The rapidly advancing age of incident dialysis patient has coincided with a rising mortality rate during the first year of dialysis. This is occurring despite a steady decline in mortality of prevalent patients. These statistics suggest that there is a subset of sick, elderly dialysis patients who will not survive the first 6 months of dialysis. It may be that these patients would be better served with a conservative, palliative approach that does not include initiation of dialysis. Even though hospice care is universally available to the Center for Medicare and Medicaid Services population, dialysis patients encounter many barriers to obtaining this benefit and have a hospice utilization rate only one quarter that of cancer patients. This article discusses the barriers to and goals of palliative care in the chronic kidney disease/end-stage renal disease population.