Analysis of the surprise question as a tool for predicting death in neonates

The Surprise Question "Would you be surprised if the patient died in the next 12 months?" lacks pediatric research, particularly in neonatal patients. Our study aims to analyze the Surprise Question's predictive ability in neonates and explore pediatricians' views on palliative care patient identification. A prospective cross-sectional study was conducted from February 2021 to June 2023, including all newborns admitted to the Neonatal Intensive Care Unit of a pediatric tertiary hospital and its pediatricians. Patients with less than a year since admission were excluded from final analyses. Recorded variables included patient demographics and condition, pediatricians' profile and opinions regarding the Surprise Question, and palliative care patient identification. The Surprise Question was formulated to one or more pediatricians per neonate at admission, 7 days of life, and 28 days of life, with patient status recorded after 12 months to elaborate a confusion matrix of prognostic test results. A total of 51 pediatricians participated. Most felt they had limited criteria for identifying palliative care patients (55%), believed the Surprise Question could be useful (77%), and predicted death (75%). The Surprise Question was answered at least in one out of the three moments for 262 neonates (61% male and at least 36% preterm), with sufficient sample at each moment to study its predictive ability. High negative predictive values were consistent, with higher positive predictive value at 7 days (26%). Conclusions The Surprise Question is a promising tool for predicting neonatal outcome and could guide professionals in initiating palliative care discussions. The 7-day mark appears more suitable for this application. What is Known: Previous research has established the Surprise Question as a valuable tool for predicting death in adults. However, limited research exists on its use in pediatric patients and its role remains unexplored in the neonatal period. What is New: The study evaluates the Surprise Question as a tool for predicting death within the first year of life when applied in the neonatal period. It offers insights into its predictive ability and most suitable time for its application. This study sheds light on its applicability in neonatal care, offering a valuable tool for early identification and referral to palliative care.