Feeding as complex adaptive systems: embodied agency, moral labour, and institutional dynamics in end-of-life dementia care

Feeding practices in end-of-life dementia care are marked by complex tensions between upholding resident autonomy, fulfilling care imperatives, and navigating institutional constraints. This ethnographic study, conducted across two aged care homes in Adelaide, South Australia, explores how these dynamics unfold as a complex adaptive system shaped by ethical dilemmas, caregiver adaptations, institutional structures, and resident agency. Over twelve months, participant observation during mealtimes at two facilities (one with 76 beds and the other with 160 beds) was supplemented by 18 semistructured interviews. These interviews included 7 residents, 8 staff members, and 3 family members. Data were thematically analysed using NVivo within the Complex Adaptive Systems framework. Findings reveal four interconnected dimensions: (1) Embodied distress and agency; (2) Food refusal as an adaptive interaction; (3) Institutional constraints and unintended consequences; and (4) Feeding as moral labour. The study challenges static models of autonomy versus care, advocating for flexible and person-centred approaches that prioritise relational ethics, adaptive practices and policymaking. By framing feeding as a complex adaptive system, this work contributes to social science debates on institutional rigidity, caregiver adaptation, and the embodied realities of end-of-life dementia care, offering pathways to harmonise systemic constraints with the dynamic needs of residents and caregivers.