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 Explanation of quality assessment: moderate methodological limitations in the studies contributing to this sub-finding; moderate concerns about coherence due to a conflicting sub-finding on patients and family members not wanting to deactivate their device; partial relevance due to the contributing studies being conducted outside of the UK and one of the studies discussing implantation devices other than just ICDs; moderate concerns about inadequacy as there was a relatively small amount of evidence which lacked depth. There was an overall judgement of very low confidence in this sub- finding due to the concerns regarding the methodological limitations, relevance and adequacy. Finding 2: Discussions Review sub-finding 5: Initiating the conversation Some ICD recipients felt that discussions should be initiated by a healthcare professional such as a cardiologist, nurse or social worker. Others felt that healthcare professionals initiating conversations about ICD deactivation would be too emotionally distressing. Nurses felt that they were often the ones to bring up the conversation with the family during the dying process when the family started to ask 'why is it taking so long'. Doctors felt that ICD discussions were important but guidelines on how to initiate the conversation were unclear. Explanation of quality assessment: minor methodological limitations in the studies contributing to this sub-finding; minor concerns about the coherence of the sub-finding; partial relevance due to the contributing 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 and adequacy. 