Over a decade ago, the Renal Physicians Association and the American Society of Nephrology published the clinical practice guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, to assist nephrologists, patients, and families in making decisions to initiate and withdraw dialysis. Since then, researchers have extensively studied dialysis decision-making, and there is a substantial body of new evidence with regard to 1) the poor prognosis of some elderly stage 4 and 5 chronic kidney disease patients, many of whom are likely to die before initiation of dialysis or for whom dialysis may not provide a survival advantage over medical management without dialysis; 2) the prevalence of cognitive impairment in dialysis patients and the need to periodically assess them for decision-making capacity; 3) the under-recognition and undertreatment of pain and other symptoms in dialysis patients; 4) the underutilization of hospice in dialysis patients; and 5) the distinctly different treatment goals of ESRD patients based on their overall condition and personal preferences. The Renal Physicians Association developed this second edition of the guideline to provide clinicians, patients, and families with 1) the most current evidence about the benefits and burdens of dialysis for patients with diverse conditions; 2) recommendations for quality in decision-making about treatment of patients with acute kidney injury, chronic kidney disease, and ESRD; and 3) practical strategies to help clinicians implement the guideline recommendations.