Despite the usefulness of advance directives, most dialysis patients do not complete them. Current views of the advance care planning process emphasize that development of a specific written advance directive is only one small part of the process. Patients and families use advance care planning discussions to plan for death, achieve control over their health care, and strengthen relationships. Studies of chronic dialysis patients have shown that discussions about end-of-life care occur within the patient-family and not the patient-physician relationship. Successful advance care planning requires that dialysis care providers incorporate end-of-life care wishes and palliative care into the overall health care plans for their patients. This review focuses on the past impediments to achieving useful advance directives among dialysis patients and their families and provides some suggestions to improving this important aspect of dialysis patient care.