Traditionally, outpatient dialysis facilities have chosen to enact DNR policies at a local level with input by the practitioners at those facilities. Under the new CMS Conditions for Coverage, and most state laws, this is no longer an option. We continue to have significant growth in the ESRD patient population and one of the largest segments of that growth is amongst elderly individuals. From 1996 to 2003, the number of octogenarians and nonagenarians nearly doubled to 13,577. After accounting for population growth, this represented a 57% increase in the rate of dialysis initiation in this age group. Notably the one-year mortality for this segment of the dialysis population was 46% during this time period. So clearly, many of these patients and their proxies will be dealing with end-of-life issues as they are being introduced to outpatient dialysis. Having a consistent and implementable policy to deal with this will be critical for the modern dialysis facility to meet this need.