Surprise, Surprise: Improving the Referral Pathway to Palliative Care Interventions in Advanced Heart Failure

This article refers to "Predicting one-year mortality in heart failure using the 'Surprise Question': a prospective pilot study" by S. Straw et al., published in this issue on pages 227-234.Historically, the cornerstones of therapy for heart failure (HF) have involved modification of disease progression and amelioration of symptoms with drugs and/or devices.1,2 Specialized palliative care is specifically pertinent to the advanced HF population, a cohort with poor prognosis and high symptom burden.Despite the growing advanced HF population globally, palliative care utilization is both infrequent and delayed.3 Indeed, only 5% of elderly patients discharged after HF hospitalization receive specialized palliative care via hospice, and 34% of these patients die within 72 h of arrival to a hospice facility.4 In contrast, 53% of advanced HF patients discharged without hospice died within 1 year, representing a vulnerable group that may have benefited from specialized palliative care.4 Variable disease trajectory in advanced HF introduces difficulty in accurate prognostication, which may partially explain the underutilization of palliative care in this at-risk cohort.5 The Surprise Question (Would you be surprised if this patient were to die within the next year?) is a simple query employed in other chronic illnesses, can be proposed to a wide spectrum of clinicians, and may provide insight into prognosis of HF patients, thereby identifying those who may benefit from specialized palliative care referral.