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Evaluating Performance of the Surprise Question to Predict 12-Month Mortality in Patients With End-Stage Liver Disease

Sarah Homann,Jamie L. Pfaff,Elizabeth Stovicek,R. Agarwal,S. K. Misra,Jill M. Pulley,J. Siemann,Ashley Spann,Stacey Tillman,C. L. Gatto,M. Karlekar

Published 2025 in The American journal of hospice & palliative care

ABSTRACT

Introduction Patients diagnosed with end-stage liver disease (ESLD) often struggle with a heavy symptom burden that compromises their quality of life. Introduction of specialty palliative care (PC) may help address these issues but is underutilized in ESLD. This study aimed to assess the performance of the surprise question (SQ) in this population as a potential screen to identify patients with a life expectancy of less than 12 months. Methods A retrospective cohort analysis was performed. In a previous study (COMPASS Trial, NCT03022630), attending hepatologists were asked the SQ: “Would you be surprised if this patient were to die in the next 12 months?” as a prompt to consider consultation to specialty PC. Here, we consider the full collection of SQ answers and reconcile against record of death to examine the accuracy of the SQ as a predictor in this patient population. Results The SQ had high sensitivity (93%) but low specificity (38%) for predicting 12-month mortality in ESLD patients. The SQ also had a positive predictive value of 42% and a negative predictive value of 92%. Patients who were SQ+ (physician responded: No, I would not be surprised) were more likely to die within the year than those who were SQ−. Conclusion In ESLD, the SQ may serve as a useful screening test to identify patients at higher risk of mortality which may prompt PC engagement.

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