Although most deaths in the United States occur in hospitals, data suggest that hospitals and physicians are not equipped to handle the medical and psychosocial problems of dying patients. In this article, we review the barriers to achieving a peaceful death, including inadequate medical professional education on palliative care, and public and professional uncertainty about the difference between foregoing life-sustaining treatment and active euthanasia, and health professionals' difficulty recognizing when patients are dying and the associated sense that death is a professional failure. Other barriers include fiscal constraints on the length of stay, the number of nurses available to care for dying patients, legal and regulatory constraints on obtaining opioid prescriptions, and a segregated system of hospice care that requires patients to be separated from familiar health care providers and settings in order to receive palliative care at the end of life. Identifying the opportunities that can improve the delivery of palliative care at the end of life is the first step toward developing corrective approaches. Strategies that enhance these opportunities are proposed.