The importance of intimate expression continues throughout one’s life span, including when one approaches the end of life. Caregivers, focused on treatment of symptoms, often fail to consider sexual needs and preferences. This lack of focus on psychological and physical needs associated with intimate expression may be especially pronounced for people who identify as a sexual or gender minority. Reasons for a lack of focus among practitioners include conflicting moral beliefs, lack of knowledge regarding inclusive resources, discomfort exploring sexual needs, and cultural stigma against SGM individuals. Bronfenbrenner’s ecosystemic framework is used to illuminate how practitioners can support end-of-life sexuality and intimacy among SGM patients in multiple nested contexts. These contextual levels move from the macrosystem through the microsystem and factor in transitions, shifts, and the historical context by inclusion of the chronosystem. We provide suggestions for healthcare practitioners who interact with people at the end of life to theoretically conceptualize and intervene at each intersecting level. Our overarching goals is to inform the creation of more culturally responsive environments in which individuals are comfortable expressing their gender and sexual identity if they choose to do so and where caregivers recognize and support patients’ desires for intimate expression.