J Maddox et al. Action: Meticulous management of HF therapies particularly diuretic agents is a critical component of symptom management and should continue through the end of life. Principle 3: Palliative care consultation and comple- mentary approaches to care may further ameliorate re- fractory HF symptoms of dyspnea, fatigue, and pain, although study results have been mixed. These ap- proaches also improve patient satisfaction and quality-of- life metrics. Action: Targeted specialty palliative care consultation can be helpful for especially complex decisions, refractory symptoms, and end of life. Palliative care teams should have expertise in management of both HF- and non HF- related symptoms. Principle 4: Patients with HF often face major treat- ment decisions over time and should be provided with support when thinking through the bene ts and burdens of each treatment option. Action: Decision support tools (patient decision aids) help frame options, which should then be followed by dynamic and personalized conversations. Principle 5: Proactive shared decision-making discus- sions simplify dif cult decisions in the future. Action: Preparedness planning discussions should occur at least annually between patients and clinicians, leading to review of clinical status and current thera- pies, estimates of prognosis, clari cation of patient values and beliefs, anticipation of treatment decisions, and advanced care directives that identify surrogate decision-makers and healthcare proxies (3). Resources to assist patients in these dif cult discussions may be useful (e.g., the Advanced Care Training module from HFSA: hfsa.org). Similar preparedness-planning discus- sions should occur at the time of major procedural in- terventions (e.g., LV assist device implantation, heart transplantation). Principle 6: Attention to the clinical trajectory is required to calibrate expectations and guide timely de- cisions, but prognostic uncertainty is inevitable and should be included in discussions with patients and caregivers. Action: Worsening disease and milestone events (e.g.