The Surprise Question in Hemodialysis, Frailty, Nutrition, Patient-reported Quality of Life, and All-Cause Mortality: The Osaka Dialysis Complication Study (ODCS)

Abstract

Rationale & Objective

A response “no” (SQ-No) to the surprise question (SQ) of whether a clinician would be surprised if a dialysis patient died in the next 6 months is associated with a higher risk of all-cause death. It is uncertain what domains are intuitively assessed with the SQ. We hypothesized that the SQ would assess the patient’s frailty, malnutrition, or patient-perceived health-related quality of life in a cohort of patients on maintenance hemodialysis.

Study Design

Cohort study.

Setting & Participants

A multicenter study including 994 patients on maintenance hemodialysis in Japan.

Predictors

(1) SQ answered by nurses; (2) frailty by modified Cardiovascular Health Study criteria; (3) malnutrition as evaluated by Geriatric Nutritional Risk Index (GNRI); and (4) patient-perceived health-related quality of life examined by the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS).

Outcomes

All-cause mortality.

Analytical Approach

Cox proportional hazard models.

Results

Median age and dialysis vintage were 66 and 5.9 years, respectively, 35.8% were women, and 39.6% had diabetic kidney disease. The prevalence of SQ-No and frailty was 19.7% and 45.9%. Median GNRI and SF-36 PCS scores were 96.3 and 36.9, respectively. During the 5-year follow-up, 247 patients died. SQ-No, being frail, low GNRI, and low SF-36 PCS were each significant predictors of a higher risk for mortality independent of potential confounders. SQ-No remained a significant predictor after further adjustment for frailty or GNRI, but SQ-No was no longer significant when adjusted for SF-36 PCS.

Limitations

We did not assess the agreement of responses to the SQ between different raters.

Conclusions

The predictive ability of the SQ was closely related to SF-36 PCS in hemodialysis patients. Nurses’ answer to the SQ appears to assess the physical domain of patient-perceived health-related quality of life rather than objectively assessed frailty or malnutrition.

Plain Language Summary

“Would I be surprised if this patient died in the next 6 months?” This question posed to a clinician is called the “surprise question” (SQ) and the answer “no” (SQ-No) has been shown to predict a higher risk of mortality in patients undergoing hemodialysis. We examined which domains are intuitively assessed with the SQ, such as frailty, malnutrition, and patient-perceived quality of life in a cohort of hemodialysis patients. We found that the association between the SQ response and mortality was independent of frailty and malnutrition but was closely related to the physical domain of patient-perceived quality of life. The results suggest that the SQ appears to assess the physical domain of patient-perceived health-related quality of life rather than objectively assessed frailty or malnutrition.