Whilst dying is an inevitable end point of the ageing of older adults, this aspect of the ageing process is often ignored. This symposium considered what we gain when we consider dying in old age with respect to services, policy and society. The four presentations considered different aspects of dying in old age: different diseases that older people live and die with (heart failure and dementia); particular settings of care in care homes where some older people live and die; and policy imperatives that shape the care older people receive towards the end and at the end point of life.

Living and Dying in a Care Home
Dr Katherine Froggatt, Lancaster University, UK
k.froggatt@lancaster.ac.uk

Care homes are places where a significant proportion of older people die and are the focus of increased attention from specialist service providers with regard to the provision of end of life care in such settings. The cultural challenges of holding both living and dying in such settings mirrors perspectives on dying and death present in contemporary Western society. A number of studies have identified the difficulties that arise in the provision of end of life care in care homes for older people of holding both living and dying, for the residents who live there, relatives who visit and staff who work there. Drawing on recent participatory research undertaken in two English care homes, how life and death are managed in this setting was discussed with its relevance to understanding wider societal views of ageing and dying.

End of life care for people with dementia: Challenges for specialist services
Professor Claire Goodman, University of Hertfordshire, UK
c.goodman@herts.ac.uk

Older people with dementia at the end of their life are often subject to unnecessary investigations and treatments. The majority of research on palliative care for people with a diagnosis of dementia has been undertaken in specialist units and hospices. Less is known about providing palliative care for this population when they are being supported at home or in care homes. This paper drew on the findings from an integrative review of qualitative and quantitative studies on palliative care for community dwelling older people with dementia and their carers. Identifying research studies that address the palliative care needs of people that die with, but not necessarily from, dementia was problematic. This reflects the way in which current care provision for dying people is based on particular assumptions. The extent to which the research evidence supports these assumptions and current service provision for end of life care for this population was discussed. The relevance of the most commonly used outcome indicators for quality end of life care for older people with dementia was questioned. The need to redefine and reframe palliative care for a population with such complex and long term needs was presented.

Dying with Heart Failure
Dr Merryn Gott, University of Sheffield, UK
m.gott@sheffield.ac.uk

This paper drew on a recently completed longitudinal study which used mixed methods to explore how older people in England live and die with heart failure. 542 people >60 and 213 of their informal carers were followed over 2 years (or until death) to explore quality of life and views about service provision. A particular focus of the discussion will be upon the ways in which participants understood a ‘good death’. A comparison was drawn between these accounts and the philosophy underpinning specialist palliative care delivery. This challenged the assumption widespread in practice and policy that specialist palliative care is the best (and maybe only) means of improving the end of life experiences of older people.

Policy and ageing and dying
Dr Liz Lloyd, University of Bristol, UK
liz.lloyd@bristol.ac.uk

The contemporary policy framework relevant to death and dying in old age is subject to important changes. This paper highlighted key policy trends and discussed the ways in which these have been influenced by a range of actors within the policy process. A crucial aspect of the discussion concerns recent thinking within policy circles on the application of ‘best practice’ in cancer care to the care of older people. Prevalent cultural norms and values are reflected in policies on death and dying in old age. The focus on policies is situated in a broader discussion of ageing and death within Western culture and provides a critical analysis of key concepts employed within policy outputs. The concept of ‘dignity’, for example, is now widely used in policies and practices, and is seen to have particular resonance for care and support at the end of life. The paper offered an analysis of the ways in which contemporary policy changes on death and dying in old age may be conceptualised as both progressive and contradictory and will consider the implications of current developments in this area of policy for gerontological knowledge.

The papers raised a number of common issues that led to a lively discussion at the end of the symposium. This included the way in which older adults may be set apart either because of their health condition or the place in which they live. Whilst issues of preference, choice, and autonomy were raised in the policy paper, these ideas were also implicitly present in all the papers where people’s experiences were considered. (NB for people with dementia, there is little literature that considers their experiences towards the end of life).

In the discussion the notion of entitlement was raised, which draws on a citizenship perspective, rather than a health care view to understand what it is older people want towards the end of life. It was agreed this seminar brought into perspective some experiences and meanings of dying in old age that are infrequently considered or developed.