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. 2018 Jun;21(6):789-795.
doi: 10.1089/jpm.2017.0509. Epub 2018 Feb 8.

The Surprise Question and Identification of Palliative Care Needs among Hospitalized Patients with Advanced Hematologic or Solid Malignancies

Kathryn Elizabeth Hudson  1 , Steven Paul Wolf  2 , Gregory P Samsa  2 , Arif H Kamal  3 , Amy Pickar Abernethy  4   5 , Thomas William LeBlanc  3   6
Affiliations

The Surprise Question and Identification of Palliative Care Needs among Hospitalized Patients with Advanced Hematologic or Solid Malignancies

Kathryn Elizabeth Hudson et al. J Palliat Med. 2018 Jun.

Abstract

Background: Little is known about quality of life (QOL), depression, and end-of-life (EOL) outcomes among hospitalized patients with advanced cancer.

Objective: To assess whether the surprise question identifies inpatients with advanced cancer likely to have unmet palliative care needs.

Design: Prospective cohort study and long-term follow-up.

Setting/subjects: From 2008 to 2010, we enrolled 150 inpatients at Duke University with stage III/IV solid tumors or lymphoma/acute leukemia and whose physician would not be surprised if they died in less than one year.

Measurements: We assessed QOL (FACT-G), mood (brief CES-D), and EOL outcomes.

Results: Mean FACT-G score was quite low (66.9; SD 11). Forty-five patients (30%) had a brief CES-D score of ≥4 indicating a high likelihood of depression. In multivariate analyses, better QOL was associated with less depression (OR 0.91, p < 0.0001), controlling for tumor type, education, and spiritual well-being. Physicians correctly estimated death within one year in 101 (69%) cases, yet only 37 patients (25%) used hospice, and 4 (2.7%) received a palliative care consult; 89 (60.5%) had a do-not-resuscitate order, and 63 (43%) died in the hospital.

Conclusions: The surprise question identifies inpatients with advanced solid or hematologic cancers having poor QOL and frequent depressive symptoms. Although physicians expected death within a year, EOL quality outcomes were poor. Hospitalized patients with advanced cancer may benefit from palliative care interventions to improve mood, QOL, and EOL care, and the surprise question is a practical method to identify those with unmet needs.

Keywords: advance care planning; depression; hospice care; inpatients; palliative care; quality of life.

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Conflict of interest statement

Dr. Hudson's work was supported by Duke University's Hematology T32 Training grant and NIH Ruth L. Kirschstein NRSA Institutional Research Training Grant, 5 T32 HL 7057-38. Dr. Abernethy is an employee of Flatiron Health, Inc. Dr. Kamal is funded by the Agency for Healthcare Research and Quality (K08 HS023681-A1). Dr. LeBlanc's research is supported by a Sojourns Scholar Award from the Cambia Health Foundation and a Mentored Research Scholar Grant from the American Cancer Society. Duke Biostatistics Core's support of this project was made possible by Grant Number UL1TR001117 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCATS or NIH. None of the authors have relevant conflicts of interest to report.

This article expresses the views of the authors only and does not represent an official position of Duke University.

Comment in

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