The demographic transition in the United States poses inherently cultural challenges to the nation’s existing health care system. The ethnographic works contained in Gray Areas uniquely addresses these challenges by examining the complex relationships among lifespan development and identity, paid and unpaid caregiving roles, and the historical dominance of the medical model in long-term care settings. Families and service providers alike struggle with the definition of “quality of life” and with how its realization seemingly evades long-term care institutions for frail or cognitively impaired elders. The differing roles and priorities of these stakeholders often serve to further frustrate the successful transition of elders into a long-term care setting. By providing ethnographic insight into the minutiae of resident, family, and staff interactions as well as historical and macrolevel perspectives on the political–economic development of the long-term care system, the contributors to Gray Areas provide both a sorely needed overview of the current state of chronic illness care in the United States and a working model for qualitative researchers seeking to understand nursing home culture.

Nursing homes are popularly conceived of as a last resort, and many Americans assert a preference for death over institutionalization. Stafford’s introductory chapter traces the proliferation of nursing homes and links mechanisms for their financial development to social perspectives on medical aspects of older age. He describes and illustrates a model for understanding “the nursing home as a contested cultural space upheld by social processes” (p. 10). This model visually demonstrates the difficulties inherent in providing individualized quality caring within a nursing home setting by contextualizing interpersonal exchange within competing frameworks of nursing home inhabitants as patients and nursing home residents as persons.

The model encapsulates the essential cultural tension within nursing homes. Nursing homes invoke the social power and authority of allopathic medicine on many levels, yet these markers of medical authority may falsely signify immediate access to medical treatment. Jeanie Kayser-Jones’s research evaluates the decision-making process for acute illness incidents in nursing homes and found that many cases are inadequately treated. Despite appearances to the contrary, nursing homes suffer from infrequent physician visits and a lack of diagnostic equipment. Recently, nursing homes have marketed themselves as providing specialized care for specific chronic conditions, for example, Alzheimer’s disease (AD). J. Neil Henderson explores the rhetoric surrounding AD special care units, which are characterized by higher staffing, decreased sensory stimulation, and increased security compared with other units. Henderson’s work connects the socially acceptable desire for medical treatment of a progressive disease with the socially less acceptable desire for relief from care for a demented family member.

The essential tension of the nursing home cultural model is also evidenced in several authors’ discussions of personal autonomy and failure to thrive. Stafford’s piece, “Homebodies,” describes how facilities attempt to ease the tension between their competing identities as hospital and home via a simulation of home life. Stafford underscores the importance of identity and selfhood in the meaning making of space; the normalcy evoked by nursing homes is made abnormal by virtue of its spatial and historical dislocation. Eating, a basic sphere of social interaction, is transformed into medicalized interventions and, ultimately, into sites of resistance. Nursing homes provide nutritious food and monitor the weight and eating habits of residents, but they often operationalize these responsibilities by producing uniformly bland, textureless meals devoid of positive social meaning. Joel Savinshinsky explains how residents’ resistance to eating may serve as a venue to express their lack of autonomy, markedly redefining the ultimate cause of “failure to thrive.”

Residents’ noninstituionalized family members are also members of nursing home culture. Graham Rowles and Dallas High create a model for understanding the different decision-making roles family members claim and demonstrate that positive familial engagement enhances this change fine with me the quality of life for residents. Renee Shield’s contribution reminds readers that the hierarchical power structure among staff must be taken into consideration by family members. Margaret Perkinson’s research investigates the positive effects of facility-initiated family involvement on family–staff relations and resident care. Perkinson’s project invited family members and nursing assistants to develop a family guide to the nursing home, validating various stakeholders’ vantage points and producing a model for improving family–facility interaction. Maria Vesperi’s chapter addresses the reflexivity required by residents and anthropologists alike as they struggle to make sense of their own aging trajectories. Vesperi reflects on residents’ reluctance to acknowledge this suggestion accepted their loved ones’ roles in the institutionalization process.

Nursing homes may strive to become more homelike while retaining the authority vested in them as medical facilities; however, a plethora of new alternatives to nursing homes is being aggressively marketed to “soon to be old” and older adults alike. Continuing care, independent living, and assisted living facilities frame themselves as residential communities for active seniors who desire the security of knowing that help is nearby. The final chapter in this volume investigates the rhetoric used by an assisted living facility. Paula Carder describes the linguistic devices used by administrative staff to underscore the themes of independence, individuality, and privacy. It is clear that nursing homes are becoming more responsive to their clientele; however, the importance of using culture as a model for understanding the dynamics within these institutional communities has not changed. This volume demonstrates that anthropological insights into the relationships among meaning making, aging, and the experiences of long-term care residents remain relevant and vital components to improving quality of life for those nearing the end of the lifecourse.