The 'Surprise'-Question in Haemato-Oncology: The Estimating Physician and Time to Death Reduce Prognostic Uncertainty – An Observational Study

Background/Objectives: Patients with haematological malignancies use less frequently specialized palliative care, although they may have unmet needs for symptom control, psychosocial and existential burden. The ‘Surprise’-Question “Would you be surprised if this patient died in the next 12 months” helps physicians identifying patients who may benefit from palliative care. We tested influencing factors of the feasibility of the ‘Surprise’-Question in haemato-oncology outpatients. Methods: We performed a prospective cohort study comparing patients with solid tumours and haematological malignancies. All patients in the haemato-oncology outpatient clinics of a German university hospital were screened by haemato-oncologists with the ‘Surprise’-Question. Results: Survival analysis was performed in 672 patients (76% haematological malignancies) at 3 and 12 months. Within one year 110 patients (16%) died. Of these, 30/ 52 (58%) patients with solid tumours, but only 12/ 53 (23%) with haematological malignancies were identified in advance by the ‘Surprise’-Question, which reflects ambiguous test sensitivity. A substantial part of haematology patients in their last year of life were not identified (77%). The match of survival estimates and actual outcome was fair (Cohen’s kappa 0.37). The proximity from prediction to event and the estimating physician rather than patient characteristics influenced the accuracy of the instrument. Conclusions: For the first time the feasibility of the ‘Surprise’-Question in haematology outpatients was proven. Factors improving the haemato-oncologists’ clinical intuition should be further explored to facilitate timely conversation about issues important to patients nearing the end of life.