How Robust Is the ‘Surprise Question' in Predicting Short-Term Mortality Risk in Haemodialysis Patients

Background/Aims: The ‘surprise question' (SQ) may aid timely identification of patients with end-of-life care needs. We assessed its prognostic value and variability among clinicians caring for a cohort of haemodialysis (HD) patients. Methods: Clinicians (29 nurses and 6 nephrologists) in each of our 3 HD units were asked to pose the SQ concerning all patients dialysing in their unit. There were 344 patients, 116 in Unit 1, 132 in Unit 2 and 96 in Unit 3. Results: An adverse SQ response: ‘I would not be surprised if this patient were to die in the next 12 months' was reported by individual clinicians for between 6 and 43% of patients (mean 24 ± 9%). Nephrologists responded adversely for more patients than nurses did. Fifty-two patients died during the 12 months of follow-up. There were wide variations between clinicians in the predictive power of SQ responses. Mean odds ratios were significantly higher for nephrologists than for nurses. SQ responses of 49% of clinicians improved baseline models of 12-month mortality, more so for nephrologists (67%) than for senior nurses (50%) and nurses of lesser seniority (36%). Unit performance differed significantly. Agreements between clinicians on SQ responses improved the positive predictive value, i.e. the more clinicians agreed on an adverse response, the greater its predictive power. Conclusion: SQ provides a unique contribution to the prediction of short-term prognosis in HD patients, though predictive power varies with clinical discipline, seniority and clinical setting. Agreements between clinicians on adverse responses may have clinical utility.