Physicians who initiate discussions about hospice face several challenges. For example, they must determine whether hospice is appropriate, given a patient's goals and prognosis. Furthermore, even if hospice is clearly appropriate, the initial discussion can be uncomfortable for everyone. Although there are clear benefits to timely hospice referral for many patients, the introduction of hospice is frequently perceived by patients and families as bad news. Given these challenges, it is not surprising that hospice discussions happen very late in the course of illness and that most patients receive hospice care for only a short period. Physicians can overcome many of these challenges by considering indicators of a limited prognosis, framing the hospice discussion in terms of the patient's goals and needs for care, and recommending hospice when they think it is the best option. This approach, which has much in common with other “bad news” discussions, can provide structure for what can be a difficult conversation. Moreover, this approach can help physicians to deal with misperceptions and strong emotions and to present hospice as the best way to meet the needs of patients and their families in light of their clinical circumstances, prognosis, goals, and values.