Chapter 5 92 ABSTRACT Background The surprise question (SQ), ‘Would I be surprised if this patient died within 1 year?’, is a simple instrument to identify patients with palliative care needs. The SQ-performance has not been evaluated in patients with advanced cancer visiting the emergency department (ED). Objective To evaluate SQ’s test characteristics and predictive value in patients with advanced cancer visiting the ED. Design Observational cohort study. Setting Patients >18y with advanced cancer in the palliative phase visiting the ED of an academic medical centre. Methods Attending physicians answered the SQ (not surprised (NS) or surprised (S)) and estimated ECOG-performance status. Disease, visit, and follow-up characteristics were retrospectively collected from charts. SQ’s sensitivity, specificity, positive (PPV) and negative predictive values (NPV) and Harrell’s c-index were calculated. Prognostic values of SQ and other variables were assessed using Cox proportional hazards models. Results Two-hundred-and-forty-five patients were included (203 NS (83%) and 42 S (17%)), median age 62 years, 48% male. Follow-up on overall survival was updated until February 2019. At ED-entry, NS-patients had worse ECOG-performance and more symptoms. At study closure, 233 patients had died (95%). Median survival was 3.0 months for NS-patients (IQ-range 1-8); 9.0 months for S-patients (IQ-range 3-28) (p<0.0001). SQ-performance for 1-year mortality: sensitivity 89%, specificity 40%, PPV 85%, NPV 50%, c-index 0.56, HR 2.1 for approaching death. ECOG 3-4 predicted death in NS-patients; addition to the SQ improved c-index (0.65); sensitivity (40%), specificity (92%), PPV (95%), NPV (29%)). Conclusions At the ED, the SQ plus ECOG 3-4 helps identifying patients with advanced cancer and a limited life-expectancy. Its use supports initiating appropriate care related to urgency of palliative care needs.
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