Elderly patients comprise the most rapidly growing population initiating dialysis therapy and may derive particular benefit from comprehensive assessment of geriatric syndromes, coexisting comorbid conditions, and overall prognosis. Palliative care is a philosophy that aims to improve quality of life and assist with treatment decision making for patients with serious illness such as kidney disease. Palliative skills for the nephrology provider can aid in the care of these patients. This review provides nephrology providers with 4 primary palliative care skills to guide treatment decision making: (1) use prognostic tools to identify patients who may benefit from conservative management, (2) disclose prognostic information to patients who may not do well with dialysis therapy, (3) incorporate patient goals and values to outline a treatment plan, and (4) prepare patients and families for transitions and end of life.