The hospice vision of providing democratic and humane care of the dying needs to be operationalized in the "real world" of health care bureaucracies. It is at this interface between idealists and the demands of mainstream health care that hospice organizations experience compromise, diversion, and an ongoing threat to their singleness of purpose. This discussion explores this process of routinization through research findings on a hospice organization known as Karuna Hospice Service (KHS). Such findings suggest that, although this hospice inevitably defers to the bureaucratic demands of the system, KHS's spiritual discourse does offer some protection to the formalizing and dehumanizing demands of routinization. Such research findings are provided as a contribution to exploring and documenting the ways in which hospices are negotiating this difficult and important ideological challenge. It is argued that effectively meeting such a challenge is of central importance for the survival of the hospice movement.