Of the biggest personal and professional challenges I’ve faced as someone who studies ageing and the ageing process has been dealing with the recent passing of my father. Much of my academic career has focused on studying healthy ageing, successful ageing, and resilience, and I’ve found myself wrestling with questions that were familiar professionally but much harder personally. What might “healthy dying” look like? Could there be such a thing as “successful dying”? Watching someone I love go through the end of life has made me reconsider what these concepts mean in practice, and how much of that experience our models can capture.
These questions took me back to a paper I wrote as a budding PhD student at Cambridge. Published in the Canadian Medical Association Journal in 2013 with my supervisors Professor Blossom Stephan and Professor Dame Carol Brayne, with the title “Deathless models of aging and the importance of acknowledging the dying process”. Whilst the title was written with the intent to attract the reader’s attention, it had a more serious intent to reflect concerns about models of ageing that gave surprisingly little attention to how life ends.
Our primary thesis was that definitions centred on maintaining high physical and cognitive functioning could leave people outside the category of successful ageing as they began to decline towards death. This obscured differences in their experiences and the psychological and social strengths that might remain. We suggested that ageing research should follow those trajectories through to the end of life, rather than treating ageing well and dying well as separate concerns.
At the time, I approached this primarily as a conceptual and methodological problem. I was thinking about definitions, measurements, and what happened when models failed to accommodate the full course of a person’s life. Revisiting the paper now, I find myself thinking about the practical questions behind those abstractions. What matters when recovery is no longer possible? How do we recognise wellbeing when someone’s abilities are changing? What can still be supported, even as so much is being lost?
The field has, of course, continued to develop. The World Health Organization’s approach to healthy ageing focuses on the capabilities that enable wellbeing, including the interaction between a person and their environment. It explicitly recognises that freedom from disease is not a prerequisite for healthy ageing. This provides a more inclusive starting point, although I still find the language of healthy or successful dying difficult to apply to someone I love.
Part of that difficulty lies in the connotations of the words themselves. “Successful” can imply an achievement, something accomplished through the right decisions or sufficient effort, but typically has a value judgement attached to it. Applied to dying, it risks setting a standard against which people and families might feel they have fallen short, implying that becoming ill or dying is, by definition, “unsuccessful”. Personally, I am uneasy with any framework that suggests that fear, distress, dependence, or an unpredictable illness represents a personal failure. A useful concept of dying well would need to accommodate experiences that are difficult, unresolved, and largely beyond anyone’s control.
For me, the question has become what a positive end-of-life experience might mean within the reality of loss. Positive is a difficult word here, too. It can feel uncomfortable to place it alongside the death of a parent. Yet I think there is room to ask about comfort, connection, dignity, and being understood without diminishing the sadness. Recognising something valuable in the process does not make the loss less painful.
A biopsychosocial perspective offers a way to think through this. Physical wellbeing might involve attending to pain, discomfort, and other symptoms. Psychological wellbeing might involve responding to fear, preserving a sense of identity, or supporting the person’s wishes as far as possible. Social wellbeing might involve trusted relationships, opportunities for connection, and the experience of being treated as someone whose life and preferences matter. These dimensions need to be considered together, with room for what each person values.
What interests me is that changes across these dimensions need not happen in the same way or at the same pace. Increasing physical dependence does not tell us everything about someone’s experience. A person may still value familiar company, participate in decisions, or find reassurance in a relationship. Where communication becomes difficult, the challenge of understanding and supporting those experiences becomes greater. It also makes me question how readily we equate independence with wellbeing.
There is an established body of research examining what people consider a good death. A 2021 systematic review of systematic reviews identified recurring themes including relief from pain and psychological distress, support from loved ones, involvement in treatment decisions, and effective communication with professionals. The authors also highlighted limitations in how these concepts were defined and represented across different settings. These themes offer useful questions to ask, while leaving considerable work to understand how they apply to an individual life.
Thinking about trajectories across the life course brings another set of questions into view. Which relationships provide support when illness progresses? How do earlier experiences of care influence trust or fear? What happens when someone’s preferences change, or become harder to communicate? How might financial circumstances, housing, and access to services shape the options available? I want to understand how these factors come together over time, and where support could make a meaningful difference.
This also means looking beyond the individual. Any account of dying well needs to consider what families and caregivers are being asked to manage, and whether they have adequate support themselves. It needs to consider the services available and how readily people can access them. Otherwise, we risk describing desirable experiences without attending to the conditions that make them possible.
As a researcher, I am left wanting approaches that can take these experiences seriously without reducing them to a single score or threshold. As a son, I am much more aware of how difficult it can be to make sense of them while they are happening. Academic familiarity with a subject does not remove its emotional weight. In my case, it has brought new questions alongside the grief, rather than providing ready answers.
I am still working through what my father’s death means to me, personally and professionally. Returning to a paper written more than a decade ago has been an unexpectedly difficult part of that process. I remain interested in how we support people to age well, but I now feel much more strongly the need to carry that concern into the end of life. What wellbeing can mean as death approaches is a question I will continue to sit with, with a different understanding of why it matters.
About the Author
Theodore D Cosco joined the Oxford Institute of Population Ageing in 2016 as a Research Fellow. Dr. Cosco is a Chartered Psychologist (British Psychological Society) trained in applied social research methods (MSc 2011, Trinity College Dublin) and epidemiology (PhD 2015, University of Cambridge), and Assistant Professor of Mental Health and Aging in the Department of Gerontology, Simon Fraser University. His research interests include resilience, mental health, and the interface between technology and healthy ageing.
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