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. 2019 Mar;6(1):70-76.
doi: 10.15441/ceem.17.293. Epub 2019 Mar 28.

Prognostic Value of a Modified Surprise Question Designed for Use in the Emergency Department Setting

Free PMC article

Prognostic Value of a Modified Surprise Question Designed for Use in the Emergency Department Setting

Samir A Haydar et al. Clin Exp Emerg Med. .
Free PMC article


Objective: Few reliable and valid prognostic tools are available to help emergency physicians identify patients who might benefit from early palliative approaches. We sought to determine if responses to a modified version of the surprise question, "Would you be surprised if this patient died in the next 30 days" could predict in-hospital mortality and resource utilization for hospitalized emergency department patients.

Methods: For this observational study, emergency physicians responded to the modified surprise question with each admission over a five-month study period. Logistic regression analyses were completed and standard test characteristics evaluated.

Results: 6,122 visits were evaluated. Emergency physicians responded negatively to the modified surprise question in 918 (15.1%). Test characteristics for in-hospital mortality were: sensitivity 32%, specificity 85%, positive predictive value 6%, negative predictive value 98%. The risk of intensive care unit use (relative risk [RR], 1.87; 95% confidence interval [CI], 1.45 to 2.40), use of 'comfort measures' orders (RR, 3.43; 95% CI, 2.81 to 4.18), palliative-care consultation (RR, 3.06; 95% CI, 2.62 to 3.56), and in-hospital mortality (RR, 2.18; 95% CI, 1.72 to 2.76) were greater for patients with negative responses.

Conclusion: The modified surprise question is a simple trigger for palliative care needs, accurately identifying those at greater risk for in-hospital mortality and resource utilization. With a negative predictive value of 98%, affirmative responses to the modified surprise question provide reassurance that in-hospital death is unlikely.

Keywords: Emergency service, hospital; Palliative medicine; Surprise question; Terminal care.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

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