Explanation of quality assessment: moderate methodological limitations in the contributing studies; minor concerns about the coherence with nothing to lower confidence; partial relevance due to the contributing studies being conducted outside of the UK; minor concerns about inadequacy as the evidence provided reasonable depth. There was an overall judgement of moderate confidence in this sub-finding due to the concerns regarding methodological limitations and relevance. Review sub-finding 10: Patients decide Healthcare professionals felt that 'competent' ICD recipients should decide whether to deactivate their device. They highlighted the importance of discussions with the person and family, and felt that all cardiologists considering implanting a device should have an end of life discussion. Patients reported that the frequency and pain of shocks, overall quality of life and recommendations of the physician could impact their decision. Nurses felt that families sometimes put pressure on patients to get a device or to keep a device active. Explanation of quality assessment: moderate methodological limitations in the studies contributing to this sub-finding; minor concerns about the coherence; 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 very low confidence in this sub-finding due to the concerns regarding methodological limitations, relevance and adequacy. Advanced heart failure and palliative care Chronic Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 10.3.3.4 Qualitative evidence summary Finding 1: Attitudes and understanding Study design and sample size Finding Quality assessment Number of studies contributing to the finding Design Criteria Rating Overall assessment of confidence Awareness focus groups USA, 2 Canada ICD recipients and family members were unaware that ICDs could be deactivated. 