Trade-off between clinical benefits and harms Overall, the committee were not persuaded that any of the risks tools included in the review identified patients with a high risk of mortality with sufficient accuracy to support their use. The SHFM was the most commonly reported tool included in the review. The estimated AUC for the SHFM ranged from 0.66 to 0.76 across the 10 cohort datasets. Because of this inconsistency, the committee could not be confident that the tool would meet its minimum threshold for AUC of 0.70. The data from 1 large cohort suggested an AUC of 0.66, but at the clinically relevant thresholds, the sensitivity of the tool was very low. Sensitivity was estimated at 0.5% for a threshold of 50% predicted mortality, and 20.7% at 20% predicted mortality. This meant that the vast majority of patients who died within a year had relatively low predicted mortality risks in other words, the tool failed to identify the patients who would die within the year. The committee agreed that a tool with such low sensitivity was therefore not helpful for identifying patients who may benefit from a more detailed palliative care assessment. In contrast, the specificity of the tool was high, 99.9% at the 50% predicted mortality threshold and 93.1% at the 20% predicted morality threshold. This suggested that at these thresholds, the tool was accurate at identifying patients who were less likely to die within the year. Based on this evidence, the committee discussed whether the tool could be used as a rule out tool, to identify those patients who were unlikely to need a palliative care needs assessment. 