End-stage heart failure (ESHF) represents a phase of progressive disease characterized by refractory symptoms, frequent hospitalizations, high mortality, and substantial physical and psychosocial burden for patients and caregivers. Despite advances in guideline-directed medical therapy and device-based interventions, many patients with ESHF experience diminished quality of life and face complex decisions regarding advanced therapies and end-of-life care. Palliative care and hospice services offer a patient-centered approach that prioritizes symptom relief, goals-of-care alignment, and support for patients and families across the disease trajectory, yet remain underutilized in this population. This narrative review examines the evolving role of palliative care in ESHF, with particular attention to its integration in ambulatory and inpatient settings, its intersection with advanced therapies such as continuous inotropes and mechanical circulatory support, and its relationship to hospice care at the end of life. We synthesize current guideline recommendations, clinical trial data, and observational studies demonstrating that palliative care improves symptom burden, quality of life, psychosocial outcomes, and advance care planning, while potentially reducing hospital utilization. Additionally, this review explores the nuanced role of mechanical circulatory support within a palliative framework and highlights the challenges of hospice enrollment for patients with ESHF, including those with left ventricular assist devices. By emphasizing early, longitudinal palliative engagement and clear differentiation between palliative and hospice care, this review underscores opportunities to improve goal-concordant care for patients with ESHF and identifies areas for future research to optimize care delivery, prognostication, and caregiver support.

End-stage heart failure, Palliative care, Hospice care, Quality of life, Mechanical circulatory support