Objective: To compare hospice residents in nursing homes with residents who are noted as end-stage, but not in hospice programs. Design: Descriptive comparison of the outcomes reported on Minimum Data Set (MDS) for all residents admitted to Missouri nursing homes in 1999. Setting: Nursing homes. Participants: Residents of nursing homes designated as either hospice or end-stage on admission MDS. Measurements: Percentage of hospice residents having various conditions as compared with other end-stage residents. Results/Conclusions: Overall the clinical conditions of both hospice and nonhospice endstage residents were similar. A greater percentage of hospice residents were found to have living wills, DNR orders, and cancer, and to be in moderate or severe pain. Hospice and nonhospice residents experienced similar time from admission to death or discharge (20 and 36 days, respectively). Based on the clinical condition of the two groups, it would appear that there are limited clinical reasons for the low utilization of the hospice benefit in nursing homes. The increased prevalence of advance care planning may lead toward use of hospice or may result from hospice enrollment. Hospice services seem to be thought of more frequently for residents with cancer and residents experiencing pain. Nursing homes must recognize their role as caregivers to the dying before palliative care is seen as a need for nursing home residents. Nursing homes need education in determining when a patient is appropriate for palliative care as only 4% are designated as end of life, and only 2% are shown to be receiving hospice care in hospice-contracted facilities.