Advanced heart failure, defined by the ACC/AHA as stage D, is the end of the heart failure disease spectrum in which symptoms are present at rest despite optimal medical management. In other words, the heart’s pumping function is weakened so that it is fails to meet the body’s demands and a patient feels symptoms like shortness of breath even at rest. The unpredictable clinical trajectory of HF complicates the planning of end-of-life care, leading to underutilization of palliative care and hospice. Heart failure is typically characterized by acute crises or exacerbations followed by periods of stability as patients receive rescue treatment that can essentially bring them back to their prior functional status. This can last for months or even years. Eventually, however, one of the complications will be lethal. What makes the trajectory even more complex is the difficulty in predicting who is at-risk for sudden death and the lack of prognostic indicators to identify when hospice is needed. Hospice should therefore be focused on the provision of palliative care that meets the patient’s goals of care.