Abstract Research Patients who reach end stage renal disease (ESRD) late in life are increasingly being placed on hemodialysis (HD) without feeling they have ever been given a choice of treatment options. A moral imperative to treat everyone has resulted in a 57% age adjusted increase in HD among octa- and nonagenarians from 1997- 2003. Most patients report they were not presented with any options but to start dialysis. Despite growing recognition of this failure to respect patients' autonomy, little is known about how patients chose between ESRD treatment options or whether decision aids (DA) can improve the situation. DAs have been shown to empower patients to make choices consistent with their values and goals of care. DAs also increased patient participation in decision making and positively impacted patient-provider communication. We hypothesize that a simple in-visit DA that shows individualized risk and benefit estimates of treatment options for ESRD will facilitate shared decision making and help patients choose the treatment consistent with their values and preferences, increasing their autonomy. In this study we propose: To bolster the dignity, autonomy, and quality of life of elderly patients with ESRD by 1) Improving risk prediction and its point of care translation through a decision aid 2) Critically assessing the ethical and economic tensions surrounding the current payment reform in dialysis to safeguard patient autonomy and access to care and to inform future health policy. Successful completion of this project has the potential to affect the lives of thousands of elderly patients facing these difficult decisions annually in the US, through wide dissemination and policy implications. Candidate Dr. Thorsteinsdottir is passionate about justice in health care and resource allocation during these challenging times of aging populations. She brings to these tasks a unique mix of education and experiences. She is board certified in general internal medicine and palliative care and has completed a fellowship in bioethics at Harvard Medical School. She also has practiced in many different health care settings in different health care systems. By undertaking these aims Dr. Thorsteinsdottir will position herself for independence as an aging outcomes researcher. Her overall goal is to become an independently funded researcher and a national leader in geriatric outcomes research: To this end her objectives are 1. Improve skills in observational data analysis in older adult populations: Because of the paucity of randomized data on the frail elderly and inherent challenges with recruiting into such trials, it is essential to be able to navigate large observational registries to determine the risks and benefits of therapies for the very old. Formal development in this area will position Dr. Thorsteinsdottir for future collaborations with national as well as international colleagues through established institutional collaborations such as the Hig...