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The “Surprise Question”

When caring for someone with advanced disease, many physicians and other health professionals ask the question “Is this patient palliative yet?”. This is the wrong question to ask, especially since most health professionals and the public continue to unfortunately equate palliative care with only the last days or weeks of life — terminal or EOL phase. (See article: Palliative Care: Early is Better than Late).

A much more appropriate question is “Could this patient benefit from a palliative care approach?” Such an approach could be done earlier and alongside treatments to control the disease, such as chemotherapy or treatments to control advanced heart failure or COPD. Palliative care could therefore already start when a patient still has many months and even longer to live, particularly if they are experiencing issues, such as uncontrolled symptoms or psychological distress, that affect their quality of life.

The “surprise question” was developed by researchers in the United States to bring to clinicians’ attention the need to activate palliative care earlier. Clinicians are encouraged to ask the following question when they have a patient with a progressive incurable illness: “Will I be surprised if this patient dies in the next 6 to 12 months?” If the answer is “No, I will not be surprised”, then a palliative care approach needs to be activated in that patient. A palliative care approach refers to some basic interventions that do not necessarily require a specialist palliative care team and includes goals of care discussions, symptom assessment and management, assessment of needs across the four domains (physical, psychological, social, spiritual/religious/existential), assessment of functional status, an assessment of overall quality of life and advance care planning.

Some prognostic indicator guidelines are available. One of the most commonly used is the GSF Prognostic Indicators Guide from the Gold Standards Framework Program based in the United Kingdom. The GSF Indicator guide provides general indicators and disease specific indicators that help answer the surprise question. In a recent publication in the CMAJ, You and colleagues provide another useful framework first developed by Walter et al. Readers are encouraged to read this¹.

The surprise question has been used successfully in family medicine clinics in the Niagara region² and is used in over 1200 clinics in the United Kingdom as part of the Gold Standards Framework Program³. In the GSF framework, family medicine clinics also create a registry of patients who could benefit from a palliative care approach (i.e. when the answer to the question is “No, I will not be surprised if this patient dies in the next 6 to 12 months”).

Note that answering “No, I will not be surprised” does not mean that a family physician or other specialist has to refer the patient or transfer the patient’s care to a specialist palliative care team. This may only be required if there are very complex needs or if the family physician or specialist wishes to confirm or discuss a care plan. In most cases, the family physician or specialist may provide palliative care alongside other treatments to control the disease as best possible.

The surprise question is not meant to restrict palliative care to the last year of life, but promotes activating palliative care earlier than only the last days or weeks. It does not mean that clinicians are accurate at predicting life expectancy, but it does bring to the clinician’s attention the need for increased vigilance, ensuring that palliative care needs are addressed earlier and that we are not waiting for the last days or weeks.

Dr. José Pereira
Head and Professor, Division of Palliative Care, Department of Medicine, University of Calgary.
Medical Chief, Department of Palliative Medicine, Bruyère Continuing Care.
Medical Chief, Division of Palliative Care, Department of Medicine, The Ottawa Hospital.
Medical Lead, Champlain Regional Hospice Palliative Care Program.


¹ You JJ, et al. Just ask: discussing goals of care with patients in hospital with serious illness. CMAJ 2013 July 2013 DOI:10.1503/cmaj.121274
² Marshal D, et al. Enhancing family physician capacity to deliver quality palliative home care: An end-of-life, shared-care model Can Fam Physician 2008;54:1703.e1-7
³ Dale J, et al. A national facilitation project to improve primary palliative care: impact of the Gold Standards Framework on process and self-ratings of quality. Qual Saf Health Care 2009;18:174-180. Doc10.1136/qshc.2007.024836

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