[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Smith  AK, McCarthy  E, Weber  E,  et al.  Half of older Americans seen in emergency department in last month of life: most admitted to hospital, and many die there.  Health Aff (Millwood). 2012;31(6):1277-1285. doi:10.1377/hlthaff.2011.0922PubMedGoogle ScholarCrossref
Wilber  ST, Blanda  M, Gerson  LW, Allen  KR.  Short-term functional decline and service use in older emergency department patients with blunt injuries.  Acad Emerg Med. 2010;17(7):679-686. doi:10.1111/j.1553-2712.2010.00799.xPubMedGoogle ScholarCrossref
Deschodt  M, Devriendt  E, Sabbe  M,  et al.  Characteristics of older adults admitted to the emergency department (ED) and their risk factors for ED readmission based on comprehensive geriatric assessment: a prospective cohort study.  BMC Geriatr. 2015;15:54. doi:10.1186/s12877-015-0055-7PubMedGoogle ScholarCrossref
Smith  AK, Fisher  J, Schonberg  MA,  et al.  Am I doing the right thing? provider perspectives on improving palliative care in the emergency department.  Ann Emerg Med. 2009;54(1):86-93, 93.e1. doi:10.1016/j.annemergmed.2008.08.022PubMedGoogle ScholarCrossref
Oulton  J, Rhodes  SM, Howe  C, Fain  MJ, Mohler  MJ.  Advance directives for older adults in the emergency department: a systematic review.  J Palliat Med. 2015;18(6):500-505. doi:10.1089/jpm.2014.0368PubMedGoogle ScholarCrossref
Steinhauser  KE, Christakis  NA, Clipp  EC, McNeilly  M, McIntyre  L, Tulsky  JA.  Factors considered important at the end of life by patients, family, physicians, and other care providers.  JAMA. 2000;284(19):2476-2482. doi:10.1001/jama.284.19.2476PubMedGoogle ScholarCrossref
O’Connor  AE, Winch  S, Lukin  W, Parker  M.  Emergency medicine and futile care: taking the road less travelled.  Emerg Med Australas. 2011;23(5):640-643. doi:10.1111/j.1742-6723.2011.01435.xPubMedGoogle ScholarCrossref
Ray  A, Block  SD, Friedlander  RJ, Zhang  B, Maciejewski  PK, Prigerson  HG.  Peaceful awareness in patients with advanced cancer.  J Palliat Med. 2006;9(6):1359-1368. doi:10.1089/jpm.2006.9.1359PubMedGoogle ScholarCrossref
Wright  AA, Zhang  B, Ray  A,  et al.  Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.  JAMA. 2008;300(14):1665-1673. doi:10.1001/jama.300.14.1665PubMedGoogle ScholarCrossref
Detering  KM, Hancock  AD, Reade  MC, Silvester  W.  The impact of advance care planning on end of life care in elderly patients: randomised controlled trial.  BMJ. 2010;340:c1345. doi:10.1136/bmj.c1345PubMedGoogle ScholarCrossref
Khandelwal  N, Kross  EK, Engelberg  RA, Coe  NB, Long  AC, Curtis  JR.  Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review.  Crit Care Med. 2015;43(5):1102-1111. doi:10.1097/CCM.0000000000000852PubMedGoogle ScholarCrossref
Lakin  JR, Block  SD, Billings  JA,  et al.  Improving communication about serious illness in primary care: a review.  JAMA Intern Med. 2016;176(9):1380-1387. doi:10.1001/jamainternmed.2016.3212PubMedGoogle ScholarCrossref
Dixon  J, Matosevic  T, Knapp  M.  The economic evidence for advance care planning: systematic review of evidence.  Palliat Med. 2015;29(10):869-884. doi:10.1177/0269216315586659PubMedGoogle ScholarCrossref
Khandelwal  N, Benkeser  DC, Coe  NB, Curtis  JR.  Potential influence of advance care planning and palliative care consultation on ICU costs for patients with chronic and serious illness.  Crit Care Med. 2016;44(8):1474-1481. doi:10.1097/CCM.0000000000001675PubMedGoogle ScholarCrossref
Shen  MJ, Prigerson  HG, Paulk  E,  et al.  Impact of end-of-life discussions on the reduction of Latino/non-Latino disparities in do-not-resuscitate order completion.  Cancer. 2016;122(11):1749-1756. doi:10.1002/cncr.29973PubMedGoogle ScholarCrossref
Bernacki  R, Paladino  J, Neville  BA,  et al.  Effect of the Serious Illness Care Program in outpatient oncology: a cluster randomized clinical trial.  JAMA Intern Med. 2019;179(6):751-759. doi:10.1001/jamainternmed.2019.0077PubMedGoogle ScholarCrossref
Paladino  J, Bernacki  R, Neville  BA,  et al.  Evaluating an intervention to improve communication between oncology clinicians and patients with life-limiting cancer: a cluster randomized clinical trial of the Serious Illness Care Program.  JAMA Oncol. 2019;5(6):801-809. doi:10.1001/jamaoncol.2019.0292PubMedGoogle ScholarCrossref
Zhang  B, Wright  AA, Huskamp  HA,  et al.  Health care costs in the last week of life: associations with end-of-life conversations.  Arch Intern Med. 2009;169(5):480-488. doi:10.1001/archinternmed.2008.587PubMedGoogle ScholarCrossref
Smith  TJ, Coyne  P, Cassel  B, Penberthy  L, Hopson  A, Hager  MA.  A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs.  J Palliat Med. 2003;6(5):699-705. doi:10.1089/109662103322515202PubMedGoogle ScholarCrossref
Mack  JW, Cronin  A, Keating  NL,  et al.  Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study.  J Clin Oncol. 2012;30(35):4387-4395. doi:10.1200/JCO.2012.43.6055PubMedGoogle ScholarCrossref
Stone  SC, Mohanty  S, Grudzen  CR,  et al.  Emergency medicine physicians’ perspectives of providing palliative care in an emergency department.  J Palliat Med. 2011;14(12):1333-1338. doi:10.1089/jpm.2011.0106PubMedGoogle ScholarCrossref
Ouchi  K, George  N, Schuur  JD,  et al.  Goals-of-care conversations for older adults with serious illness in the emergency department: challenges and opportunities.  Ann Emerg Med. 2019;74(2):276-284. doi:10.1016/j.annemergmed.2019.01.003PubMedGoogle ScholarCrossref
Ouchi  K, George  N, Revette  AC,  et al.  Empower seriously ill older adults to formulate their goals for medical care in the emergency department.  J Palliat Med. 2019;22(3):267-273. doi:10.1089/jpm.2018.0360PubMedGoogle ScholarCrossref
Barnes  S, Gott  M, Payne  S,  et al.  Predicting mortality among a general practice-based sample of older people with heart failure.  Chronic Illn. 2008;4(1):5-12. doi:10.1177/1742395307083783PubMedGoogle ScholarCrossref
Cohen  LM, Ruthazer  R, Moss  AH, Germain  MJ.  Predicting six-month mortality for patients who are on maintenance hemodialysis.  Clin J Am Soc Nephrol. 2010;5(1):72-79. doi:10.2215/CJN.03860609PubMedGoogle ScholarCrossref
Lakin  JR, Robinson  MG, Bernacki  RE,  et al.  Estimating 1-year mortality for high-risk primary care patients using the “surprise” question.  JAMA Intern Med. 2016;176(12):1863-1865. doi:10.1001/jamainternmed.2016.5928PubMedGoogle ScholarCrossref
Lilley  EJ, Gemunden  SA, Kristo  G,  et al.  Utility of the “surprise” question in predicting survival among older patients with acute surgical conditions.  J Palliat Med. 2017;20(4):420-423. doi:10.1089/jpm.2016.0313PubMedGoogle ScholarCrossref
Moroni  M, Zocchi  D, Bolognesi  D,  et al; SUQ-P group.  The ‘surprise’ question in advanced cancer patients: A prospective study among general practitioners.  Palliat Med. 2014;28(7):959-964. doi:10.1177/0269216314526273PubMedGoogle ScholarCrossref
Moss  AH, Ganjoo  J, Sharma  S,  et al.  Utility of the “surprise” question to identify dialysis patients with high mortality.  Clin J Am Soc Nephrol. 2008;3(5):1379-1384. doi:10.2215/CJN.00940208PubMedGoogle ScholarCrossref
Moss  AH, Lunney  JR, Culp  S,  et al.  Prognostic significance of the “surprise” question in cancer patients.  J Palliat Med. 2010;13(7):837-840. doi:10.1089/jpm.2010.0018PubMedGoogle ScholarCrossref
Pang  WF, Kwan  BC, Chow  KM, Leung  CB, Li  PK, Szeto  CC.  Predicting 12-month mortality for peritoneal dialysis patients using the “surprise” question.  Perit Dial Int. 2013;33(1):60-66. doi:10.3747/pdi.2011.00204PubMedGoogle ScholarCrossref
Ouchi  K, Jambaulikar  G, George  NR,  et al.  The “surprise question” asked of emergency physicians may predict 12-month mortality among older emergency department patients.  J Palliat Med. 2018;21(2):236-240. doi:10.1089/jpm.2017.0192PubMedGoogle ScholarCrossref
Stagg  V.  CHARLSON: Stata module to calculate Charlson index of comorbidity. http://EconPapers.repec.org/RePEc:boc:bocode:s456719. Accessed June 3, 2016.
Elixhauser  ASC, Palmer  L.  Clinical Classifications Software. Rockville, MD: Agency for Healthcare Research and Quality; 2015.
Glare  P, Virik  K, Jones  M,  et al.  A systematic review of physicians’ survival predictions in terminally ill cancer patients.  BMJ. 2003;327(7408):195-198. doi:10.1136/bmj.327.7408.195PubMedGoogle ScholarCrossref
Christakis  NA, Lamont  EB.  Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study.  BMJ. 2000;320(7233):469-472. doi:10.1136/bmj.320.7233.469PubMedGoogle ScholarCrossref
Amano  K, Maeda  I, Shimoyama  S,  et al.  The accuracy of physicians’ clinical predictions of survival in patients with advanced cancer.  J Pain Symptom Manage. 2015;50(2):139-46.e1. doi:10.1016/j.jpainsymman.2015.03.004PubMedGoogle ScholarCrossref
Clerkship Directors in Emergency Medicine.  Differences between the emergency department, the office, and the inpatient settings. https://www.saem.org/cdem/education/online-education/m3-curriculum/emergency-medicine-in-the-us-healthcare-system/differences-between-the-emergency-department-the-office-and-the-inpatient-setting. Accessed July 31, 2019.
Nawar  EW, Niska  RW, Xu  J.  National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary.  Adv Data. 2007;(386):1-32.PubMedGoogle Scholar
Haydar  SA, Almeder  L, Michalakes  L, Han  PKJ, Strout  TD.  Using the surprise question to identify those with unmet palliative care needs in emergency and inpatient settings: what do clinicians think?  J Palliat Med. 2017;20(7):729-735. doi:10.1089/jpm.2016.0403PubMedGoogle ScholarCrossref
Copeland-Fields  L, Griffin  T, Jenkins  T, Buckley  M, Wise  LC.  Comparison of outcome predictions made by physicians, by nurses, and by using the Mortality Prediction Model.  Am J Crit Care. 2001;10(5):313-319.PubMedGoogle Scholar
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Emergency Medicine
    September 13, 2019

    Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital

    Author Affiliations
    • 1Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
    • 3Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
    • 4Department of Emergency Medicine, Maine Medical Center, Portland, Maine
    • 5Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 6Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
    • 7Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 8Department of Medicine, University of California, San Francisco
    • 9Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
    • 10Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 11Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts
    JAMA Netw Open. 2019;2(9):e1911139. doi:10.1001/jamanetworkopen.2019.11139
    Key Points español 中文 (chinese)

    Question  What is the association of emergency clinicians’ assessment of mortality risk with the actual 1-month mortality among older adults who are admitted to the hospital from the emergency department?

    Findings  In this prospective cohort study including 10 737 older adults who visited the emergency department, emergency clinicians’ response of no to the question, “Would you be surprised if your patient died in the next one month?” was associated with 1-month mortality after controlling for confounders. However, the diagnostic test characteristics of the surprise question were poor.

    Meaning  Asking emergency clinicians the surprise question may be a valuable tool to identify older patients in the ED with high risk of 1-month mortality.


    Importance  The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making.

    Objective  To determine the association of the question, “Would you be surprised if your patient died in the next one month?” (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED).

    Design, Setting, and Participants  This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019.

    Exposures  Treating emergency clinicians were required to answer the surprise question, “Would you be surprised if your patient died in the next one month?” in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital.

    Main Outcomes and Measures  The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality.

    Results  The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]).

    Conclusions and Relevance  This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen.