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There is no good death. It always hurts, both the dying and the left behind. But there is a good enough death. u003e u003e —Ann Neumann, The Good Death Advances in mechanical circulatory support (MCS) have resulted in improved quality of life (QOL) and survival for the majority of patients implanted for destination therapy (DT).1 However, some patients will have persistently limiting heart failure (HF) symptoms and poor QOL.2 Nearly all patients receiving a left ventricular assist device (LVAD) as DT will eventually die with their device in situ. Palliative care (PC) is considered essential for the management of patients who receive a DT-LVAD. Although the clinical course of patients with MCS for DT has been documented,3,4 there is a paucity of data describing in detail how patients die. Such data can inform how to structure PC services for these patients.See Article by Dunlay et al  this issue of Circulation: Heart Failure , Dunlay et al5 provide a description of end of life (EOL) experiences at the Mayo Clinic, where there is a strong history of collaboration between the PC and MCS teams. The study population, typical of those receiving a DT-LVAD, died an average of 14 months after device implantation, predominately from multiorgan failure, hemorrhagic stroke, and progressive HF. In addition to the three distinct clinical trajectories previously described,6 they identified a unique trajectory, termed acute, which was heralded by an unexpected event resulting in an abrupt decline and death within 14 days (Figure). Despite initial PC engagement that included a PC consult for preparedness planning,7 less than half saw a PC provider in the …

Palliative Care Throughout the Journey of Life With a Left Ventricular Assist Device