Mandatory Mortality Surprise Question Screening in the ED: Identification and Associations with End-of-Life Care Outcomes

Abstract

Background:

Early identification of patients with serious illness remains challenging in the emergency department (ED), where clinical decisions are made under time constraints. The mortality surprise question (MSQ) is a brief prognostic screen that may help identify patients needing end-of-life services. Its impact when implemented as mandatory clinical decision support with ED admission workflows has not been well characterized.

Objective:

The study evaluates the associations between MSQ responses within a mandatory ED admission workflow with serious illness processes such as palliative care consults, hospice-related outcomes, mortality, and readmission.

Methods:

We conducted a retrospective cohort study of adults admitted from the ED within a large academic health system 1 year following implementation of the mandatory MSQ. A “No” response (“I would not be surprised if this patient died in the next 6 months”) linked directly to a care pathway prompting goals-of-care conversations with scripting, advance care planning (ACP) review, and optional orders for palliative care or hospice consultation. Outcomes included consultation rates (primary outcome), timing of palliative care, ACP documentation, mortality, readmissions, and provider-level differences in responses. Outcomes were measured from the electronic health record during the index hospitalization unless otherwise specified.

Results:

Among 113,397 admissions (74,816 patients), MSQ completion was 100%; 7.8% received a “No” response. These patients were older, had greater comorbidity, and higher prior utilization. A “No” response was strongly associated with increased palliative care consultation (adjusted odds ratio [aOR]: 7.14), ACP documentation (aOR: 2.70), hospice referral (aOR: 3.89), comfort-measures-only orders (aOR: 3.97), hospice disposition (aOR: 3.84), higher inpatient mortality (aOR: 2.53), and increased 30-day readmission (aOR: 1.51). Palliative care consultation occurred earlier among MSQ “No” than MSQ “Yes” encounters. Length of stay (LOS) was modestly longer. Attendings were more likely than trainees or advanced practice providers to respond “No.”

Conclusions:

Within mandatory MSQ screening at the ED-admission interface, the MSQ “No” response identified a subgroup with substantial complexity, end-of-life care needs, and heightened vulnerability to readmissions. These patients may benefit from both earlier serious illness conversations and enhanced transitional support.