A 84-year-old gentleman with Stage 5 Chronic Kidney Disease from diabetic nephropathy required community hospital step-down after repeated hospitalisations for fluid overload. Renal function decline outpaced appointments for initiation of peritoneal dialysis (PD). Biological and psychosocial barriers to dialysis initiation had to be tackled across settings in a collaborative, multi-disciplinary manner aligning various stakeholders. These included initial delirium that affected his mental capacity regarding placement and treatment, and concern regarding potential contraindications to PD. At the patient level, Family Physicians (FPs) are well-placed to assess mental capacity of patients, advocating and communicating their capacitated preferences to all stakeholders, collaborating with relevant subspecialists for dialysis initiation; and co- managing with community FP partners as medical experts in the anticipatory transitional care for patients with rapidly progressive End-Stage Renal failure. The role of IPCARE as a systemic key enabler is also discussed.