For best EOL care, PC should begin before implantation of the MCS device and continue throughout the duration of support, especially for patients with increasing comorbidities [502]. The main goals of PC for patients with LT-MCS are management of symptoms, psychosocial issues and spiritual concerns. Therefore, although communication with patients with advanced HF is complex due to the highly unpredictable course of the disease, among other things, there should ideally be a discussion with the patient and caregivers about expectations, goals and EOL preferences during the evaluation of patients for destination therapy LT-MCS. This discussion should lead to a comprehensive EOL plan, focusing on conditions for withdrawal of MCS or related medications, such as anticoagulation, being drawn up preoperatively and made available to all relevant parties [502, 504]. An advance health care directive, also known as a living will, including designation of a proxy decision maker for when the patient is unable to make his or her own decisions, can be a great help [507]. However, the plan should be re-evaluated whenever necessary, since the patient's acceptance of aggressive treatments may change. Life-prolonging support may be discontinued with the patient in the hospital, in a hospice for terminal patients or at home. However, it should be pointed out that hospice care prior to withdrawal may be problematic, since many hospice staff lack experience and training with MCS therapies [502].