Patients with end-stage liver disease (ESLD) have delayed referral to palliative care or hospice despite prognostic indicators of their morbidity and mortality, such as elevated MELD scores and high rates of hospitalization. Their 1-month survival rate after hospice referral is half that of other patients with terminal diseases. They commonly undergo invasive procedures and suffer burdensome symptoms near the end of life. Costs to patients and the healthcare system often exceed the expected benefit.