Patients with end stage liver disease (ESLD) have a significant symptom burden comparable with patients with cancer and other life limiting conditions. While the field of palliative care has developed over the past 50 years, research has shown that patients with ESLD often do not receive adequate palliative care support. One of the main barriers is that clinicians may be too focused on life-prolonging interventions such as liver transplantation and the treatment of complications of cirrhosis that end-of-life discussions and advance care planning is overlooked till a very late phase of the illness. Physicians managing ESLD should therefore learn how to palliate symptoms specific to ESLD concurrently while managing patients who often have unpredictable prognoses. They should also be familiar with having conversations regarding advance care planning with patients including those who may be awaiting liver transplantation.