Discussion of prognosis: staff reported difficulties in discussing prognosis and future care options due to the unpredictable disease trajectory, uncertainty about whether patients wanted to know their prognosis, and the challenge of handling the emotional response of patients and their families. Some healthcare professionals also found it challenging to balance the need to be honest with the patient about their condition (which could raise anxiety) with building trust and the desire to maintain hope and a positive outlook for patients faced with a life-limiting illness. Patients identified that prognosis was rarely discussed and the evidence showed that their understanding of their prognosis was generally poor. Patients desire for more knowledge about their prognosis was highly individual, whilst some preferred not to know more, many were worried by the uncertainty of what the future held. Improving communication/information flow: staff identified training and education needs regarding diagnosing and prognosticating heart failure to improve communication with the patient and family. Staff commented that single consultant appointments are too short to relay all the information a patient would need regarding diagnosis and prognosis. It was suggested that information and education be delivered within the context of a relationship of trust and continuity between the patient and the health care professional, and in an appropriate setting. Healthcare professionals identified the variability in patients ability and willingness to receive information about their condition requires staff to tailor the information to the needs of the individual. Many patients desire more detail, preferably in lay terms, written information and greater access to support. Family and informal carers wished to be involved in all communications. Quality of the evidence The confidence ratings for the different sub-findings in the review were varied, ranging from high to low. 