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The care of the end-stage patient has not been extensively studied, and little is known about best care practices. Therefore, using new definitions for mode of death due to heart failure, we performed a retrospective chart review of records from a university-based heart failure disease management program to characterize the population of patients dying from heart failure and to define clinical predictors that identify patients who will likely die of metabolic and/or progressive causes. Of 74 deaths recorded over a 60-month period, 17.6% and 21.3% were deemed to be metabolic or progressive, respectively. Utilization of resources was considerable, and only a small number of patients died while in hospice. Patients who required continuous inotropic support and those with preexisting renal failure were at highest risk for non-sudden cardiac death. We conclude that prospective identification of patients at risk for metabolic and progressive heart failure death is possible. The numbers of these patients is likely to increase in an era of implantable cardioverter-defibrillators. Intervention studies designed to evaluate and improve strategies that emphasize symptom control should target this group.