The authors examined the processes and factors that influence physicians' decision-making processes as regarding hospitalization of nursing home residents. In a large nonprofit nursing home, 6 full-time male physicians and 1 female nurse practitioner completed questionnaires that described the medical decision-making process for 52 nursing home residents for whom hospitalization was considered. The questionnaire covered the following topics: medical event description, the decision-making process, considerations in making treatment decisions, and the role of advance directives. Hospitalized residents had fewer treatments considered and fewer treatments chosen than those who were not hospitalized. Residents with fractures were the most commonly hospitalized residents, whereas residents in frailer conditions, with breathing problems, and for whom the physician considered quality of life to be most important were less likely to be hospitalized. The results of this study clarify the complexity of factors affecting the decision-making process and suggest a methodology that may assist in discerning those factors in the future.