Are we giving the right answers to the 'surprise question'?
Despite the uncertainty around predicting death, it is important for GPs to help people with terminal illness have open and honest conversations about their future care, says Dr Catherine Millington-Sanders
‘Would you be surprised if this person died in the next 12 months?’
This is the question that doctors will often ask themselves to help determine whether someone is nearing the end of their life – and whether they would benefit from palliative care.
Asking the question isn’t necessarily about prognosis – it’s more a tool to help us reflect on our patient’s circumstances, ensure that they are receiving the best possible care, and enable us to help them plan for the future.
It won’t be wholly surprising for GPs that recent research, looking at how effective this method is for making accurate predictions, has found mixed results. Clinicians made accurate predictions in around three-quarters of cases. While this is good, it is not perfect and it does raise the prospect that some might be missing out on the care that they need.
But indeed, this is what general practice is all about – working in the best interests of the patient in front of us to mitigate risk and achieve the best possible health outcomes.
No two people are the same and every illness offers a variety of possible outcomes, so in most cases the answer to the ‘surprise question’ (or similar questions) is a calculated guess, taking into account our knowledge of the patient.
In my experience as a GP, whether someone has 12 or 24 months left to live, the focus should be the same – on choice and shared decision-making, including those who are important to the patient in the discussion.
That is why Marie Curie, who funded the research, have suggested that – even if we’re unable to provide a definitive answer to the ‘surprise question’ – simply recognising that someone is living with a terminal illness means that we can do more to help them.
We know that identifying people early gives patients, those important to them, and professionals, the opportunity to work together to plan care. It is associated with improved experience – allowing time to have open and honest conversations and helping the patient to make informed choices about their future care.
Our patients may live with advanced illnesses for many years and therefore conversations with them should be open-ended and ongoing. Care planning should begin from the start of a person’s illness and, while the steps we take may vary, it should always be based on the needs and best interests of the individual sat in front of us.
GPs have of course long recognised the need to use tools such as the ‘surprise question’ sensitively and cautiously. Identifying someone as ‘likely to die’ must never be a tick box exercise – and I know from my conversations with GPs around the country, this is something they feel very strongly about.
For someone who is dying and their family, not knowing can make what is already a distressing time, all the harder. But accepting that it is often impossible to give people the certainty they desire, we should recognise the opportunity we have to help them have the best quality of life possible for the time they have left.
With this in mind, the RCGP and Marie Curie are currently developing new national standards to help general practice provide the best possible care to people living with terminal illnesses and their families.
Dr Catherine Millington-Sanders is the RCGP and Marie Curie Clinical Lead for End of Life Care