• James Downar, Russell Goldman, Ruxandra Pinto, Marina Englesakis, and Neill K J Adhikari.
• Divisions of Respirology/Critical Care and Palliative Care, University Health Network; and Temmy Latner Centre for Palliative Care (Downar), Sinai Health System; Temmy Latner Centre for Palliative Care (Goldman), Sinai Health System; Department of Critical Care Medicine (Pinto), Sunnybrook Health Sciences Centre; Library and Information Services (Englesakis), University Health Network, Toronto General Hospital; Department of Critical Care Medicine (Adhikari) and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont. james.downar@utoronto.ca.
• CMAJ. 2017 Apr 3; 189 (13): E484E493E484-E493.

BackgroundThe surprise question - "Would I be surprised if this patient died in the next 12 months?" - has been used to identify patients at high risk of death who might benefit from palliative care services. Our objective was to systematically review the performance characteristics of the surprise question in predicting death.MethodsWe searched multiple electronic databases from inception to 2016 to identify studies that prospectively screened patients with the surprise question and reported on death at 6 to 18 months. We constructed models of hierarchical summary receiver operating characteristics (sROCs) to determine prognostic performance.ResultsSixteen studies (17 cohorts, 11 621 patients) met the selection criteria. For the outcome of death at 6 to 18 months, the pooled prognostic characteristics were sensitivity 67.0% (95% confidence interval [CI] 55.7%-76.7%), specificity 80.2% (73.3%-85.6%), positive likelihood ratio 3.4 (95% CI 2.8-4.1), negative likelihood ratio 0.41 (95% CI 0.32-0.54), positive predictive value 37.1% (95% CI 30.2%-44.6%) and negative predictive value 93.1% (95% CI 91.0%-94.8%). The surprise question had worse discrimination in patients with noncancer illness (area under sROC curve 0.77 [95% CI 0.73-0.81]) than in patients with cancer (area under sROC curve 0.83 [95% CI 0.79-0.87; p = 0.02 for difference]). Most studies had a moderate to high risk of bias, often because they had a low or unknown participation rate or had missing data.InterpretationThe surprise question performs poorly to modestly as a predictive tool for death, with worse performance in noncancer illness. Further studies are needed to develop accurate tools to identify patients with palliative care needs and to assess the surprise question for this purpose.© 2017 Canadian Medical Association or its licensors.

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