Would you be surprised? The use of a simple question to identify and improve care for our end-of-life population

From the 2018 HVPAA National Conference

Nicole Adler (NYU Langone Health), William Winfree (NYU Langone Health), Frank Volpicelli (NYU Langone Health), Jonathan Austrian (NYU Langone Health), Robert Press (NYU Langone Health)


The Palliative Care Information Act was passed in New York State to ensure palliative care counseling was provided to patients within six months of the end of life. We implemented the Mandatory Surprise Question (MSQ), which asks, “Would you be surprised if this patient died within the next six months?”


In 2017, we launched a supportive care initiative to improve the value of care that we deliver to patients at the end of life. The goal was to help our providers identify patients at the end of life, and improve the follow-up actions from this identification. With the MSQ as the backbone, we set out to create a framework around identification, education, and expected next steps for patients where the MSQ answer was “No.”


In order to enable the “thoughtful pause” associated with the MSQ, we proceeded in four steps: 1- launched a re-education campaign around the intent of, and expectations for answering the MSQ; 2- enhanced the functionality of the MSQ by creating admission and discharge orders in the electronic medical record (EMR); 3- added validity to responses by requiring attending co-signature of MSQ orders; 4- directly linked MSQ responses to appropriate follow-up activities in the EMR, i.e. if the answer to the question was “No”, best practice alerts and checklist activities were added to encourage advance care planning (ACP) note completion, Medical Orders for Life Sustaining Treatment (MOLST) documentation, and consults to social work, palliative care, or geriatrics as appropriate.


Comparing the 3 quarters prior to the intervention to the 3 quarters following the intervention: 1- the percent of adult patients discharged with an answered MSQ rose from 73% to 98% (34% increase); 2- the percent of adult “MSQ = No” patients discharged with a completed ACP note rose from 12% to 21% (71% increase); 3- the percent of adult patients with a code status of “Do Not Resuscitate” that were discharged with a MOLST in the EMR rose from 12% to 19% (65% increase). Additionally, of the >39,000 admit and discharge MSQ orders placed since enhancing the EMR functionality, 95% were co-signed by an attending physician.


Organizational commitment to identifying end-of-life patients and ensuring appropriate follow-up has resulted in significant improvements to the way we deliver end-of-life care. By implementing a multi-pronged, cross-campus, EMR-based, and education-focused initiative, we were able to impact compliance and culture change.  The MSQ is intended to create a pause for providers, during which they can make decisions that positively impact the downstream care that is delivered to patients near the end of life.


Implications for the Patient

By providing a simple mechanism for early identification of end-of-life patients, we better enable providers to offer thoughtful advanced care planning, ensuring that the planned care trajectory matches the patient’s goals. The ultimate result is higher quality and value care delivered to patients at the end of life.

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