Background: Self-care of heart failure has been described as a naturalistic decision-making process, but the data available to defend this description are anecdotal. Objectives: The aim of this study was to explore the process used by adults with chronic heart failure to make decisions about their symptoms. Methods: This was a secondary analysis of data obtained from four mixed methods studies. The full data set held qualitative data on 120 adults over the age of 18 years. For this analysis, maximum variation sampling was used to purposively select a subset of 36 of the qualitative interviews to reanalyze. Results: In this sample, equally distributed by gender, 56% Caucasian, between 40 and 98 years, the overarching theme was that decisions about self-care reflect a naturalistic decision-making process with components of situation awareness with mental simulation of a plausible course of action and an evaluation of the outcome of the action. In addition to situation awareness and mental simulation, three key factors were identified as influencing self-care decision making: (a) experience; (b) decision characteristics such as uncertainty, ambiguity, high stakes, urgency, illness, and involvement of others in the decision-making process; and (c) personal goals. Discussion: These results support naturalistic decision making as the process used by this sample of adults with heart failure to make decisions about self-care.