Refusal of treatment can have fatal consequences for heart failure patients who could otherwise benefit from ventricular assist device therapy. Ethical dilemmas arise when treatment refusals seem based on unsound reasoning by patients. Using a clinical case from our medical center, we explored the complex ethical issues associated with patient refusal of ventricular assist device therapy due to the patient's perception of large device size as compared to other mechanical heart technologies. Early on, the medical team must assess a patient's refusal of therapy by reflecting on the decisionmaking capacity of the patient to determine whether such refusal is truly "informed," and all incidents of informed refusal should be clearly documented in the patient's chart.