The applicability of the “surprise question” as a prognostic tool in patients with severe chronic comorbidities and its relationship with the advance directives

Abstract Background: Life expectancy in recent decades has increased the prevalence of chronic diseases in the population, requiring an approach to new health topics, such as discussions on quality of life and expectations about death and dying. The concept of advance directives (ADs) gives individuals the opportunity to make known their decisions about the treatments they would like to receive at the end of life. Despite the recognition of relevance in clinical practice, the applicability of the concept presents challenges, including establishing the appropriate prognosis for each patient and the ideal time to approach the patient. Some prognostic tools were developed, such as the surprise question (SQ): “Would you be surprised if your patient died in 12 months?”, which is used in some clinical settings to predict patient deaths and to make decisions regarding advance directives (Ads). Method: In our one-year observational study, from July 1, 2016, to February 28, 2017, second-year resident physicians in the medical residency program (MRPIM) applied SQ to all patients with multiple and varied chronic noncommunicable comorbidities, who were followed up at the general medicine outpatient clinic (GMOC) of a tertiary university hospital in São Paulo. The frequency of the outcome (death or nondeath within 12 months) was analyzed by correlating it with the clinical data (impact of the variables studied). Results: Eight hundred forty patients participated in the study: 6% died within one year, and there was a 24.9% prediction of death (214 patients), of which 14.9% died within one year. The correct prognosis for the subgroup of 626 patients among the residents (NPV) was 96.8% (CI = 95.4%-98.2%) and PPV = 14.9% (CI 10.1%-19, 6%), with a positive correlation between the outcomes death and the answer No to SQ, according to the number of comorbidities. Conclusion: The SQ, in addition to care, contributed to health education, communication and care planning shared by the doctor and patient. The project was registered under nr: 69430117.3.000.0048, under Brazilian Federal Government Committee of Ethic in Research with humans