Palliative social workers (PSWs) have become an invaluable part of interdisciplinary palliative care teams. PSWs bring their knowledge of grief, loss, and bereavement and their compassion, empathy, and high ethical standards to the work. PSWs also practice within a social justice and cultural humility lens, allowing them to challenge and empower patients, colleagues, and the systems in which they work. Cases in which sexual and gender diverse older adults (SGDOA) require the appointment of a surrogate decision-maker can be complicated and distressing and can benefit specifically from the support of a PSW. This chapter reviews the evolution of the PSW role in inpatient medical teams and, using a composite case illustration, examines the current dilemmas that palliative teams encounter when providing palliative care to SGD older adults who require the appointment of surrogate decision-makers. The author’s reflections will be noted, as well as opportunities for future study.