Some patients were aware of the seriousness of their condition but reported a lack of understanding of the prognosis. Some patients were unaware that heart failure is a terminal condition and reported feeling very frightened when informed at the end-stage. Methodological limitations were rated moderate overall. Three studies were rated moderate limitations due to limitations on the role of the researcher and methodology, as well as limitations in context for one study and data richness and lack of link between findings and conclusions for another study. Two studies had serious limitations: one study due to the secondary use of data and the subsequent inability to assess methodology in detail, along with vague descriptions of this analysis; and the second study due to the lack of reflection on the researcher role in the study, limited context, reasoning for choice of methods and richness of data. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Coherence was rated minor concerns overall. Agreement between papers was very good with the majority demonstrating patients lack of understanding of their prognosis. It was only slightly downgraded to minor concerns overall due to some variability in patients understanding. Relevance was rated no or very minor concerns. The relevance of the subfinding to the focus of the review was very high. The data stemmed from five studies from the UK in a relevant population. Adequacy was rated as no concerns. The subfinding was explicitly supported by quite a few studies. The overall assessment of confidence was moderate, having been downgraded by one increment due to moderate methodological and minor coherence limitations. Review subfinding 3c: Patients concerns Some patients preferred not to know more about their prognosis, perhaps using denial as a way of coping. 