Background: The aim of this study is to discover how many nursing homes (NHs) in Flanders (Belgium) have policies on advance care planning (ACP) and their content regarding different medical end-of-life decisions. Methods: A structured mail questionnaire was sent to the NH administrators of all 594 NHs in Flanders (Belgium) at the end of 2006. The questionnaire asked about the existence, timing of implementation and content of ACP policy documents (guidelines and patient-specific planning forms), and on NH characteristics related to end-of-life care. Results: The response rate was 58.1%. The development of ACP policy documents began in 1989 with major increases in implementation taking place from 2000. In 2006, ACP policy documents were available in 95.1% of NHs. Most of these NHs had ACP guidelines as well as ACP patient-specific planning forms. Almost all patient-specific planning forms included anticipatory do-not-hospitalize (90.0%) and do-not-resuscitate decisions (83.2%). Anticipatory decisions about terminal sedation (29.2%) and euthanasia (19.7%) were mentioned less often and these decisions were not permitted to be made in all NHs. One out of three NHs had policies on the appointment of a patient's representative. Conclusion: By the end of 2006, almost all NHs in Flanders (Belgium) had an ACP policy. The implementation of ACP policies in Flemish NHs lagged behind other countries, but has developed rapidly since 2000. However, some NHs appear to ban some end-of-life options which are actually legal in Belgium. Further research is needed to investigate whether ACP policies have much impact on the quality of end-of-life care in NHs.