Over 600,000 Americans have ESRD at a cost to society of more than $42 billion a year, and patients over the age of 75 constitute the fastest growing segment of the ESRD population in the United States. Up to one-third of these elderly patients have four or more comorbid chronic health conditions, and hemodialysis (HD) does not always substantially prolong their lives. This year, Wong and associates reported that 49% of elderly long-term HD patients spent time in an ICU in their final month of life, compared with 24% of cancer patients, suggesting intensity of care at the EOL is substantially higher in ESRD than that received by other Medicare beneficiaries with life-limiting illnesses. According to analyses from the United States Renal Data System, these decisions may have important economic ramifications. This figure demonstrates that the costs of care in the last week of life for those using hospice and withdrawing from dialysis was approximately half the cost of those who did neither. In light of the substantial prevalence of symptoms, costs, and high mortality rates, it is time to reconsider the care, and especially the EOL care, offered to the ESRD population with advancing age.