However, the staff reported having difficulties handling patient denial, discussing poor prognosis and dealing with the emotional involvement of patients and their families. It was said in this study that cardiac staff often lack the communication skills required to handle these sensitive issues. Methodological limitations were rated serious overall. Three studies were rated moderate limitations due to the lack of the role of the researcher, plus another two out of the following limitations: lack of context, data richness, data analysis or loose linkage between findings and conclusions. Two studies were rated serious limitations, one due to the secondary use of data and the subsequent inability to assess methodology in detail, along with vague descriptions of this analysis; whilst the second study due to a lack of reflection on the researcher role in the study, limited context, reasoning for the choice of methods and richness of data. One study was rated as having very serious limitations due to the limited information on the background and reflection of the researcher, data collection, data richness, relevance of findings and a link to conclusions. Coherence was rated no or very minor concerns overall. Agreement between papers was very good. 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 six studies from the UK in a relevant population. Adequacy was rated as no concerns. The subfinding was explicitly supported by quite a few studies in much detail. The overall assessment of confidence was moderate, having been downgraded by one increment due to methodological limitations. Review subfinding 3b: Understanding of prognosis Patients often reported that prognosis was rarely discussed. Some patients were aware of the seriousness of their condition but reported a lack of understanding of the prognosis. 