# The ‘Surprise’ Question in Haemato-Oncology: The Estimating Physician and Time to Death Reduce the Prognostic Uncertainty—An Observational Study

## TL;DR

This study shows that the 'Surprise' Question, used to identify patients who may benefit from palliative care, is less effective for those with blood cancers compared to solid tumors, and its accuracy depends more on the physician than on patient factors.

## Contribution

The first validation of the 'Surprise' Question in haemato-oncology outpatients, revealing its limited sensitivity for haematological malignancies and physician-dependent accuracy.

## Key findings

- The 'Surprise' Question had low sensitivity (0.23) for haematological malignancies, missing 77% of patients in their last year of life.
- Physician factors, not patient characteristics, were the main influence on the accuracy of the 'Surprise' Question.
- The tool's predictive value for survivors was high (94%), preventing premature palliative care for those with better prognoses.

## Abstract

The ‘Surprise’ Question, an intuitive instrument used to estimate a patient’s survival, has been tested in different entities and settings. Despite the limitations in its accuracy, it has been recommended for the early integration of palliative care because the tool is suitable for triggering reflection on the patient’s overall situation. For the first time, we validated the ‘Surprise’ Question in haemato-oncology outpatients. The test sensitivity was poor for haematological malignancies (0.23) compared to solid tumours (0.58), i.e., many haematology patients in their last year of life were not identified (77%), but the specificity and predictive value for the survivors were safe, preventing patients with a better prognosis from receiving palliative care too early (94%). Notably, the accuracy of the ‘Surprise’ Question depended on the estimating physician rather than on objective prognostic factors. The clinical practice of using the ‘Surprise’ Question for screening for patients with limited survival may miss a substantial proportion of patients with haematological malignancies who may benefit from palliative care. The physician factors associated with skilful prognostication should be further explored.

Background/Objectives: Patients with haematological malignancies less frequently receive specialist palliative care, although they may have unmet needs for symptom control and alleviating psychosocial and existential burdens. The ‘Surprise’ Question, ‘Would you be surprised if this patient died in the next 12 months?’, helps physicians to identify patients who may benefit from palliative care. We tested the influencing factors of the feasibility of the ‘Surprise’ Question in haemato-oncology outpatients. Methods: We performed a prospective cohort study comparing patients with solid tumours and haematological malignancies. All the patients in the haemato-oncology outpatient clinics of a German university hospital were screened by haemato-oncologists using the ‘Surprise’ Question. Results: A survival analysis was performed on 672 patients (76% with haematological malignancies) at 3 and 12 months. Within one year, 110 patients (16%) died. Of these, 30/52 (58%) were patients with solid tumours, but only 12/53 (23%) patients with haematological malignancies were identified in advance by the ‘Surprise’ Question, which reflects ambiguous test sensitivity. A substantial part of the haematology patients in their last year of life were not identified (77%). The match between the survival estimates and actual outcomes was fair (Cohen’s kappa 0.37). The proximity from prediction to event and the estimating physician rather than patient characteristics influenced the accuracy of the instrument. Conclusions: For the first time, the feasibility of the ‘Surprise’ Question in haematology outpatients was proven. Factors that would improve haemato-oncologists’ clinical intuition should be further explored to facilitate timely conversations about issues important to patients nearing the end of life.