Surprise Question and performance status indicate urgency of palliative care needs 99 Table 2. Visit and follow-up characteristics of 245 patients with advanced cancer visiting the emergency department Total n=245 SQ = no n=203 SQ = yes n=42 P-value Diagnostic imaging, n (%) 148 (60.4) 119 (58.6) 29 (69.0) 0.65 Laboratory testing, n (%) 201 (82.0) 168 (82.8) 33 (78.6) 0.027 Limitations on LSTs discussed and documented, n (%) 104 (42.4) 102 (50.2) 2 (4.8) <0.0001 Time spent at the ED in hours (IQ-range) 3:31 (2:37-4:29) 3:30 (2:37-4:29) 3:34 (2:32-4:49) 0.51 Hospitalization after ED-visit, n (%) 186 (75.9) 157 (77.3) 29 (69.0) 0.37 Observed survival after ED-visit in months, median (IQ-range) 3 (1-11) 3 (1-8) 9 (3-28) <0.0001 Place of death, n (%) 0.50 Home 89 (36.3) 77 (37.9) 12 (28.6) Hospice 26 (10.6) 25 (12.3) 1 (2.4) Hospital ward 44 (18.0) 37 (18.2) 7 (16.7) Intensive Care Unit or ED 4 (1.6) 2 (1.0) 2 (4.8) List of abbreviations: LSTs: life-sustaining treatments; ED: emergency department Prognostic value of the SQ Table 3 lists the test characteristics of the SQ for death <1 year: sensitivity 89.1% (95%CI 83.9%-93.1%), specificity 40.4% (95%CI 27.0%-54.9%), PPV 84.7% (95%CI 81.5%-87.5%) and NPV 50.0% (95%CI 37.3%-62.8%). Harrell’s c-index for the SQ to discriminate patients who died <1 year was 0.56 (95%CI 0.53-0.60). Addition of other predictors to the SQ Significant univariable predictors of approaching death are presented in Table 4. The following predictors were significant in multivariable analyses: NS-answer to the SQ (HR 3.16); ≥1 ED-visit in the preceding 6 months (HR 1.70); ECOG performance status 3-4 (HR 2.10); neurologic deterioration or delirium at the ED (HR 11.33). Harrell’s c-index for this model including an NS-answer to the SQ was 0.66, and 0.63 without an NS-answer to the SQ. Akaike’s information criterion was better in the model with NS-answer to the SQ than in the model without NS-answer to the SQ (2136.317 versus 2154.737, p<0.0001). In a sub-analysis among the 203 NS-patients, only ECOG performance status 3-4 was predictive of approaching death (HR 2.50; 95%CI 1.88-3.33; p<0.0001). NS-patients with ECOG 3-4 had a HR of 2.45 (95%CI 1.85-3.25; p<0.0001) of approaching death compared to S-patients or NS-patients with ECOG 0-2. Median survival for NS plus ECOG 0-2 was 6.0 months (95%CI 4.7-7.3) and 1.0 month (95%CI 0.6-1.4) for NS-ECOG 3-4 patients. Test characteristics of the SQ plus ECOG 3-4 for death >1 year were: sensitivity 40.1% (95%CI 33.1%-47.4%), specificity 92.3% (95%CI 81.5%-97.9%), PPV 95.1% (95%CI 88.1%- 98.0%) and NPV 29.4% (95%CI 26.6%-32.4%; Table 5). Harrell’s c-index for the combination of SQ and ECOG 3-4 to discriminate patients who died <1 year was 0.65 (95%CI 0.62-0.69). 5
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