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., recurrent hospitalization or progressive intolerance of medications due to hypotension and kidney dysfunc- tion) should trigger heightened preparation with patients and families, but without speci c estimates of how much time remains due to high levels of unpredictability in the clinical course of HF. Principle 7: The transition from do everything to comfort only/hospice is often bridged through a phase of quality survival, during which time patients increasingly weigh the bene ts, risks, and burdens of initiating or continuing life-sustaining treatments. Action: Revising the medical regimen for symptom relief and quality of life may involve discontinuation of some recommended therapies (e.g., reducing neurohor- monal antagonists in the setting of symptomatic hypo- tension, deactivation of de brillator therapy) and the addition of therapies not usually recommended (e.g., opioids for refractory dyspnea). These decisions should be individualized and made in partnership with the patient, their caregivers, and their care team. 6. DISCUSSIONS AND IMPLICATIONS OF PATHWAY The primary objective of this updated ECDP is to provide a framework for the many decisions required in the man- agement of patients with HFrEF. Most importantly, the checklists and algorithms provided in this ECDP should be applied only in the context of the most recent update to the AHA/ACC guidelines for management of adults with chronic HF and, in this case, patients with HFrEF. No guideline, pathway, or algorithm should ever supersede clinical judgment. Management of HFrEF often involves multidisciplinary care, may require complex decision-making, and bene ts from a solid foundation of knowledge to manage these occasionally fragile patients. 