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After typically a number of years of symptom management with medication, lifestyle measures, and cardiac device use, heart failure progresses to an advanced stage.

At what's called Stage D heart failure, those medical and device treatments are no longer enough to keep symptoms under control. End-stage disease typically causes fatigue and shortness of breath, called dyspnea, that may interfere with daily life. Pain, nausea, anxiety, and depression are also common.

Supportive care, called palliative care, can help address these issues. It doesn't mean stopping treatment or giving up, and it's not the same as hospice.

Rather, palliative care helps you to live with a better quality of life and can even reduce heart failure hospitalizations. This kind of care -- whether coordinated by your cardiologist, primary care physician, or a specialist -- can include a wide range of physical, emotional, psychosocial, and spiritual interventions.

Specialized interventions may be needed in advanced heart failure. Depending on your condition and the goals and preferences you discuss with your healthcare team, these options may include:

• Heart transplantation
• Placement of a mechanical pump to assist the heart, known as a left ventricular assist device (LVAD)
• Continuous intravenous inotropic drugs, which can be an infusion administered at home or in the hospital, to help the heart muscle contract

Most patients survive 6 to 12 months with Stage D heart failure; some survive substantially longer. During this period, you may cycle through sudden worsening (exacerbation) that requires hospital care and then periods where your condition is somewhat better.

Once life expectancy drops to less than 6 months, your physician may recommend hospice care. Certain life-prolonging therapies may be stopped in favor of comfort-only care. For example, cardiac devices that administer a shock to restart the heart might no longer fit goals of care and be turned off.

Your healthcare team may use some decision support tools to help you understand your options. Consider completing an to ensure that your wishes are clear for your family and physicians, especially in case of hospitalization.

Thinking ahead about what your goals and preferences are for this stage of life may help you to get the care you want in a more comfortable setting and ease suffering for you and your family.

Read previous installments in this series:

For Your Patients: What is Heart Failure?

For Your Patients: How Is Heart Failure Diagnosed?

For Your Patients: Getting the Most From Heart Failure Visits

For Your Patients: Self-Care for Heart Failure

For Your Patients: What to Expect From Cardiac Rehabilitation

For Your Patients: Managing Heart Failure With Other Chronic Conditions

For Your Patients: Heart Failure Device Therapy

For Your Patients: Making the Most of Heart Failure Medication

For Your Patients: Managing Your Mood With Heart Failure

"Medical Journeys" is a set of clinical resources reviewed by doctors, meant for physicians and other healthcare professionals as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.