Surprise Question and performance status indicate urgency of palliative care needs 101 Table 4. Predictors of approaching death in 245 patients with advanced cancer visiting the emergency department Predictors Univariable analysis Multivariable analysis HR 95% CI P-value HR 95% CI P-value Surprise Question 2.06 1.44-2.94 <0.0001 3.16 1.75-5.70 <0.0001 Local anti-cancer treatment in preceding 3 months 1.07 0.80-1.42 0.65 NS Systemic anti-cancer treatment in preceding 3 months 0.69 0.52-0.92 0.010 NS ≥1 ED-visit in the preceding 6 months 1.31 1.00-1.71 0.048 1.70 1.17-2.47 0.006 Home care 1.48 1.02-2.15 0.041 NS LST discussed and documented 1.66 1.24-2.23 0.001 NS ECOG 3-4 1.99 1.53-2.61 <0.0001 2.09 1.44-3.05 <0.0001 Neurologic deterioration or delirium 12.39 1.66-92.55 0.014 11.33 1.42-90.68 0.022 Dyspnoea 1.51 1.04-2.19 0.029 NS Referral for new symptom 0.66 0.49-0.88 0.005 NS Referral for acute symptom 0.75 0.56-1.01 0.054 NS Abbreviations: HR: hazard ratio; CI: confidence interval; NS: not significant; ED: emergency department; LST: life-sustaining treatment; ECOG: Eastern Cooperative Oncology Group DISCUSSION In our study, the Surprise Question (SQ) identified patients with advanced cancer at the ED with a poor performance status and multiple symptoms. The SQ had a high sensitivity (89.1%) for death within one year for patients in whom attending physicians would not be surprised (NS-patients). NS-patients had a HR of 2.1 for approaching death compared to patients in whom attending physicians would be surprised (S-patients). However, with a Harrell’s c-index of 0.56, the SQ discriminates poorly between patients who died within one year or not. Besides the SQ, other predictors for approaching death in patients with advanced cancer visiting the ED were: recent multiple ED-visits, a poor performance status and neurologic deterioration or delirium. In NS-patients, only ECOG performance status 3-4 was predictive of approaching death (HR 2.5). Addition of ECOG 3-4 to the SQ improved specificity (92.3%) at cost of sensitivity (40.1%) in screening for death within one year. Our study shows that all patients with advanced cancer visiting the ED in the palliative phase of disease have a limited life-expectancy: median survival was three months. This explains our findings of the high sensitivity (89.1%) but poor discriminative ability (c-index 0.56) of the SQ for death within one year after the ED-visit. Our results are in 5
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