Journal of Palliative Medicine

“Would I be surprised if Mr. X died in the next 12 months?”

Packed with humanity this question is a powerful prognosticator according to the limited literature on the Surprise Question (heretofore aka SQ). And there is the rub. Prognostication is such a poor science that we have come to rely on a combination of intuition, experience and ahem, surprise or lack there of! Don’t get me wrong-prognostication clearly helps with planning treatment, setting goals where time may be short, focusing on the care of the patient, not the disease. However when it boils down to a hunch, a sixth sense of an individual’s impending mortality I feel that, for the entire exponential tech wherewithal of the 21^st century, we should be doing better. Or should we?

“A year is a long time for a sick person”. This is the astute observation of a lay co-worker when I tried to explain the concept of the SQ. His reactions were illuminating. “Obvious, commonsense, anybody can make this judgment,” were some thoughts he proffered. “Why not ask the nurses? They have more contact (with the patients) than doctors do. Why not split it into 3 month periods?” Rich stuff indeed! I tried to reason that the SQ does not ‘give’ someone a year to live; my conclusion is it functions as a clinician’s probabilistic guesstimation that an individual may pass any time within the next twelve months.

It got me thinking how the SQ could evolve:

• What other rich information can be gleaned from clinician perspectives on how well or otherwise their patients are doing? What is the concordance/discordance between providers?  How congruous is the clinician perspective with the patient’s?
• Can we stratify surprise e.g. mild surprise (oh, really?), moderate surprise (no, you’re kidding!)  and whopping (OMG I don’t ####ing believe it!! -drops cup) surprise?
• What can we learn from the “false positives” i.e. those individuals who died whose death did surprise you and why?
• What about those clinicians who are never surprised? At anything, because of burnout maybe or because they have an innate pessimism, cue “realism”, cue fatalism? Maybe they would be better off in a different vocation.
• Are some clinicians better than others when it comes to the SQ? What variables in a clinician’s experience determine how accurate their SQs are? Duration, fellowship training, IM vs. FM, international grad vs. American, age, previous career? PCP vs. specialist vs. Palliative care provider?
• What about asking the individual themselves? Would you be surprised if you died in the next 12 months? Why not? Would your family be surprised?
• Spouse /other family members? Is it too emotive? Can it be done gently in the context of a larger conversation about the future? Could it help an individual and their families confront and perhaps acknowledge one’s mortality and, in effect, gain ground as a useful concept when prioritizing life left?

Ultimately though what bothers me most about prognostication is…. prognostication. It gives no perspective on how well someone is living or dying or existing in the luminal space between. Let us focus on this and the surprise will take care of itself.