Background: Clinicians are often faced with the dilemma of how best to manage patients with advanced dementia who present to the hospital with repeated episodes of aspiration pneumonia. Rarely, if at all, are the opinions of the group that is most likely to be directly affected, that is the older nursing home resident, sought. This study seeks to fill that gap. Aims: To study the choices and preferences of a group of elderly nursing home residents in the treatment of recurrent aspiration pneumonia on a background of severe disability from end-stage dementia. Methods: A descriptive cross-sectional interview study using a hypothetical scenario carried out in six nursing homes within eastern Sydney, from June to August 2000. Views and attitudes towards hospitalization, antibiotic use, tube feeding and other treatment measures, given a situation of recurrent aspiration pneumonia and end-stage dementia, were obtained. Results: Fifty-two elderly nursing home residents who were cognitively intact and not depressed were interviewed. Most of the subjects would prefer further hospital admissions (61.5%, P < 0.1) and would choose to have antibiotic treatment (73.1%, P < 0.001). Slightly more than half would not agree to artificial ventilation. Sixty-nine percent of the respondents would not agree to feeding via a nasogastric tube (P < 0.05) and 71% would not agree to a feeding gastrostomy (P < 0.001). Most would agree to a modified diet (75%, P < 0.0001) and to continue oral feeding despite the attendant risk of re-aspiration (59.6%, P < 0.01). Conclusions: The participants generally preferred to be treated in a hospital setting given the scenario. Most disagreed with the use of artificial feeding.