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The cornerstone of contemporary nursing home care is a commitment to patient rehabilitation. Improved care is an important and worthwhile goal, but it is a goal that has yet to make room for the dying. A significant proportion of older people will spend their final days in a nursing home. This article calls for a culture shift in nursing home care to promote improved care for not only those who can be rehabilitated but also those who are dying.

This article begins by addressing challenges to achieving this culture that are particular to the nursing home context. It then explains how adjusting the general framework for end of life decision-making to better account for the nursing home context can help make room for the dying. End of life care should be framed around issues that commonly face the dying rather than the extreme scenario of, for example, the person in the vegetative state. Focusing on more common issues may help to reduce incidences of unnecessary hospitalization and improve pain treatment at the end of life.

The article concludes by considering three fundamental assumptions in the current structure for end of life decision-making that are particularly ill-suited to the nursing home environment. First, the concept that palliative care is synonymous with “care for the dying” may cause providers to withhold such care until an individual is labeled as “dying.” Second, it is problematic to single-mindedly focus on the autonomy of the patient in end of life decisions when family members and caregivers are integrally involved in long-term care. Third and finally, the legal structure of end of life decisions weighs in favor of medical intervention, and this may affect one’s ability to opt for palliative care.