Background: Prognostication of survival in advanced cancer patients has been challenging and contributes to poor illness understanding. Prognostic disagreement occurs even amongst providers and is a less studied phenomenon. We introduced the Surprise Question (SQ), “Would I be surprised if this patient died in the next 1 year, 6 months, and 1 month?”, at multidisciplinary rounds to see if introduction of this prognostic prompt resulted in increased utilization of palliative care.
Methods: The SQ was asked between March 2016 – May 2016 on the Medical Oncology service at a tertiary academic medical center. The question was asked three times a week at Multidisciplinary Rounds (MDR) which are attended by the Hospital Medicine provider, Palliative Care provider, and consulting Oncologist. Primary Oncologists and bedside nurses were also asked the SQ. We looked for changes in referral rates to outpatient palliative care clinic, community based palliative care clinic, inpatient palliative care consults, and hospice 3 months prior to, during, and 3 months post intervention.
Results: The SQ was asked for 323 admissions during the intervention period. Palliative care utilization pre-, during, and post-intervention was 30.1%, 31.1%, and 30.4%, respectively. An optimistic answer was defined as answering “Yes” to the SQ and a less optimistic answer was defined as answering “No.” When answering the 1 year SQ, nurses were significantly more optimistic than Hospital Medicine providers, Palliative Care providers, and Oncologists (42% vs. 16%, p<0.0001; 21% vs. 0%, p=0.008; 38% vs. 26%, p=0.04). Oncologists were significantly more optimistic than Hospital Medicine providers (27% vs. 17%, p=0.03) for the 1 year SQ as well as the 6 and 1-month SQ. Hospital Medicine physicians (p=0.01 for 6 months) and nurses (p=0.01-0.02) were less optimistic the more years they had been working. Oncologists with > 9 years of experience answered the SQ generally more optimistically. Among patients who were readmitted during the intervention period, the nurses responded differently to the 1 year and 6 month SQ about half the time between admissions. The answer to the SQ was not influenced by length of stay.
Conclusions: Regular prognostication of the cancer patient in an inpatient medical setting does not increase referrals to inpatient or outpatient palliative care or hospice. Medical Oncologists were significantly more optimistic than Hospital Medicine providers. Increased years in clinical practice impacted views of prognosis differently for Hospital Medicine physicians and nurses when compared to Oncologists. Our study suggests that the introduction of a prognostic tool alone will be insufficient to increase specialty palliative care utilization for cancer patients. Continued research is needed to better utilize prognostic tools to identify patients who may benefit from a palliative approach.
To cite this abstract:Singh, S; Lee, D; Rodriguez, A; Min, SJ; Fischer, S . USEFULNESS OF THE SURPRISE QUESTION ON AN INPATIENT ONCOLOGY SERVICE. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 216. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/usefulness-of-the-surprise-question-on-an-inpatient-oncology-service/. Accessed September 16, 2019.