Congestive heart failure can become a debilitating, terminal illness in many patients despite maximal medical therapy. Patients with advanced heart failure have persistence of severe clinical symptoms limiting their daily life, marked left ventricular systolic dysfunction, and poor exercise capacity. Although individual disease trajectory in these patients can be difficult to predict, overall mortality remains high despite recent advances in medical and surgical therapy. Palliative care should be considered for patients with high mortality estimates, especially those patients with a one-year survival estimate of less than 25% who are not candidates for cardiac transplantation or destination mechanical support. Palliative models for heart failure management shift the focus of care from curing this debilitating disease to managing symptoms and incorporating treatment based on patient quality of life and survival goals. This article discusses strategies for identifying and treating reversible causes of heart failure, for treating rhythm disturbances, and for maintaining hemodynamic stability. Confounding medical and psychological problems affecting overall patient energy levels and well-being are reviewed. Finally, various venues and sites of care are discussed.