The clinical syndrome of heart failure is increasing in prevalence, as is the number of elderly persons with heart failure. Increasing frailty and progression of heart failure in large numbers of patients means clinicians are increasingly challenged to provide end-of-life care for heart failure patients. End-of-life care has been little studied, but management can be understood from early clinical trials of advanced heart failure. Evidence-based heart failure medications, including angiotensin-converting enzyme inhibitors and beta blockers, improve symptoms in patients with advanced heart failure and depressed ejection fraction and should usually be continued in end-stage disease. Patients also should have ongoing meticulous management of fluid status to maximize quality of life. End-of-life care should be planned with the patient and family and should incorporate comprehensive symptom management, bereavement support, and spiritual support. Ongoing communication with patients and families about prognosis can ease the planning of care when the end of life nears.