We thank Drs. Romo and Lynn for their letter1 regarding our article, “The ‘surprise question’ for predicting death in seriously ill patients: a systematic review and meta-analysis.” 2 We agree that the surprise question was not originally intended as a prognostic test. Our systematic review and meta-analysis was aimed at studying how the surprise question is being used, rather than how it was intended to be used.
We also agree that a poor short-term prognosis does not equate to unmet palliative care needs. However, if the surprise question is an inaccurate predictor of this poor surrogate for unmet palliative care needs, it does not follow that the surprise question would be an accurate predictor of these unmet needs. Our review did not identify studies of the accuracy of the surprise question for identifying unmet palliative needs, and a more recent study suggests that the surprise question probably identifies patients similar to those found by other systems that incorporate general and disease-specific triggers, such as the Necesidades Paliativas (NECPAL) tool.3
Romo and Lynn highlight the potential of the surprise question to identify unmet needs in patients with noncancer illness, where those needs may exist for years before death. But even if the surprise question accurately predicted palliative care needs, there are other important barriers to the use of the surprise question as a universal trigger for a palliative approach. Multiple studies of the surprise question in the United Kingdom suggest that primary care providers are unwilling to use it in the noncancer population.4–7 A qualitative study concluded that “GPs did not appear to include the surprise question within their usual practice and expressed concerns regarding its use to facilitate discussion of advance care plans. These concerns highlighted the subjective nature of the surprise question and potential barriers to conducting discussions of preferences for future care.”4
The surprise question has been a widely studied tool for many years, but we must acknowledge that the published data highlight poor prognostic performance and other important barriers that will reduce the real-world effectiveness of any intervention that relies on it.
Footnotes
Competing interests: None declared.