• Dana Tripp, Jaclyn Janis, Benjamin Jarrett, F Lee Lucas, Tania D Strout, HanPaul K JPKJTufts University School of Medicine, Boston, MA, USA.Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA., Isabella Stumpf, and Rebecca N Hutchinson.
• Tufts University School of Medicine, Boston, MA, USA.
• J Gen Intern Med. 2021 Sep 1; 36 (9): 2656-2662.

BackgroundPatients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP.ObjectiveTo assess how well the SQ predicts mortality and prompts ACP for COPD patients.DesignRetrospective cohort study.SubjectsPatients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018.Main MeasuresEmergency department (ED) and inpatient clinicians answered, "Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?" The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-of-care conversation, change in code status, or completion of ACP document).Key ResultsThe 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39-4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67, 95% CI 1.64-4.36).ConclusionsThe 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.© 2021. Society of General Internal Medicine.

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