BACKGROUND: Despite mortality rates that exceed those of most cancers, hospice remains underutilized in patients with end-stage renal disease (ESRD) on dialysis and nearly half of all dialysis patients die in the hospital. OBJECTIVE: To review the impact of advance care planning on withdrawal from dialysis, use of hospice, and location of death. DESIGN: Retrospective review. SETTING: A rural outpatient dialysis unit. PARTICIPANTS: Former dialysis patients who died over a 5-year period. EXPOSURE: Advance care planning, the use of physician orders for life-sustaining therapy program (POLST). MAIN OUTCOME AND MEASURE: Use of hospice among patients withdrawing from dialysis, location of death. RESULTS: Advance care planning was associated with a low incidence of in-hospital death and among those who withdrew, a high use of hospice. CONCLUSIONS AND RELEVANCE: Comprehensive and systematic advance care planning among patients with ESRD on dialysis promotes greater hospice utilization and may facilitate the chance that death will occur out of hospital.