The Surprise Question and Identification of Palliative Care Needs among Hospitalized Patients with Advanced Hematologic or Solid Malignancies

J Palliat Med. 2018 Jun;21(6):789-795. doi: 10.1089/jpm.2017.0509. Epub 2018 Feb 8.


Background: Little is known about quality of life (QOL), depression, and end-of-life (EOL) outcomes among hospitalized patients with advanced cancer.

Objective: To assess whether the surprise question identifies inpatients with advanced cancer likely to have unmet palliative care needs.

Design: Prospective cohort study and long-term follow-up.

Setting/subjects: From 2008 to 2010, we enrolled 150 inpatients at Duke University with stage III/IV solid tumors or lymphoma/acute leukemia and whose physician would not be surprised if they died in less than one year.

Measurements: We assessed QOL (FACT-G), mood (brief CES-D), and EOL outcomes.

Results: Mean FACT-G score was quite low (66.9; SD 11). Forty-five patients (30%) had a brief CES-D score of ≥4 indicating a high likelihood of depression. In multivariate analyses, better QOL was associated with less depression (OR 0.91, p < 0.0001), controlling for tumor type, education, and spiritual well-being. Physicians correctly estimated death within one year in 101 (69%) cases, yet only 37 patients (25%) used hospice, and 4 (2.7%) received a palliative care consult; 89 (60.5%) had a do-not-resuscitate order, and 63 (43%) died in the hospital.

Conclusions: The surprise question identifies inpatients with advanced solid or hematologic cancers having poor QOL and frequent depressive symptoms. Although physicians expected death within a year, EOL quality outcomes were poor. Hospitalized patients with advanced cancer may benefit from palliative care interventions to improve mood, QOL, and EOL care, and the surprise question is a practical method to identify those with unmet needs.

Keywords: advance care planning; depression; hospice care; inpatients; palliative care; quality of life.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Cohort Studies
  • Depressive Disorder / psychology*
  • Female
  • Hematologic Neoplasms / nursing*
  • Humans
  • Inpatients / psychology*
  • Male
  • Middle Aged
  • Needs Assessment / statistics & numerical data*
  • Neoplasms / nursing*
  • North Carolina
  • Palliative Care / psychology*
  • Prospective Studies
  • Quality of Life / psychology*