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Doctors and nurses working in hospital emergency rooms need to make quick decisions about patients who are very sick. They often have to guess which patients might die within a short time, like three months or a year. Knowing this can help them decide how to treat the patient and whether the patient would benefit from receiving palliative care.
To help with this, health workers use something called the “Surprise Question” or SQ. The SQ is very simple: the doctor or nurse asks themselves, “Would I be surprised if this patient died within the next three months?” or “Would I be surprised if this patient died within the next year?” If the answer is “No, I would not be surprised,” it means the patient might be at higher risk of dying.
A group of researchers wanted to see how well this question works when asked in the emergency room for all kinds of patients, not just people already known to be very sick. They also wanted to find out if nurses and doctors agree on their answers to this question and how good they are at guessing which patients might die within 3 or 12 months.
How the Study Worked
The study took place in the emergency room of a hospital in the Netherlands. It lasted six weeks in 2023. During this time, every adult patient who came to the emergency room was included in the study if a doctor or nurse answered the SQ for them. There were no special rules about who could or couldn’t be in the study. In total, 1,958 patients were included. These patients had an average age of 64 years, and about half were men.
Both nurses and doctors answered the SQ after they examined each patient. They did this without talking to each other about their answers. Their answers were then checked against what actually happened to the patients over the next year to see if the patients lived or died.
What the Researchers Found
Out of all the patients, 8.3% died within three months, and 13.9% died within a year. Death was more common among patients who were older than 50 and those who came to the emergency room with medical problems rather than injuries or surgeries.
When nurses answered the SQ for three-month survival, they said “No, I wouldn’t be surprised if the patient died” for 5.3% of the patients. Doctors answered “No” for 7.6% of patients.
For the 12-month question, nurses answered “No” for 22.6% of patients, and doctors did so for 23.7%.
How Accurate Was the Surprise Question?
The SQ worked better for predicting who would die within 12 months than for predicting death within three months. For predicting death within a year, doctors were better at this than nurses. The accuracy was measured using a special score called AU-ROC, where 1.0 is perfect and 0.5 means no better than guessing. Nurses scored 0.722, and doctors scored 0.847 for the 12-month question, which is pretty good.
The SQ was very good at predicting who was not going to die within a year, meaning if the doctor or nurse said “Yes, I’d be surprised if this person died,” that person usually lived. But it wasn’t as good at catching everyone who would die, especially within three months.
When both the nurse and doctor gave the same answer to the SQ, the prediction became even stronger. If both said they would not be surprised if the person died, the patient had a much higher chance of dying. If both said they would be surprised, the patient was much more likely to survive.
Older and Sicker Patients
The SQ worked especially well for patients who were over 50 or who had medical problems rather than surgical ones. In younger or surgical patients, the SQ wasn’t as useful because fewer of them died, so there weren’t enough cases to measure accuracy well.
Agreement Between Nurses and Doctors
Nurses and doctors did not always agree in their answers to the SQ. For the 3-month question, their agreement was considered “fair,” and for the 12-month question, it was “moderate.” This means they sometimes saw the patient’s condition differently. Nurses often have more personal contact and may notice how the patient is functioning day-to-day, while doctors focus more on medical tests and diagnoses.
Even though their views differ, having both perspectives might give a better overall picture of the patient’s health. When both agree, the prediction is stronger.
Why This Matters
Knowing which patients might die soon is important because it helps doctors and nurses make decisions about care quickly. If a patient is not expected to live long, doctors might suggest palliative care, which focuses on comfort and quality of life rather than trying to cure a disease.
The SQ is a simple tool that doesn’t require special equipment or tests, which makes it useful in busy emergency rooms. It can also help start important conversations with patients and families about care options.
Limitations of the Study
This study was done in just one hospital, so results might be different elsewhere. Also, nurses answered the SQ for more patients than doctors, which might have affected how well they agreed with each other.
What’s Next?
The researchers suggest that hospitals could improve predictions by having both nurses and doctors answer the SQ together. They also suggest combining the SQ with other tools to make predictions even better. Future research could look at ways to use the SQ to help plan better care for patients who are very sick.
Conclusion
The Surprise Question is a simple, helpful tool in the emergency room to guess if a patient might die within a year, especially for older and sicker patients. While doctors and nurses may not always agree, using the SQ can help guide better care for those who need it most.
Source: Theunissen, M., Lardenoye, S., van den Beuken-van Everdingen, M. H., & Stassen, P. M. (2025). The surprise question: predictive accuracy in an unselected emergency department population–a prospective study in nurses and physicians. Annals of Medicine, 57(1), 2529575.
