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The Surprise Question
  1. Mellar P Davis and
  2. Erin Vanenkevort
  1. Geisinger Health Care System, Danville, Pennsylvania, USA
  1. Correspondence to Dr Mellar P Davis, Geisinger Health Care System, Danville, USA; mdavis2{at}

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What is already known?

  • A clinician’s negative surprise question response predicts a twofold to eightfold increase in mortality within the next year when compared with a positive surprise question response.

What does this study add?

  • Most patients with a negative surprised question response will survive a year or longer.

  • By likelihood ratios, the Surprise Question alone has weak prognostication value when used alone.

How might this affect research, practice or policy?

  • The original intent of the Surprise Question as a means of palliative care referral or advance care planning has not been adequately explored in clinical trials and palliative benefits and economic outcomes are completely unknown which requires further research.

  • Clinical decisions should not be made based on the Surprise Question at the present time.

What is known?

A negative surprise question (I would not be surprised if this patient died within the year) (NSQ) was not originally intended as a prognostic tool but as a means of selecting patients for palliative care referral and advance care planning.1 The surprise question is included in the Gold Standards Framework in the UK and the Necesidades Paliatinas (NECPAL) programme of Catalonia.2 Since 2010, the surprise question has been explored as a prognostication tool in over two dozen studies with two systematic reviews published in 2017 (table 1).3 4 The tool has been used for the prognostication of cancer and non-cancer illnesses, and most clinicians believe the Surprise Question is helpful in predicting survival which unlike other prognostic tools does not require an estimate of the time frame to death but the possibility that a …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.