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60 Can the ‘surprise question‘ be used to correctly identify people nearing the end of life?: a review
  1. Victoria Vickerstaff1,2,
  2. Nicola White1,
  3. Nuriye Kupeli1 and
  4. Patrick Stone1
  1. 1Marie Curie Palliative Care Research Department, University College London, London, UK
  2. 2Research Department of Primary Care and Population Health, University College London, London, UK


Introduction It has been shown that clinicians are inaccurate at prognostication (White et al., 2016) and recognising dying patients (Neuberger et al., 2013). Patients who would benefit from palliative care may be missed because validated prognostic tools (Pirovano et al., 1999; Morita et al., 1999) are not routinely used, either due to the perceived complexity or inconvenience. The surprise question (SQ) (“Would you be surprised if this patient died within the next χ months?”) offers an alternative to standard prognostic estimates.

Aim To evaluate the performance of the SQ in patients nearing the end of life.

Methods We searched numerous databases, including: Medline, Embase, CINAHL, AMED. Studies were included if they reported the SQ and were written in English.

Results Out of the 357 studies identified, 22 were included in the review. In these studies, 25 718 estimates were reported. The results showed a wide variation in the reported accuracy of the SQ, with sensitivity ranging from 11.6% to 96.6% and specificity ranging from 13.9% to 78.6%. The AUROC score across the studies ranged from 0.512 to 0.822. Doctors appeared to be more accurate than nurses at recognising people in the last year of life (c-statistic=0.735 vs. 0.688).

Conclusions The performance of the SQ varied greatly across the studies. Further work is required to understand the processes by which clinicians arrive at their prognostic estimates, to refine the accuracy of the SQ and to compare its performance against other more sophisticated prognostic tools, particularly in populations where a higher proportions of deaths occur.


  1. . Morita, T., Tsunoda, J., Inoue, S. and Chihara, S., 1999. The Palliative Prognostic Index: a scoring system for survival prediction of terminally ill cancer patients. Supportive Care in Cancer, 7(3), pp.128–133.

  2. . Neuberger, J., Guthrie, C. and Aaronovitch, D., 2013. More care, less pathway: a review of the Liverpool Care Pathway. Department of Health.

  3. . Pirovano, M., Maltoni, M., Nanni, O., Marinari, M., Indelli, M., Zaninetta, G., Petrella, V., Barni, S., Zecca, E., Scarpi, E. and Labianca, R., 1999. A new palliative prognostic score: a first step for the staging of terminally ill cancer patients. Journal of pain and symptom management, 17(4), pp.231–239.

  4. . White, N., Reid, F., Harris, A., Harries, P. and Stone, P., 2016. A systematic review of predictions of survival in palliative care: How accurate are clinicians and who are the experts?. PLoS One, 11(8), p.e0161407.

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