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A qualitative study exploring use of the surprise question in the care of older people: perceptions of general practitioners and challenges for practice
  1. Margaret Elliott1 and
  2. Caroline Nicholson2
  1. 1Department of Social Science, Health and Medicine, Institute of Gerontology, King's College London, London, UK
  2. 2National Nursing Research Unit, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
  1. Correspondence to Dr Margaret Elliott, Marie Curie Palliative Care Research Unit, Division of Psychiatry, Charles Bell House, 67-73 Riding House Street, London W1W 7EJ, UK; margaret.elliott{at}


Objective The question “Would you be surprised if this patient were to die in the next 6–12 months?” has been included in UK palliative care guidance with the aim of supporting the identification and care planning of those nearing the end of life. Little is known about how the surprise question is utilised in the care of older people within primary care. This study sought to explore the perceptions and experiences of general practitioners (GPs).

Method Semistructured interviews were conducted with 12 GPs. Each interview reflected on the care of two people, aged 80 years or older, selected by the GP as possibly being in the last year of life. Analysis followed a grounded theory approach within a framework of interpretive thematic analysis.

Results Data discussing 22 clinical cases revealed the difficulties experienced by GPs when assessing prognosis for older people with non-malignant conditions, despite their recognition of multiple mortality risk factors and high symptom burden. GPs did not appear to include the surprise question within their usual practice and expressed concerns regarding its use to facilitate discussion of advance care plans. These concerns highlighted the subjective nature of the surprise question and potential barriers to conducting discussions of preferences for future care.

Conclusions Greater understanding is needed as to the difficulties experienced by GPs when assessing prognosis in older people. We propose a thematic model which could support GPs by focusing assessment on the supportive and palliative care needs of older people nearing the end of life.

  • end of life
  • older people
  • surprise question
  • advance care plan
  • primary care

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  • Contributors MLE designed the study, developed the analytical approach, conducted the interviews, transcribed the data, developed the initial analysis and wrote the first draft of the paper. CN checked the coding and data analysis, and supported the interpretation and development of research findings. MLE and CN revised the article together and approved the final version.

  • Competing interests None.

  • Ethics approval King's College London GSSHM Research Ethics Panel 22/03/2013 ref KCL 12/13-317.

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