Firstly, an extended first consultation will incur an additional cost due to the required extra time from the clinician to fully explain the person s diagnosis and prognosis. However, the committee considered that a standard consultation appointment is unlikely to be long enough to allow sufficient time to explain the diagnosis and prognosis as recommended in the patient experience guideline and thought this was necessary for good clinical practice. Furthermore, this type of recommendation is endorsed by the patient experience guideline which specifies that when discussing patient views and preferences that adequate time should be allowed so that Chronic Heart Failure Domiciliary oxygen therapy in people with advanced heart failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 discussion does not seemed rushed. In many centres, extended consultations are likely to already be occurring. The committee also acknowledged that further communication training would incur a cost. The committee were aware of training for other chronic conditions that could also be extended to heart failure specialists. Furthermore, such training is likely be undertaken in a group setting to minimise cost, or alternatively could be provided through e-learning, or at medical school in future. The committee acknowledged that the benefits of improved communication training would be advantageous across the entire treatment pathway for chronic heart failure patients as well as other conditions outside of heart failure, and therefore overall, the long-term cost effectiveness of training in effective communication is likely to be negligible. Other considerations The committee acknowledged The Second Conversation Project which was currently piloting an educational intervention, to enable junior doctors to build their skills and confidence in navigating end of life discussions which they agreed would provide insight into the benefit of this type of training and may be extrapolated to the heart failure population. 