Brief Summary Older patients ≥65 years with chronic kidney disease (CKD) face challenges in decision making around dialysis initiation. These patients report little effort by physicians to elicit treatment preferences, discuss prognoses or explain the burdens/benefits of dialysis options including conservative management. Older patients with CKD often prefer maintaining the quality of life over prolonging life, and many regret their decision to start dialysis: nearly one quarter withdraw from dialysis each year. Shared dialysis decision-making requires active engagement between nephrologists and patients to align patient, caregiver and physician communication around common goals. The proposed study is a pilot randomized cluster pragmatic trial of a shared dialysis decision- making (DIAL-SDM) intervention for nephrologists (n=20) and their patients ≥65 years old (n=60) with an estimated glomerular filtration rate (eGFR) of ≤ 20 ml/min/ /1.73 m2. Nephrologists in the Intervention Group will receive 3 remote online communication training sessions, delivered by a standardized patient instructor (SPI) via Zoom technology who will enact clinical scenarios and offer feedback. In parallel, patients (and caregivers, if available) will receive 2 coaching sessions provided by a health coach, who will explore each patient's relevant contextual information (values, preferences, and goals), and help them identify and practice important questions for their nephrologist. Nephrologists in the Control Group will provide their patients with usual care. The study outcomes will be assessed during two nephrology office visits and at 6 months. Specifically, we aim to: Aim 1 (primary): Assess the feasibility, acceptability, and fidelity of the DIAL-SDM intervention. Aim 2 (secondary): Test the preliminary effectiveness of the intervention on (a) active patient participation in dialysis decision-making, as measured by the Active Patient Participation Coding scores from audio-recordings of office visits; (b) shared dialysis decision-making, as measured by OPTION scale scores from audio-recordings of the office visits, and patient-reported Shared Decision-Making Questionnaire; (c) patients' initial choice of dialysis options (home vs. in-center dialysis vs. conservative management).