The subfinding was general and supported by numbers of studies; it was descriptive and supported by the richness of data. The overall assessment of confidence was low, having been downgraded by two increments due to concerns over methodology and coherence. 3. Discussion of prognosis Review subfinding 3a: Difficult conversations Staff noted that discussions of prognosis are difficult, given the difficulty of diagnosis in the first place and due to the unpredictable disease trajectory of heart failure, and they were reluctant to have them. Some healthcare professionals also found it challenging to balance the need to be honest with the patient about their condition (which could raise anxiety) with building trust and maintaining hope and a positive outlook when faced with a life-threatening illness. Some healthcare professionals Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 considered that patients may not want to know everything about their prognosis, perhaps hinting at a degree of paternalism or recognition of denial as a way of coping. Some felt it was more appropriate to address prognosis over time, given these uncertainties and in response to changing circumstances, particularly when a patient might be approaching the end of their life. A common professional perception was that these types of exchange between clinician and patient did not happen often enough. In one study cardiac staff confirmed that issues such as future care in the event of an exacerbation or end-of-life preferences are rarely raised with patients. It was suggested that lessons could be learnt from communication in cancer where clear information about prognosis is provided to patients. However, the staff reported having difficulties handling patient denial, discussing poor prognosis and dealing with the emotional involvement of patients and their families. 