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. However, the evidence Chronic Heart Failure Advanced heart failure and palliative care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 reviewed demonstrated that clinical markers, even when combined in a sophisticated, weighted risk tool algorithm, failed to accurately identify high risk patients at an individual level. Including a list of factors in the guideline would not only be challenging (how to select key factors from the many included in the various risk tools) but also risked misapplication in practice, particularly if the factors were not considered in the context of the individual patient and their overall health status. Rather than using risk tools or a list of factors, the committee agreed that the best approach was for healthcare professionals to discuss with the specialist MDT any person with heart failure whose condition is deteriorating over a period of time, and to consider a palliative care needs assessment in those people. The committee agreed that all HF services should have a process in place to identify patients who should be referred for a formal assessment of palliative care needs, and adjust their service configuration as appropriate to ensure this can occur. The committee also agreed that if palliative care processes or services were thought to be necessary, they should be implemented or engaged early, given the uncertainty of the prognosis for many patients with heart failure. The committee emphasised that involvement of palliative care services and use of palliative care processes includes a broad spectrum of interventions, and that different levels of care and support can be provided at various stages of the person s disease pathway. 