Good decision making is important, especially with patients who are disadvantaged in the ways common to long-term care institutions. Few decisions are as important as where to live and where to receive medical care for chronic illnesses, and these decisions deserve careful consideration by providers. Dying is common in long-term care facilities but is commonly managed poorly. Physicians could help this situation by encouraging advance directives, better educating patients, knowing more adequate symptom control measures, and understanding moral and legal considerations better. Pressures for cost containment are forcing physicians to re-examine and defend their role as patient advocate and to defend reasonable expenditures even on patients who are close to death.