Despite the many technical advances in medical care and dialysis delivery, mortality and morbidity remain high in patients with end-stage renal disease. This is particularly true in older patients, who often have a great number of coexisting diseases. In this population, life expectancy and quality of life may be rather poor, raising a number of ethical issues about the decision of starting start or withdrawing renal replacement therapy. Unfortunately, clear behavior guidelines on these critical issues are still insufficient. Reasons for not starting dialysis include old age, neurologic impairment, end-stage organ failure other than the kidneys, metastatic cancer, multiple comorbidities, and patient or family refusal. Similar reasons often underlie dialysis withdrawal of dialysis. Often these difficult decisions are left to care givers and family members or surrogates, since only a minority of patients with severe medical conditions discuss end-of-life care before becoming mentally impaired. The final shared decision should be the result of weighing beneficence (to maximise maximize good) with non-maleficence (to not cause harm); in the presence of severe medical conditions and/or mental impairment, dialysis may represent a prolongation of death rather than life.