Addressing end-of-life concerns has always been an important part of treating patients with end-stage renal disease (ESRD), particularly among older patients. Although long-term dialysis does not restore normal life expectancy for patients with ESRD, it has added countless years of incremental survival for millions. With improvements in medical technology and therapies that are keeping more people with other chronic conditions alive, indications for long-term dialysis have expanded dramatically to include a growing number of patients who develop kidney disease as a complication of an underlying disease. As a result, a worldwide increase in ESRD has been fueled by the aging of the population and by the rising prevalence of diabetes and hypertension. In many countries, older patients now make up the fastest growing segment of the dialysis population. In the United States, the rate of patients 75 years or older starting on dialysis has almost tripled over the past 2 decades from 550 to 1550 per million.4 Despite the hope for longer survival that dialysis may offer, the 5-year survival rate among US patients 75 years or older is approximately 15%.4 Therefore, older patients who develop ESRD must try to optimize their quality of life while living with a grave, life-limiting chronic disease, often against a background of comorbid conditions and functional status limitations. Consequently, although dialysis offers the potential for increased survival, it may do so with tremendous limitations in quality of life and survival, especially among older patients.