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Predictions to identify when terminally ill patients die are often inaccurate

03 August 2017

Research funded by Marie Curie has revealed that a simple method, routinely used by clinicians to identify patients who may be approaching their last year of life, is frequently inaccurate.

The study, conducted by researchers at The Marie Curie Palliative Care Research Department at University College London (UCL), looked at 25,718 predictions made by clinicians using the “Surprise Question” method over a ten-year period.

The findings reveal that the accuracy of predictions varied considerably, with clinicians tending to over-predict the number of people they thought would die. Over half of those predicted to die within a specified time period lived longer than expected.

Clinicians made inaccurate predictions with about one third of the patients who did die, however they were considerably better at identifying which patients would survive rather than which patients would die. They were accurate in 84 per cent of these cases.

There was some evidence to suggest that the Surprise Question was slightly more accurate when used with cancer patients (with 79 per cent  accuracy compared to 72 per cent), supporting the idea that patients with a cancer diagnosis have a more predictable disease trajectory than other illnesses.

The Surprise Question forms part of the Gold Standards Framework guidance used widely in hospitals, hospices and general practices to help identify patients who may be approaching the last year of life.

Incorrect identification of patients could mean that some miss out on palliative care which should be provided when a patient has been identified as terminally ill. If patients are being over-identified as terminally ill, they may be unnecessarily referred to services for which there are limited resources.

The researchers emphasise that the Surprise Question is not specifically designed or promoted as a way of predicting  survival, the purpose is to raise clinicians’ awareness of which patients may benefit from palliative care. However, the findings of the study highlight the need to develop more accurate ways of identifying such patients.

Paddy Stone, Professor of Palliative and End of life care at the Marie Curie Research Department at UCL, said:

“Clinicians are often, understandably, reluctant to make specific prognostic predictions and so the Surprise Question plays a role in encouraging them to identify those of their patients who may benefit from palliative or end of life care, without the need for a precise survival prediction.

“But while it does have some utility in this respect, it falls short as an accurate predictor of survival – in terms of over-identifying the number of people whom it predicts will die and missing a proportion of those who do go on to die – and therefore the search is on for more accurate ways to recognise when patients are dying, that are both more sensitive and more specific.”

 Commenting in response to the study, Claire Henry, MBE, Director of Improvement and Transformation at national hospice care charity Hospice UK, said:

“The findings of this survey highlight that the Surprise Question for clinicians should not be used in isolation but alongside a range of other clinical assessment tools to determine when someone needs palliative care.”

“It also shows the importance of considering patients’ individual needs, rather than relying purely on prognosis, and the need for good communication between patients and clinicians and honest conversations between them about palliative care early on.”

“We hope this research will lead to significant  improvements in identifying patients approaching their last year of life so that more people are able to get the support they need and also help ensure better targeted care.”

To read the study visit How accurate is the ‘Surprise Question’ at identifying patients at the end of life?

See more articles in Research

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