Further, if the tools were misused as a criterion for access to palliative care services that would also cause substantial harm, given they fail to identify many of the patients who may benefit from such interventions. The committee acknowledged that tools with a reasonably high AUC may be useful to establish risk at a population or cohort level, but they fail to demonstrate sufficient accuracy at the individual level. For those reasons, the committee agreed to make an explicit recommendation that the tools should not be used to determine whether to offer referral to palliative care services. The committee discussed that the trajectory of heart failure can be very unpredictable, especially in newly diagnosed patients and with the risk of sudden death, making prognostication is challenging in heart failure. This probably explained the poor performance of many of the identified risk tools. This uncertain trajectory makes identifying heart failure patients in need of palliative care services very difficult in clinical practice. The committee agreed that there are also inequalities issues across the country and potentially between different conditions in terms of access to palliative care services. This may partly stem from the particular challenges of prognostication in heart failure. In addition, the palliative care expert co- optee noted that people with heart failure sometimes see themselves as living with the condition rather than dying with it, and may be reluctant to access palliative care services because of the perception that they are for cancer patients. The committee discussed ways in which identification of heart failure patients in need of a specialist palliative care assessment could be improved, without the use of a formal risk tool. The committee discussed whether it would be possible to come up with an evidence-based list of markers that might trigger referral for specialist assessment. 