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Palliative Care 2015: Study Finds the Answer to One Question Can Help Identify Patients Nearing the End of Life

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Key Points

  • The answer to a simple question—Would you be surprised if this patient died within the next year?—can help predict the risk of cancer death within 1 year better than clinical variables, such as cancer type, stage, age of the patient, or time since diagnosis.
  • Using this “Surprise Question,” oncology clinicians enrolled in this randomized study identified about 60% of patients who died within 1 year.
  • Because the Surprise Question failed to identify about 40% of patients who died within a year, more research is needed to understand the factors that contribute to nonrecognition of so many patients and to develop better predictors of patient death.

Determining the answer to a simple question, “Would you be surprised if this patient died within the next year?” can be an important tool to help predict which patients with cancer may be in their final year of life, according to the findings from a study by Vick et al. The tool, known as the “Surprise Question,” was found to be more accurate in predicting the risk of cancer death within 1 year than other factors such as cancer type, stage, the age of the patient, or time from diagnosis. The study (Abstract 8), will be presented at the 2015 Palliative Care in Oncology Symposium, being held October 9–10, in Boston.

Study Methodology

From July 2012 to October 2014, researchers at Ariadne Labs enrolled 81 oncology clinicians, including oncologists (59), nurse practitioners (18), and physician assistants (4), from Dana-Farber Cancer Institute in Boston, into a randomized trial. The trial investigated the impact of a structured intervention to improve conversations about end-of-life goals.

The clinicians answered the Surprise Question—“Would you be surprised if this patient died within the next year?”—regarding nearly 5,000 patients, aged 19 to 95 with all types and stages of cancer, as the first step in Ariadne Labs’ patient-centered Serious Illness Care Program. The researchers used a weighted propensity score approach to calculate adjusted proportions of survival at 6 months and 1 year. To determine which variable was most predictive of death, the researchers fit a multivariable Cox model and found the variable that led to the largest increase in the Cox-regression goodness-of-fit c-statistic.

Study Findings

Of the 4,617 patients the researchers had complete data on, the study participants answered “Yes” to the Surprise Question on 3,821 (83%) patients and “No” to the Surprise Question on 796 (17%) patients. Propensity-adjusted 1-year survival for “Yes” patients was 93% (95% confidence interval [CI] = 91%–96%) compared to 53% (95% CI = 46%–60%) for the “No” patients (P < .0001).

The Surprise Question was more predictive of patient death than other factors, including type of cancer, age of the patient, cancer stage, or time since diagnosis. Sensitivity of the “No” response was 59% (95% CI = 49%–68%), and specificity was 90% (95% CI = 86%–93%). Positive predictive value was 49% (95% CI = 45%–54%), and negative predictive value was 93% (95% CI = 90%–95%).

Simple, Effective Tool

“There is no generally accepted tool to identify seriously ill patients who would benefit from conversations about their values, goals, and priorities,” said Judith Vick, a medical student at the Johns Hopkins University School of Medicine in Baltimore, and lead author of this study, during a press briefing about the study results. “The Surprise Question is a simple tool that allows clinicians to identify those patients. The Surprise Question is a simple, affordable, and available tool that is easily implemented. Our results show that oncology clinicians’ own judgment using the Surprise Question identified about 60% of patients with short-life expectancy. However, given that 40% of these patients were not identified by the Surprise Question, more research is needed to understand why.”

Commenting on the study results, ASCO expert and moderator of the press briefing, Don S. Dizon, MD, Clinical Co-Director of Gynecologic Oncology at Massachusetts General Hospital, Boston, said “This important work shows that one question that clinicians actually ask themselves may be more effective than the usual clinical and laboratory parameters to identify patients that have risk of dying within a year. I think this is important, especially in an era where we are looking at values and preferences regarding current and future cancer care, and I look forward to future results of this multipronged intervention.”

No funding source was disclosed for this study. For full disclosures of the study authors, view the study abstract at abstract.asco.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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