pain, respiratory distress, and acute neurologic dysfunction.^31,32 These patients are often experiencing acute decompensation of a chronic illness and are typically in an older age group with multiple chronic conditions and social situations that are often overlooked in the acute care setting.³³ While EPs are well trained to manage the myriad of medical issues associated with acute care visits, until recently, little emphasis has been placed on the identification and management of PC needs. While recent investigations have identified the ED visit as a potential link to PC services, national organizations, including the American College of Emergency Physicians (ACEPs), the National Institutes of Health, and the Agency for Healthcare Research and Quality, have also promoted the integration of emergency and palliative medicine.^34–37 New York University investigators established the positive impact that early end-of-life discussions, initiated in the ED, can have on resource utilization, patient satisfaction, and average length of stay.¹⁴ Furthermore, our own work group has demonstrated the utility of the MESQ for identifying ED patients with unmet PC needs and for predicting in-hospital mortality.^23,24 However, before this investigation, there has not been an evaluation of emergency clinician beliefs regarding the potential pros and cons or barriers associated with the identification and management of PC needs in the ED setting through use of the MESQ.

The one-year surprise question has previously been used and studied in the ambulatory care setting by primary and specialty care providers managing chronic illnesses.^20–22,38 Notably, Lakin et al. recently reported on one-year mortality following primary care physician response to the SQ for 1737 patients seen in a large academic primary care practice.³⁹ While this team observed 4.36 times greater odds of dying in patients with a negative SQ response, the area under the receiver operating characteristic curve for the predictive ability of the SQ was only 0.57, slightly greater than chance alone. In this study, the SQ did not identify most deaths that occurred by one year, rendering it a poor screening tool for mortality in this setting and sample.³⁹ Despite this, the SQ did contribute to mortality estimation in some way as it was strongly and significantly associated with mortality at one-year follow-up, affirming the findings of previous research teams.^20–22

More recently, a revised version of the surprise question (Would you be surprised if this patient died in the next 6 to 12 months?) was evaluated as a component of the Gold Standard Framework Prognostic Indicator (GSF-PI) tool in the inpatient setting.⁴⁰ O'Callaghan et al. observed significantly increased mortality in subjects with an affirmative SQ screening response upon 12-month follow-up. Despite GSF-PI sensitivity and specificity values of 63% and 92%, respectively, the one-year time frame for the traditional surprise question may not make intuitive sense for clinicians practicing in emergency or critical inpatient settings where acuity is very high and clinicians would rarely be surprised if a patient died within 12 months.

Recognizing this limitation of the one-year SQ, Hamano et al. recently evaluated the prognostic value of two versions of the question using 7- and 30-day time frames.⁴¹ When used by home-based PC services, hospital-based PC teams, and outpatient PC units with patients experiencing advanced cancer, this team not only found high sensitivity for both versions of the SQ (85% for 7-day, 96% for 30-day time frames) but also noted low specificity across versions (68% 7-day, 37% 30-day time frames). Considering findings from both the O'Callaghan and Hamano studies suggests that while these versions of the SQ may be useful in identifying PC needs in patients with anticipated short durations of survival, predicting which patients will experience death in the near term (7- or 30-day time frame) may be more challenging than for the 12-month time frame. It is likely that unique screening tools with different time frames may be useful based upon the identified purposes of screening, population of concern, and setting, indicating that when it comes to assessing potential PC needs, one tool may not fit all clinical situations.

Although our groups of emergency and IPs initially expressed some reluctance to embrace the implementation of the SQ and MESQ as mandated fields in their respective admission order sets, our findings indicate acceptance of the surprise question as a tool for identifying those with potentially unmet PC needs across our acute care setting. The majority of clinicians were able to respond to the SQ with little difficulty, indicating that use of the tool in the ED and acute inpatient setting is feasible. A majority of our EPs, potentially the group of providers with the most reservations about tool utility, found the MESQ to be helpful; however, some felt that the MESQ is not an ideal tool for the emergency setting, suggesting room for improvement or consideration of other tools.

Previous research clearly indicates that clinician incorporation of PC into routine practice has been limited.^16–18,42 Given this, our findings that at least modest numbers of clinicians (37% of emergency clinicians, 42% of inpatient clinicians) reported that use of the surprise question influenced the care they provided are encouraging. In addition, a moderate number of physicians reported that surprise question responses influenced goals of care and prompted advance care planning discussions among care teams as well as with patients and families. Still, with the majority of participants reporting that use of the SQ did not influence the care they provided, additional research is warranted to examine uptake and influence over time as clinicians may become more comfortable with incorporating PC into hospital-based care.

Struggling with prognostic uncertainty, not wanting to cause patients and families stress or anxiety, and challenges managing difficult conversations have all been identified as barriers that impede the provision of PC for clinicians.^42–46 One qualitative study conducted with general practitioners in the United Kingdom evaluated participants' use of the SQ. Interviews revealed that many participants were concerned that the SQ was too subjective and identified patients with PC needs earlier than they were comfortable having an advance care planning discussion with their patients.⁴² The vast majority of our participants reported that they were not at all concerned that use of the MESQ or SQ might have negative effects on patient care or might cause clinicians to give up on patients too early. While patient and family perspectives were not evaluated here, providers did not worry that patients and families would be upset to learn of their use of the surprise question. However, a majority of respondents were concerned to some degree that their responses to the SQ might be inaccurate. This concern for the prognostic accuracy of the SQ may be a significant barrier to use and requires further study.

Several limitations should be considered when interpreting the results of our study. First, this survey was conducted within a single academic medical center with a specific focus on enhancing the delivery of PC services. The findings observed here may not reflect the experiences in other types of acute care settings. Similarly, this study was conducted approximately six months after we implemented the SQ in our setting and findings may have been very different had we surveyed clinicians sooner (e.g., six weeks after implementation) or later (e.g., one year after implementation). In addition, despite using methods to maximize participation (Dillman et al.), the survey response rate for IPs was 43%, and providers who chose to respond to the survey may have had more favorable opinions than those who did not participate.²⁵

An additional important issue for those considering these findings is in the development of our survey questions. We consciously developed items that would cover our three domains of interest: feasibility, utility, and barriers to SQ use. We used a variety of item formats, pilot tested the items, and revised them according to feedback we received from a variety of clinicians who would be eligible to take our survey. Even so, it is possible that the items themselves bias participant responses. Despite this, we believe these findings provide a useful snapshot on clinician assessments of SQ feasibility, utility, and barriers to use that offer direction for future research and clinical efforts.

Conclusions and Recommendations

It is essential that acute care clinicians develop mechanisms to address unmet palliative needs promptly in patients' clinical course. The SQ and its modified ED counterpart may facilitate this goal, and physician attitudes and beliefs regarding the feasibility and utility of this intervention appear not to be barriers to its clinical implementation in the acute care setting. While not a comprehensive solution, the SQ may serve well as an early and efficient screening tool that (when combined with other hospital resources) may lead to more timely interventions to improve end-of-life care and the delivery of palliative resources to patients and families. Additional research is needed to comprehensively evaluate the prognostic value of the surprise question when used in the acute care setting across a broad sample of ED and hospitalized patients.

Footnotes

Acknowledgments

The study team gratefully acknowledges the support of their clinical colleagues who provided feedback on survey items as well as those clinicians who participated in the survey. In addition, the authors thank Shelly Davgun, MPH, and Rebecca Kowaloff, MD, for their assistance in gathering data.

Author Disclosure Statement

No competing financial interests exist.

The authors received no financial support for the research, authorship, and/or publication of this article.

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