This is because of the emotional distress it would cause, and how overwhelming the information would be. Others felt that it did not make sense to begin discussions of removing a device before even implanting it 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 starting the conversation early ; partial relevance due to the contributing study 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 very low confidence in this sub-finding due to the concerns regarding relevance, adequacy and coherence. Review sub-finding 8: Avoiding discussions Healthcare professionals, ICD recipients and family members all avoided discussions about ICD deactivation, due to the difficult nature of the conversations. Some patients said that they had brief conversations with their healthcare professionals but did not discuss this further with their family members. Others were putting off talking about it because they felt that end of life issues were not relevant to the current phase of their life and were not yet a reality; they wanted to think about this nearer the time. In 1 study, ICD recipients were not willing to discuss deactivation in the focus group. Doctors reported that they rarely had discussions about ICD deactivation, even though they acknowledged the importance of doing so. They found that at a technical level it crossed their mind that it should be switched off, but that for some it wouldn't cross their mind to initiate a conversation with the patient. 