Readily available information could be edited, or further supplementary information could be provided if not all aspects are covered from available materials. This is likely to require an initial upfront cost to produce a document, after which printing costs per patient are likely to be small. The committee also acknowledged that discussions around whether ICDs remain an appropriate treatment option can require longer appointment times and often require re-visiting. However, the committee agreed that this is necessary to ensure the patient is well informed and to allow time for discussion. Around 5-10% of heart failure patients have ICDs, in which discussion about deactivation is only likely to be considered in a small proportion each year. Therefore, the committee did not consider that these recommendations would have a significant resource impact. Other considerations The committee noted that conversations around ICD deactivation, like other conversations around end of life, can be challenging for people and their families. Health care professionals should be aware that some people may require specialist psychological support or review. The committee acknowledged the Resuscitation Council (UK), the British Cardiovascular Society and the National Council for Palliative Care s guide for healthcare professionals regarding the deactivation of implantable cardioverter-defibrillators towards the end of life http://www.bhrs.com/files/files/Guidelines/CIEDs_Deactivation.pdf. The committee were reassured that the advice outlined in this document was in agreement with the recommendations they had made. 10.4 Identifying patients with an increased risk of mortality The disease trajectory for people with heart failure is difficult to predict, with episodes of stability punctuated by episodes of severe deterioration in symptoms within an overall decline over years. The uncertainty associated with length of life from diagnosis and often repeated episodes of severe deterioration can create anxiety for both patients and clinicians. 