Left ventricular assist devices as destination therapy (DT) improve quality of life for many patients with advanced heart failure. However, DT can be associated with risks such as infection, bleeding, and stroke, and may impose psychosocial strain on patients and caregivers. Furthermore, patients treated with DT eventually will die with their device in place whether death is related to the device or not. In response to these concerns, palliative medicine consultation has been suggested with standard DT care to improve focus on quality of life, symptom management, and end-of-life planning. This article reviews key issues associated with caring for patients with DT, including psychosocial, quality-of-life, caregiving, and ethical issues, and discusses end-of-life management of patients with DT, including practical considerations, but moreover, review topics regarding communication, symptom management, and provision of appropriate comfort care. © Springer Science+Business Media, LLC 2011.