Background Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question (“Would you be surprised if this patient died in the ...next 12 months?”) is a tool to assist in prognostication. However, it has not been studied in non−dialysis-dependent CKD and its reliability is unknown. Study Design Observational study. Setting & Participants 388 patients at least 60 years of age with non−dialysis-dependent CKD stages 4 to 5 who were seen at an outpatient nephrology clinic. Predictor Trinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response. Outcomes Mortality, test-retest reliability, and blinded inter-rater reliability. Measurements Baseline comorbid conditions, Charlson Comorbidity Index, cause of CKD, and baseline laboratory values (ie, serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin). Results Median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded Yes, Neutral, and No for 202 (52%), 80 (21%), and 106 (27%) patients, respectively. About 5%, 15%, and 27% of Yes, Neutral, and No patients died, respectively ( P < 0.001). Trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42-0.72), and test-retest reliability was 0.63 (95% CI, 0.54–0.72). The trinary surprise question No response had sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had sensitivity of 66% (95% CI, 49%-80%; P = 0.3 vs trinary), but lower specificity of 68% (95% CI, 63%-73%; P = 0.02 vs trinary). Limitations Single center, small number of deaths. Conclusions The surprise question associates with mortality in CKD stages 4 to 5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non−dialysis-dependent CKD.
Frailty is a predominant predictor of poor outcomes in older populations. This article presents a review of the concept of frailty and its role for prognostication among geriatric trauma and surgery ...patients. We discuss models of frailty defined in the scientific literature, emphasizing that frailty is a process of biologic aging. We emphasize the importance of screening, assessment, and inclusion of frailty indices for the development and use of prognostication instruments/tools in the population of interest. Finally, we discuss best practices for the delivery of prognostic information in acute care settings and specific recommendations for trauma and surgical care settings.
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