The Surprise Question and clinician-predicted prognosis: systematic review and meta-analysis.

Background: The Surprise Question, 'Would you be surprised if this person died within the next year?' is a simple tool that can be used by clinicians to identify people within the last year of life. This review aimed to determine the accuracy of this assessment, across different healthcare settings, specialties, follow-up periods and respondents.

Methods: Searches were conducted of Medline, Embase, AMED, PubMed and the Cochrane Central Register of Controlled Trials, from inception until 01 January 2024. Studies were included if they reported original data on the ability of the Surprise Question to predict survival. For each study (including subgroups), sensitivity, specificity, positive and negative predictive values and accuracy were determined.

Results: Our dataset comprised 56 distinct cohorts, including 68 829 patients. In a pooled analysis, the sensitivity of the Surprise Question was 0.69 ((0.64 to 0.74) I²=97.2%), specificity 0.69 ((0.63 to 0.74) I²=99.7%), positive predictive value 0.40 ((0.35 to 0.45) I²=99.4%), negative predictive value 0.89 ((0.87 to 0.91) I²=99.7%) and accuracy 0.71 ((0.68 to 0.75) I²=99.3%). The prompt performed best in populations with high event rates, shorter timeframes and when posed to more experienced respondents.

Conclusions: The Surprise Question demonstrated modest accuracy with considerable heterogeneity across the population to which it was applied and to whom it was posed. Prospective studies should test whether the prompt can facilitate timely access to palliative care services, as originally envisioned.

Prospero registration number: CRD32022298236.