Heart failure presents its own unique challenges to the clinician who desires to make excellent and humane care near the end of life a tangible reality. Accurate prediction of mortality in the individual patient is complicated by both the frequent occurrence of sudden death, both with and without devices, and the frequently chronic course that is punctuated by recurrent and more prominent acute episodes. A significant literature demonstrates that healthcare providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, and it is clear from the prognostic uncertainty of advanced heart failure that this kind of communication, and discussions regarding palliative care, need to occur earlier rather than later. This article discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation, with concurrent discussion of the ethical ramifications and pitfalls of each. A recent scientific statement from the American Heart Association begins to address some of the methodological issues involved in the care of patients with advanced heart failure. Above all, clinicians who wish to provide the highest quality of care to the dying patient need to confront the existential reality of death in themselves, their loved ones, and their patients so as to best serve those remanded to their care.