Early Identification of People Who Would Benefit From a Palliative Approach—Moving From Surprise to Routine

There is ample evidence that palliative interventions, including palliative care consultations, advance care planning, or goals of care conversations, have the potential to improve care for patients who are nearing the end of life. Professional organizations in most fields of medicine recommend the integration of a palliative approach for patients with advanced or incurable illness. Despite this, studies continue to show that many patients, especially those with noncancer illnesses, do not receive palliative care prior to death or receive it only in the final days or weeks of life.1 One of the biggest obstacles to initiating a timely palliative approach is clinicians’ inability to reliably identify people who could benefit from it. Once a patient is identified as having unmet palliative needs, they can have their specific needs assessed and managed. However, clinicians cannot perform comprehensive assessments on every patient they see; they must be selective and focus their attention on those who are most at risk. Thus, there is a need for tools that help clinicians identify the patients who most need help. Ideally, these tools would be accurate, reliable, low-cost, and integrate seamlessly into the existing workflow. The study by Ouchi et al2 presents one possible tool, the so-called surprise question, worded as “Would you be surprised if your patient died in the next one month?” in the context of emergency department visits that lead to admission to the hospital. Clinician-dependent tools, such as the surprise question, are low-cost and have been advocated for many years as part of identification systems, such as the Gold Standards Framework3 and the Supportive and Palliative Care Indicators Tool.4 However, more recent data, including from the study by Ouchi et al,2 have highlighted some important limitations in the use of the surprise question and clinician-dependent approaches in general. The surprise question is not particularly accurate for identifying patients nearing the end of life5; the study by Ouchi et al2 reported an area under the receiver operating curve of 0.73, which is lower than most other studies of the surprise question. The surprise question may miss many people who are nearing the end of life and instead focus attention on patients who are more than a year from death. While these patients could still benefit from a palliative approach, they are likely not the highest priority for clinicians who have limited time and energy to focus on palliative needs. Beyond accuracy, a study by Elliott and Nicholson6 found that the uptake of the surprise question could be poor when used in multisite studies involving many physicians, particularly those involved in primary care for noncancer illness. And while a single-item question like the surprise question might seem easy to integrate, the Gold Standards Framework3 can involve assessing up to 74 specific parameters for each patient. Clinician-dependent tools, such as the surprise question, must be given credit for much of the early identification work that has been completed to date. They allowed clinicians to take the first steps in an important area of work. As studies by Downar et al5 and Elliot and Nicholson6 have highlighted the limitations of these tools, we also need to look for other options. If a timely palliative approach is a fundamental component of quality patient care, then tools are needed that allow a more systematic and rigorous quality improvement approach and can be used to prospectively identify cohorts of patients at the end of life to measure key indices of care or drive the use of proven interventions. + Related article