"Should I refer now or wait until it's the last resort?" Moustafa Younis, MD, MSCR, Assistant Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine at UF Health Shands Hospital, explains when to start transplant conversations. Learn why early referral preserves options, the two-year ~50% mortality threshold despite optimal therapy, and common referral triggers: oxygen requirement, pulmonary hypertension, hypercapnia, frequent hospitalizations, and declining exercise capacity. He also outlines the evaluation outcomes and modifiable barriers that affect listing.