Both uncertainty regarding individual prognosis and a lack of training in communicating has limited EOL discussions between nephrologists and ESRD patients. Instruments to identify individuals undergoing maintenance HD who are at highest risk for death have only recently been shown to be reliable predictive models for clinical use. Integrated prognostic models now take into account laboratory values, comorbidities, changes in comorbidity score over time, functional status/fragility, quality of life (QOL), and sometimes either the patient's or clinician's prediction of survival. Drs. Cohen and Germain have developed a practical and reliable instrument that is available online (http://touchcalc.com/calculators/sq), as a free application for mobile devices and it is being increasingly cited for its potential value in the literature. In addition to the barriers of providing a reliable prognosis, communication has been highlighted as a barrier in a qualitative study of elderly ESRD patients and nephrologists.