OBJECTIVE To determine whether the myocutaneous flap procedure, the preferred treatment for young patients with stage III pressure ulcers, is appropriate for moderately demented nursing home residents. METHODS A model of the treatment decision was created using the decision-tree format. The probabilities of treatment outcomes in the decision tree were derived from the literature. Utilities for treatment outcomes were obtained from five internists, five geriatricians, six nurse practitioners, five plastic surgeons, and six lay people. RESULTS A majority in each group of respondents favored surgery, according to the decision analysis. Sensitivity analysis showed that surgery was preferred unless its success rate was less than 30%, or the rate of healing with conservative measures was at least 40%, which are unlikely values. Economic analysis demonstrated that surgery was $17,000 more expensive than conservative therapy. CONCLUSIONS The myocutaneous flap procedure is preferred by the majority of relevant decision makers when cost is not a consideration. The relative underutilization of surgery in practice has many possible explanations. The most likely are the failure of providers to appreciate the morbidity of pressure ulcers and the reluctance of practitioners to perform expensive procedures on demented patients.