End-of-life trajectory and quality-of-life (QOL) adjusted survival with left ventricular assist device (LVAD) as a destination therapy (DT). The effect of the use of an LVAD as DT (LVAD-DT) on quality of life (QOL) and survival in Medicare beneficiaries with chronic end-stage heart failure is evaluated by examining cumulative effects on multiple QOL domains (e.g., related to physical, mental, emotional, social, and financial areas), as well as the burden of disease and therapy on patients, caregivers, and family members. LVAD-DT had three possible effects (dotted lines) on QOL and end-of-life trajectory, compared with those of medically treated patients (solid line): (A) Premature decline in QOL with shortened survival time because of postoperative complications and high in-hospital mortality rate (range 14%–27%) within 90 days after device implantation [11–13, 15, 16]. In this situation, survival time (S1) is shortened by several months compared with survival in the medically treated patient. The LVAD is electively inactivated at the end of life resulting in abrupt death. (B) No substantial change in QOL or survival time (S2) compared with that of the medically treated patient. The LVAD is electively inactivated at the end of life resulting in abrupt death. (C) The LVAD-DT alleviates limitations of physical functioning related to left heart failure, therefore explaining an initial enhancement of QOL. A gradual decline in QOL appears over a lengthened survival time (S3) because of high combined rates of late serious complications such as infections, sepsis, neurologic disabilities, and device malfunction or failure beyond 90 days of device implantation. The progression of comorbid conditions such as pulmonary hypertension, extra-cardiac end-organ disease and active malignancy also exacerbate terminal decline in the overall QOL. In this situation, average patient survival time after LVAD-DT can be lengthened by about 12 to 24 months, compared with that of the medically treated patient [11–13]. The LVAD is electively inactivated at the end of life resulting in abrupt death.