Introduction: Despite great strides in management, stroke remains a significant cause of disability and death. Families are often abruptly confronted with critical decisions about end-of-life care; providers must balance these concerns with urgent medical or surgical treatment and an uncertain prognosis. This trial examined early Palliative Care (PC) consultation as a means to assist acutely ill patients and their families. Methods: This interdisciplinary, prospective, randomized trial used alternating days to dichotomize patients into a control group who received routine care, including PC consultation if appropriate, and an intervention group, who had PC consultation on the day after admission. Inclusion criteria were a diagnosis of acute ischemic or hemorrhagic stroke, admission to the neurological intensive care unit, and any one of: NIHSS > 14, baseline severe cognitive dysfunction, premorbid modified Rankin score > 3, metastatic cancer, intubation at admission, prior stroke with disability, readmission within 30 days, or admission from a nursing facility. PC consultation identified surrogate decision makers, addressed advance care directives and code status, and co-facilitated multidisciplinary meetings. Outcome measures were identification of a surrogate, documentation of code status, discharge destination and length of stay. Results: We enrolled 50 patients in the PC intervention group. Of the 64 patients in the control group, 18 had PC consultations as routine care; 46 (72%) did not have PC consults. There were no differences between the groups in surrogate identification, documentation of code status or discharge destination. However, compared with the 46 control patients without PC consultation, the intervention group had a significantly higher rate of surrogate identification (98% vs. 87%), χ2 (1) = 4.32, p = 0.037, and code status documentation (94% vs. 78%), χ2 (1) = 5.07, p = 0.024. Length of stay data is pending; not all patients had been discharged at the time of submission. Conclusion: Palliative Care consultation, particularly when pursued early in a patient’s hospitalization for acute stroke allows for clear documentation of a surrogate and delineation of code status, both critical to a patient’s trajectory after acute stroke.