Although shared decision making (SDM) is advocated and adopted widely in the American healthcare system, SDM can be strained and even avoided when medical decisions involve end-of-life care – particularly the decision to forgo life-saving treatment for palliative care. While palliative care has been shown to benefit patients, current research points to failed communication among patients, their families, their physicians, and other caregivers as a reason why palliative care is underutilized. This paper reviews literature that describes the cultural, social, and cognitive barriers to successful SDM in palliative care communication and further addresses institutional barriers that prevent this genre of risk communication from being utilized. Rhetorical genre theory is used as an analytical lens for viewing the barriers that must be addressed to create a rhetorical situation in which all involved in end-of-life decision making can fully participate.