Adding a second surprise question triggers general practitioners to increase the thoroughness of palliative care planning: results of a pilot RCT with cage vignettes.
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ABSTRACT: In our aging society, palliative care should be a standard component of health care. However, currently it is only provided to a small proportion of patients, mostly to those with cancer, and restricted to the terminal phase. Many general practitioners (GPs) say that one of their most significant challenges is to assess the right moment to start anticipatory palliative care. The "Surprise Question" (SQ1: "Would I be surprised if this patient were to die in the next 12 months"?), if answered with "no", is an easy tool to apply in identifying patients in need of palliative care. However, this tool has a low specificity. Therefore, the aim of our pilot study was to determine if adding a second, more specific "Surprise Question" (SQ2: "Would I be surprised if this patient is still alive after 12 months"?) in case SQ1 is answered in the negative, prompts GPs to plan for anticipatory palliative care.By randomization, 28 GPs in the south-eastern part of the Netherlands were allocated to three different groups. They all received a questionnaire with four vignettes, respectively representing patients with advanced organ failure (A), end stage cancer (B), frailty (C), and recently diagnosed cancer (D). GPs in the first group did not receive additional information, the second group received SQ1 after each vignette, and the third group received SQ1 and SQ2 after each vignette. We rated their answers based on essential components of palliative care (here called RADIANT score).GPs in group 3 gave higher RADIANT scores to those vignettes in which they would be surprised if the patients were still alive after 12 months. In all groups, vignette B had the highest mean RADIANT score, followed by vignettes A and C, and the lowest on vignette D. Seventy-one percent of GPs in groups 2 and 3 considered SQ1 a helpful tool, and 75% considered SQ2 helpful.This innovative pilot study indicates that the majority of GPs think SQ2 is a helpful additional tool. The combination of the two "Surprise Questions" encourages GPs to make more specific plans for anticipatory palliative care.
Adding a second surprise question triggers general practitioners to increase the thoroughness of palliative care planning: results of a pilot RCT with cage vignettes.
<h4>Background</h4>In our aging society, palliative care should be a standard component of health care. However, currently it is only provided to a small proportion of patients, mostly to those with cancer, and restricted to the terminal phase. Many general practitioners (GPs) say that one of their most significant challenges is to assess the right moment to start anticipatory palliative care. The "Surprise Question" (SQ1: "Would I be surprised if this patient were to die in the next 12 months"? ...[more]
Project description:BackgroundThe Surprise Question ('Would I be surprised if this patient died within 12 months?') identifies patients in the last year of life. It is unclear if 'surprised' means the same for each clinician, and whether their responses are internally consistent.AimTo determine the consistency with which the Surprise Question is used.DesignA cross-sectional online study of participants located in Belgium, Germany, Italy, The Netherlands, Switzerland and UK. Participants completed 20 hypothetical patient summaries ('vignettes'). Primary outcome measure: continuous estimate of probability of death within 12 months (0% [certain survival]-100% [certain death]). A threshold (probability estimate above which Surprise Question responses were consistently 'no') and an inconsistency range (range of probability estimates where respondents vacillated between responses) were calculated. Univariable and multivariable linear regression explored differences in consistency. Trial registration: NCT03697213.Setting/participantsRegistered General Practitioners (GPs). Of the 307 GPs who started the study, 250 completed 15 or more vignettes.ResultsParticipants had a consistency threshold of 49.8% (SD 22.7) and inconsistency range of 17% (SD 22.4). Italy had a significantly higher threshold than other countries (p = 0.002). There was also a difference in threshold levels depending on age of clinician, for every yearly increase, participants had a higher threshold. There was no difference in inconsistency between countries (p = 0.53).ConclusionsThere is variation between clinicians regarding the use of the Surprise Question. Over half of GPs were not internally consistent in their responses to the Surprise Question. Future research with standardised terms and real patients is warranted.
Project description: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.
Project description:BackgroundThe Surprise Question ("Would I be surprised if this patient were to die within the next 12 months?") is widely used to identify palliative patients, though with low predictive value. To improve timely identification of palliative care needs, we propose an additional Surprise Question ("Would I be surprised if this patient is still alive after 12 months?") if the original Surprise Question is answered with "no." The combination of the two questions is called the Double Surprise Question.AimTo examine the prognostic accuracy of the Double Surprise Question in outpatients with cancer.DesignA prospective study.ParticipantsTwelve medical oncologists completed the Double Surprise Question for 379 patients.ResultsIn group 1 (original Surprise Question "yes": surprised if dead) 92.1% (176/191) of the patients were still alive after 1 year, in group 2a (original and additional Surprise Question "no": not surprised if dead and not surprised if alive) 60.0% (63/105), and in group 2b (original Surprise Question "no," additional Surprise Question "yes": surprised if alive) 26.5% (22/83) (p < 0.0001). The positive predictive value increased by using the Double Surprise Question; 74% (61/83) vs 55% (103/188). Anticipatory palliative care provision and Advance Care Planning items were most often documented in group 2b.ConclusionsThe Double Surprise Question is a promising tool to more accurately identify outpatients with cancer at risk of dying within 1 year, and therefore, those in need of palliative care. Studies should reveal whether the implementation of the Double Surprise Question leads to more timely palliative care.
Project description:ObjectivesIn oncology and palliative care, patient question prompt lists (QPLs) with sample questions for patient and family increased patients' involvement in decision-making and improved outcomes if physicians actively endorsed asking questions. Therefore, we aim to evaluate practitioners' perceptions of acceptability and possible use of a QPL about palliative and end-of-life care in dementia.DesignMixed-methods evaluation study of a QPL developed with family caregivers and experts comprising a survey and interviews with practitioners.SettingTwo academic medical training centres for primary and long-term care in the Netherlands.ParticipantsPractitioners (n=66; 73% woman; mean of 21 (SD 11) years of experience) who were mostly general practitioners and elderly care physicians.OutcomesThe main survey outcome was acceptability measured with a 15-75 acceptability scale with ≥45 meaning 'acceptable'.ResultsThe survey response rate was 21% (66 of 320 participated). The QPL was regarded as acceptable (mean 51, SD 10) but 64% felt it was too long. Thirty-five per cent would want training to be able to answer the questions. Those who felt unable to answer (31%) found the QPL less acceptable (mean 46 vs 54 for others; p=0.015). We identified three themes from nine interviews: (1) enhancing conversations through discussing difficult topics, (2) proactively engaging in end-of-life conversations and (3) possible implementation.ConclusionAcceptability of the QPL was adequate, but physicians feeling confident to be able to address questions about end-of-life care is crucial when implementing it in practice, and may require training. To facilitate discussions of advance care planning and palliative care, families and persons with dementia should also be empowered to access the QPL themselves.
Project description:ObjectiveWe compared the performance of two tools to help general practitioners (GPs) identify patients in need of palliative care: the Surprise Question (SQ) and the Supportive and Palliative Care Indicators Tool (SPICT).MethodsProspective cohort study in two general practices in the Netherlands with a size of 3640 patients. At the start of the study the GPs selected patients by heart using the SQ. The SPICT was translated into a digital search in electronic patient records. The GPs then selected patients from the list thus created. Afterwards the GPs were interviewed about their experiences. The following year a record was kept of all the patients deceased in both practices. We analysed the characteristics of the patients selected and the deceased. We calculated the performance characteristics concerning predicting 1-year mortality.ResultsThe sensitivity of the SQ was 50%, of the SPICT 57%; the specificity 99% and 98%. When analysing the deceased (n = 36), 10 died relatively suddenly and arguably could not be identified. Leaving out these 10, the sensitivity of the SQ became 69%, of the SPICT 81%. The GPs found the performance of the digital search quite time consuming.ConclusionThe SPICT seems to be better in identifying patients in need of palliative care than the SQ. It is also more time consuming than the SQ. However, as the digital search can be performed more easily after it has been done for the first time, initial investments can repay themselves.
Project description:BackgroundOlder adults with advanced non-dialysis-dependent chronic kidney disease (NDD-CKD) face a high risk of hospitalization and related adverse events.MethodsThis prospective cohort study followed nephrology clinic patients ≥60 years old with NDD-CKD stages 4-5. After an eligible patient's office visit, study staff asked the patient's provider to rate the patient's risk of death within the next year using the surprise question ("Would you be surprised if this patient died in the next 12 months?") with a 5-point Likert scale response (1, "definitely not surprised" to 5, "very surprised"). We used a statewide database to ascertain hospitalization during follow-up.ResultsThere were 488 patients (median age 72 years, 51% female, 17% black) with median estimated glomerular filtration rate 22 mL/min/1.73 m2. Over a median follow-up of 2.1 years, the rates of hospitalization per 100 person-years in the respective response groups were 41 (95% confidence interval [CI]: 34-50), "very surprised"; 65 (95% CI: 55-76), "surprised"; 98 (95% CI: 85-113), "neutral"; 125 (95% CI: 107-144), "not surprised"; and 120 (95% CI: 94-151), "definitely not surprised." In a fully adjusted cumulative probability ordinal regression model for proportion of follow-up time spent hospitalized, patients whose providers indicated that they would be "definitely not surprised" if they died spent a greater proportion of follow-up time hospitalized compared with those whose providers indicated that they would be "very surprised" (odds ratio 2.4, 95% CI: 1.0-5.7). There was a similar association for time to first hospitalization.ConclusionNephrology providers' responses to the surprise question for older patients with advanced NDD-CKD were independently associated with proportion of future time spent hospitalized and time to first hospitalization. Additional studies should examine how to use this information to provide patients with anticipatory guidance on their possible clinical trajectory and to target potentially preventable hospitalizations.
Project description:BackgroundPrognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question ("Would you be surprised if this patient died in the next 12 months?") is a tool to assist in prognostication. However, it has not been studied in non-dialysis-dependent CKD and its reliability is unknown.Study designObservational study.Setting & participants388 patients at least 60 years of age with non-dialysis-dependent CKD stages 4 to 5 who were seen at an outpatient nephrology clinic.PredictorTrinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response.OutcomesMortality, test-retest reliability, and blinded inter-rater reliability.MeasurementsBaseline comorbid conditions, Charlson Comorbidity Index, cause of CKD, and baseline laboratory values (ie, serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin).ResultsMedian patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded Yes, Neutral, and No for 202 (52%), 80 (21%), and 106 (27%) patients, respectively. About 5%, 15%, and 27% of Yes, Neutral, and No patients died, respectively (P<0.001). Trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42-0.72), and test-retest reliability was 0.63 (95% CI, 0.54-0.72). The trinary surprise question No response had sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had sensitivity of 66% (95% CI, 49%-80%; P=0.3 vs trinary), but lower specificity of 68% (95% CI, 63%-73%; P=0.02 vs trinary).LimitationsSingle center, small number of deaths.ConclusionsThe surprise question associates with mortality in CKD stages 4 to 5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non-dialysis-dependent CKD.
Project description:BackgroundTraining in palliative care is frequently requested by health care professionals. However, little is known in detail about the subject matters and the educational preferences of physicians and staff or assistant nurses in this field.MethodsAll 897 registered GPs and all 933 registered home care nurses in the district of Steiermark/Austria were sent postal questionnaires.ResultsResults from 546 (30%) respondents revealed that GPs prefer evening courses and weekend seminars, whereas staff and assistant nurses prefer one-day courses. Multidisciplinary sessions are preferred by almost 80% of all professional groups. GPs preferred multi disciplinary groups most frequently when addressing psychosocial needs (88.8%) and ethical questions (85.8%). Staff and assistant nurses preferred multidisciplinary groups most frequently in the area of pain management (88%) and opted for multi disciplinary learning to a significantly higher extent than GPs (69%; p < 0.01). Those topics were ranked first which are not only deepening, but supplementing the professional training. On average, GPs were willing to spend a maximum amount of euro 400 per year for training seminars in palliative care, whereas nurses would spend approximately euro 190 for such classes.The results provide a detailed analysis of the preferences of GPs and nurses and offer guidance for the organisation of training seminars in palliative care.ConclusionsMedical and nursing education programs often pursue separate paths. Yet our findings indicate that in palliative care multidisciplinary training seminars are favoured by both, doctors and nurses. Also, both groups prefer topics that are not only deepening, but supplementing their professional knowledge.
Project description:Purpose of Review: A significant number of pregnancies are complicated by a fetus with a life-limiting diagnosis. As diagnoses are made earlier in the pregnancy, families experience anticipatory grief and are faced with navigating goals of care for a baby that has yet to be born. With the support of the care team, families can begin to grieve, plan, and make meaningful memories during the duration of the pregnancy, the birth of their baby, and life of the child. Creating a palliative care birth plan, which expands beyond the traditional concept for delivery planning to include prenatal, perinatal, and neonatal care has become an important method for parents to process the diagnosis, for parents to document their wishes, and for members of the care team to communicate with the goal of supporting and enhancing the experience of the family. This articles reviews recent and relevant literature on the importance of birth planning and the role of perinatal palliative care when a life-limiting fetal diagnosis is made. Recent Findings: The process of birth planning is an important component of perinatal palliative care. Through this process, families can express their fears, values, hopes, and wishes. It also offers an opportunity for providers to communicate these wishes for the remainder of the pregnancy, the delivery, birth, and time afterwards. This has been demonstrated to decrease maternal stress and promote family centered care. Summary: Perinatal birth planning is an important component of perinatal palliative care when a fetus has a life-limiting diagnosis. The process of birth planning can be supportive and therapeutic as well as an important communication tool. With multiple practices and designs of perinatal palliative care programs, there are no standard tools even though important components have been identified. Ultimately, the strategies outlined here can be used as advance care planning tools.
Project description:The addition of a citizenship question to the 2020 census could affect the self-response rate, a key driver of the cost and quality of a census. We find that citizenship question response patterns in the American Community Survey (ACS) suggest that it is a sensitive question when asked about administrative record noncitizens but not when asked about administrative record citizens. ACS respondents who were administrative record noncitizens in 2017 frequently choose to skip the question or answer that the person is a citizen. We predict the effect on self-response to the entire survey by comparing mail response rates in the 2010 ACS, which included a citizenship question, with those of the 2010 census, which did not have a citizenship question, among households in both surveys. We compare the actual ACS-census difference in response rates for households that may contain noncitizens (more sensitive to the question) with the difference for households containing only U.S. citizens. We estimate that the addition of a citizenship question will have an 8.0 percentage point larger effect on self-response rates in households that may have noncitizens relative to those with only U.S. citizens. Assuming that the citizenship question does not affect unit self-response in all-citizen households and applying the 8.0 percentage point drop to the 28.1 % of housing units potentially having at least one noncitizen would predict an overall 2.2 percentage point drop in self-response in the 2020 census, increasing costs and reducing the quality of the population count.
