Patients with end-stage heart failure have a trajectory of illness characterized by an overall gradual decline in function punctuated by periods of symptom exacerbation followed by a return nearly to their baseline. These exacerbations are not predictable. Death may come suddenly and unexpectedly for each patient, even though predictive models can draw an accurate survival curve by averaging the experience of a substantial number of people with heart failure. Heart failure patients often have treatable symptoms, such as dyspnea, fatigue, and generalized pain. In this article, we explain the trajectory of patients with heart failure, illustrate the importance of advance care planning for these patients, discuss the impact of choices to use or forgo new technologies, and suggest ways to improve the care system. Only by reexamining our health care spending priorities can we create a sustainable care system that allows patients to live both long and comfortably, reaching a balance that serves them and their communities well.