Although institutional policies related to care at the end of life (EOL) are a common feature of hospitals, there has been little examination of the ways in which these policies shape the focus and provision of care. The question asked in this study was "What effect do institutional policies relating to care at the EOL have on practice?" Data were drawn from health record reviews of 310 adults who had died in 3 acute care facilities in a major urban centre of a Western Canadian health region. Medical orders relating to care at the end of life were written for the majority of decedents, highlighting the value providers placed on care planning during this time. Relatively few providers, however, followed policy directives regarding use of care plans, terminology or documentation of discussions with patients and families about treatment plans. The findings of this study demonstrate a significant gap between institutional EOL care policies and practice in this health region, challenging institutional decision makers and front-line providers to collaborate more effectively to devise clinically relevant policies that enhance patient care at a particularly vulnerable time of life.