The purpose of this article is to discuss the symptom burden of patients with ESLD, describe how symptoms affect the transitions patients experience as they near the end-of-life (EOL), compare and contrast these transitions to other life limiting illnesses, and review current palliative care strategies recommended for ESLD. Palliative care for patients with ESLD is often poor, in part because of inadequate communication between patients and their providers, lack of criteria to help clinicians determine which patients would benefit from EOL conversations, and the lack of clear understanding of the contribution of common psychosocial issues and their effects on successful implementation of palliative care strategies. Further research is needed in these areas to improve EOL care for these patients.