Industrialization and urbanization have changed the structure of Taiwanese families. Placing elder family members with impairments in nursing homes has become a new caregiving alternative. However, Taiwanese commonly consider this placement to be a violation of traditional filial obligation. Therefore, institutionalization is a highly sensitive cultural issue. Data were gathered through semi-structured interviews with nine family members, revealing three major processes in the decision of institutionalization -- breaking harmony, rebuilding harmony and evolution, as well as four important factors that influence the decision -- the quality of the relationship between the elder and his/her family, characteristics of the elder, financial condition of the family and perceived public opinion toward institutionalization. The findings suggest that the decision process in institutionalization is a gradual, fluid, cyclical movement without definite steps.