Background Chronic progressive heart failure due to left ventricular systolic dysfunction (LVSD) affects a burgeoning proportion of the multi-morbid ageing population. Those living and dying with LVSD decline along a roller coaster disease trajectory unique to each individual and prognostication is difficult. Patient preferences may be unexplored or undermined by widely espoused, guideline driven protocols, incorporating a technological imperative in the use of life-sustaining implantable electronic devices and cardiac surgical interventions.

Aim To avoid possible barriers to patient choice along the dynamic course of LVSD and foster advance care planning (ACP) to better ensure patient-centred care at the end of life.

Methods We shall describe factors potentially confounding patient choice across four domains—those linked to the disease, the patient, the clinician and to service provision. Overarching elements of risk include:

• the individuality of each patient's clinical course

• the intrinsic unpredictability of LVSD

• a lack of acknowledgment of mortality risk by both patients and healthcare professionals.

• the requirement for both active therapy and palliative care

• recognition of transitions when goals of care require review

Discussion A lack of appreciation of the significance of LVSD and overrated perceptions about treatment option benefits may influence patient choice. Inconsistent study results also refute the common assumption that LVSD patients would trade-off burdensome longevity for a shorter, better quality life. Patient education and the use of discrete choice modelling may provide objectivity, promote consensus development, and facilitate ACP with appropriate treatment decisions towards the end of life.