OBJECTIVE This study was a prospective, in-depth exploration of the experience of dying in two nursing homes from the perspective of residents, staff, and family members. METHODS A qualitative, case study design was used. Formal and informal interviews, participant observation, and document review were the primary data collection methods. A total of 56 declining residents were followed until death or for 6 months, whichever occurred first. RESULTS The intimate linkages between structure, process, and outcome were evident in both nursing homes. The two homes had contrasting institutional philosophies, reflected in staffing and environment (structure) and processes of care. Processes included different patterns of planning, communication, and decision making. Most importantly, outcomes (residents' satisfaction with care and quality of life while approaching death) were substantively different. CONCLUSIONS Institutional philosophy and leadership permeate all aspects of care. A compliance- centered, deficiency-free approach to assessing quality of care is not sufficient to address the needs of declining residents. A client-centered philosophy that embraces "caring for dying people," combined with integrated care planning, contributes to improved resident outcomes.