Nephrologists frequently must discuss serious news with patients, especially those with advanced comorbidities. These discussions include giving bad news, addressing prognosis, and assisting with treatment decision making. Few data exist about how nephrologists approach these difficult conversations. This article presents a framework for engaging in these discussions using a case example, and provides tools for assisting with treatment decision making for initiating or forgoing dialysis. Communication skills presented include Ask-Tell-Ask for discussing serious news, the N-U-R-S-E acronym for recognizing and responding to emotion; tools for naming uncertainty when addressing prognosis; and using big picture questions to elicit patient care preferences for treatment decision making. This article provides nephrologists with the framework and skills to better engage in patient-centered decision making.