Others felt that discussions did take place upon insertion but these are usually forgotten by the time they come into focus when the person s condition has deteriorated. Explanation of quality assessment: minor methodological limitations in the studies contributing to this sub-finding; moderate concerns about the coherence of the sub-finding due to a conflicting review on having the conversation later ; partial relevance due to most of the studies being conducted outside of the UK; moderate concerns about inadequacy as there was a relatively small amount of evidence which lacked depth. There was an overall judgement of low confidence in this sub-finding due to the concerns regarding relevance, adequacy and coherence. Chronic Heart Failure Advanced heart failure and palliative care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Review sub-finding 7: Having the conversation later Some ICD recipients felt that ICD deactivation should be discussed if there was a change in their condition, and if their condition had deteriorated. They felt that patients should be of sound mind but had definitely progressed to 'end of life'. Patients felt that physicians could predict when this change could result in death, and that ICD deactivation should be discussed as a reminder of the options and to determine preferences. Similarly, other patients felt that discussions of deactivation should not happen at the time of insertion. This is because of the emotional distress it would cause, and how overwhelming the information would be. 