This article offers guidance to clinicians for approaching and conducting end-of-life decision-making conversations with Native American elders. The guidelines emphasize the need for flexibility and clarity in communication, avoidance of insistence on formal structures and rigid time frames for decision-making, sensitivity to the cultural and family situation of the elder, and recognition that cultural as well as language interpretation may be necessary. Given the great diversity of the tribes and bands as well as languages among native people and the paucity of empirical work on this topic, the tentative nature of these guidelines is stressed.