Across the world, the incidence of end-stage kidney disease is increasing in the elderly. However, they do not always fare very well on renal replacement therapy. Age at the start of dialysis, multiple comorbidities (especially if ischemic heart disease is one of them), diabetes, functional dependence, poor intellectual capacity, low serum albumin, peripheral vascular disease, and late referral have been associated with increased mortality on dialysis in various studies. Moreover, renal failure is only one of the many problems affecting the elderly and dialysis can potentially impair their quality of life tremendously. Therefore, it is often a challenge for the nephrologist to decide whether starting dialysis is in the best interest of the elderly patient. Is it sometimes nobler to provide supportive care without dialysis to an elderly patient with renal failure? Can dialysis be safely delayed where the nephrologist is uncertain of the prognosis or the patient is unsure whether or not to have dialysis? How robust is the evidence base to help inform discussion between the nephrologist and the patient/carer? What are the limitations in carrying out further research in this area? What does conservative management, which is better termed nondialytic supportive care, entail and how should it be delivered? This article aims to answer these fundamental questions confronting the nephrologist in day to day clinical practice.