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Address correspondence to Tracy L. Marx, DO, CMD, Assistant Professor, Department of Geriatric Medicine/Gerontology, Ohio University College of Osteopathic Medicine, Grosvenor Hall 346, Athens, OH 45701-2979. E-mail: marx{at}ohiou.edu

People are living longer but are dying with more disabilities, often in nursing homes. Identification of those who are dying needs to be quicker to allow discussion of goals of care and to meet their individual needs at a higher level. Pain is pervasive and undertreated in general, but institutionalized individuals are even at greater risk of receiving inadequate analgesia. Competing goals of providing good-quality palliative care while meeting federal and state expectations of improving or maintaining function can create dilemmas for those caring for terminally ill patients in nursing homes. Physicians play a critical role in improving communication between the family and the healthcare team during the transition from rehabilitative to palliative care. Hospice can be a valuable partner in the delivery of excellent pain and symptom management in end-of-life care.