The image-guided procedures discussed in this article are used to alleviate pain and suffering of patients with malignancies and/or multiple comorbidities. It is not possible to discuss the entire breadth of image-guided palliative procedures; only a few commonly requested procedures are reviewed: cholecystostomy, biliary decompression, enteral feeding and decompression tubes, chemical neurolysis (for pain control), cementoplasty, tunneled drainage catheters, transjugular intrahepatic portasystemic shunt pleurodesis, tube thoracostomy, thermal and chemical tumor ablation, transcatheter arterial chemoembolization, and selective internal radiation therapy. A decision tree is given with each procedure/disease. This review provides referring surgeons a framework for end-of-life treatment and palliation discussions.