Surprise Question and performance status indicate urgency of palliative care needs 93 INTRODUCTION Palliative care can improve the quality of life and satisfy care needs of patients with advanced disease and family.1-3 Initiating palliative care early in the disease trajectory of advanced cancer is accepted to timely prepare them for deterioration and death.4,5 However, identification of patients with limited life-expectancy and palliative care needs is difficult. Previous studies indicate that initiation of palliative care in patients with advanced cancer can follow ‘trigger-moments’, such as visits to the emergency department (ED).6,7 Patients with advanced cancer visit the ED more often in the last year of life.8,9 Since ED-triggered palliative care effectively improves their quality of life, identifying these patients at the ED can be useful.10 Familiar screening tools identifying patients with advanced cancer having palliative care needs are the Supportive and Palliative Care Indicators Tool (SPICT), Necesidades Paliativas (NECPAL) identification tool, Golden Standards Framework – Proactive Identification Guidance (GSF-PIG), Radboud indicators for Palliative Care Needs (RADPAC) and a Centre to Advance Palliative Care’s checklist.11-15 However, these screening tools may be too elaborate for use at the ED. Moreover, prediction scores for approaching death focus on prediction of death within a few days or weeks, missing out the opportunity to initiate palliative care early.16-18 An example of a simple tool to timely identify patients with palliative care needs is the ‘Surprise Question’ (SQ): ‘Would I be surprised if this patient died within one year?’. The SQ was developed for identification of palliative care needs by estimating the probability that the patient would die from current or future physical problems in the next year.19,20 A ‘not surprised’ (NS)-answer should trigger further screening for palliative care needs.21,22 In a qualitative study, attending ED-physicians indicated that the SQ was easy to use and could influence discussions about care delivery and goals of care.23 In addition, answering the SQ is more related to ‘gut feeling’, than on stern estimation of remaining life-expectancy of a patient.24 Although the aim of the SQ is to mark patients with palliative care needs, focus in research lies on the performance of the SQ to screen for patients dying within one year.21,25 Studies have shown that the SQ is accurate in screening dialysis and heart failure patients.20,26 Cancer patients with NS-answers in oncology outpatient wards27 and general practices28 had hazard ratios (HR) of death <1yr of 7.8 and 7.0, respectively. The SQ also identifies hospitalized patients with hematologic and solid tumours with unmet palliative care needs.29 A recent meta-analysis of Downar et al.20 demonstrated that, in the overall population of patients with advanced cancer, the SQ might not be sufficient as a screening tool for death within one year. It lacked sensitivity and therefore under-estimated the number of patients with palliative care needs (sensitivity 67.0%, specificity 80.2%, positive 5
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