From the Guidelines
For a surprise question in palliative care, I strongly recommend using it as a clinical tool by asking yourself, "Would you be surprised if the patient dies within a defined short time interval (e.g. seven days, thirty days or one year)?". This approach is supported by a prospective study that showed clinicians could screen cancer patients for seven- or thirty-day survival using surprise questions with 90% or more sensitivity 1. The surprise question is a simple and innovative tool to recognize patients who would benefit most from palliative care measures, and it can be used to initiate primary palliative measures with the patient.
When implementing this approach, consider the following key points:
- The surprise question helps identify patients who need additional support beyond curative treatments, including symptom management, advance care planning, and psychosocial support.
- The question doesn't require complex calculations or formal assessments, making it practical for busy clinical settings.
- While not perfect in predicting mortality, its value lies in triggering appropriate palliative interventions earlier in the disease course, which improves quality of life and aligns care with patient preferences.
- The National Comprehensive Cancer Network (NCCN) clinical guidelines support the incorporation of palliative care into the treatment of cancer at time of diagnosis regardless of stage, and hospice care is appropriate for those whose life expectancy is less than six months 1.
In the context of terminal HCC, the surprise question can be particularly useful in identifying patients who would benefit from palliative care services, such as pain management with acetaminophen or opioids, and nutritional intervention to address weight loss and muscle wasting 1. By using the surprise question as a clinical tool, healthcare providers can provide more comprehensive and patient-centered care, improving quality of life and reducing suffering for patients with terminal HCC.
From the Research
Surprise Question in Palliative Care
The surprise question is a tool used to identify patients who may benefit from palliative care. It is defined as "Would I be surprised if this patient dies within 1 year?" 2, 3.
Identification of Palliative Care Needs
The surprise question has been shown to be effective in identifying patients with advanced cancer who have unmet palliative care needs 2. A study found that patients who were identified as not being surprising to die within a year had poor quality of life and frequent depressive symptoms 2.
Prognostic Usefulness
The surprise question has also been shown to be prognostically useful in identifying patients with heart failure who are at higher risk of all-cause death 3.
Key Findings
- The surprise question identifies patients with advanced cancer who have poor quality of life and frequent depressive symptoms 2.
- The surprise question is prognostically useful in identifying patients with heart failure who are at higher risk of all-cause death 3.
- Patients who are identified as not being surprising to die within a year may benefit from palliative care interventions to improve mood, quality of life, and end-of-life care 2, 3.
Related Studies
- A study on sedatives and sedation at the end of life found that sedatives are frequently used in specialist palliative care, but there is scarce information about their use in nursing homes 4.
- A study on the effect of lorazepam with haloperidol vs haloperidol alone on agitated delirium in patients with advanced cancer found that the addition of lorazepam to haloperidol resulted in a significantly greater reduction in agitation at 8 hours 5.
Palliative Care Considerations
- Palliative care should be considered for patients who are identified as not being surprising to die within a year 2, 3.
- The surprise question can be used as a practical method to identify patients with unmet palliative care needs 2.
- Patients with advanced cancer and heart failure may benefit from palliative care interventions to improve mood, quality of life, and end-of-life care 2, 3.