Palliative and end of life care are essential, but largely overlooked, aspects of comprehensive, personalised diabetes care. Life expectancy is lower in people with diabetes than in the general population due to complications and comorbidities, especially those associated with obesity such as cardiovascular disease, frailty and cancer. This paper makes the case for early initiation of palliative care and proactive planning for end of life. Early use of palliative care improves symptom management, comfort and quality of life, and often improves function. Significantly, it reduces disease burden and unnecessary treatment. Prognostication is challenging, but tools such as the Gold Standard Framework and diabetes-related indicators of reduced life expectancy can help identify those at high risk one year mortality. Skilled conversations, underpinned by an evidence-based framework, are a critical component in helping people with diabetes, and their families, discuss these complex issues and make appropriate advance care plans based on their values and preferences.