Understanding death wishes in later life: a narrative review.

Background: Death wishes and end-of-life legislation are increasingly relevant in ageing societies, where demographic shifts and evolving legal frameworks appear to raise complex ethical and clinical challenges. Summary: Wishes to die among older adults are complex and not limited to mental illness or terminal illness. Although depression and demoralization are common, evidence suggests that many older individuals experience these wishes in the absence of psychiatric disorders. These experiences often reflect an existential response to cumulative losses in autonomy, identity, and social embeddedness. This review organizes existing literature using a multilevel explanatory framework. At the psychological-existential and identity level, death wishes are associated with depression, demoralization, loss of meaning, and narrative disruption. At the social-relational level, loneliness, perceived burdensomeness, and social disconnection play a central role. At the structural-cultural level, ageism, societal narratives of dependency, and broader cultural meanings of ageing contribute to the emergence and interpretation of death wishes. At the legal-ethical level, medical assistance in dying (MAiD) frameworks shape how autonomy, suffering, and legitimacy of death wishes are understood in different jurisdictions. Across these levels, death wishes appear to arise from interacting psychological, relational, and societal processes rather than from a single underlying cause. Qualitative studies further highlight the deeply personal nature of these experiences, often linked to feelings of being a burden, narrative closure, or perceived loss of future meaning. Clinically, evidence indicates that a purely psychiatric or autonomy-driven approach is insufficient. Instead, effective responses require narrative competence, existential sensitivity, and awareness of contextual influences. This review synthesizes these findings into an integrated conceptual framework and outlines key implications for clinical practice in geriatrics, psychiatry, and palliative care. Key message: This review argues for a multidimensional approach that recognizes death wishes not only as clinical or legal phenomena, but as deeply human expressions of suffering, identity, and relationality in the context of ageing.