The Impact of Gender and Marital Status on End-of-Life Care: Evidence from the National Mortality Follow-Back Survey

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Abstract
Background: End-of-life care poses a growing clinical and policy concern. Gender and marital status may play important roles in shaping end-of-life care. Objective: To examine gender and marital status differences across multiple end-of-life care outcomes: primary residence in the last year of life (LYL), place of death, hospice use, type of formal and informal caregivers, and primary payment source for end-of-life care. Design: Retrospective cohort study using bivariate analyses and multivariate logistic regression. Participants: A nationally representative sample of 12,771 individuals who died of natural causes, from the 1993 National Mortality Followback Survey. Results: After multivariate adjustment, the only gender differences in end-of-life care were that women were more likely to receive formal or informal care in the LYL and more likely to be on Medicaid. After adjustment, unmarried individuals (widowed, divorced/separated, and single) were more likely than married people to live their LYL and die in nursing homes, less likely to receive formal or informal care in the LYL, and more likely to be on Medicaid. Hospice use was low, with minimal gender and marital status differences. Conclusions: Marital status is a key variable mediating gender differences in end-of-life care. Unmarried individuals are less likely to receive help from informal caregivers—most notably because of the lack of spousal care—which may explain why they are more likely to end up in nursing homes. Clinicians need to be aware of the impact of marital status on endof- life care. Policymakers should consider that women will be disproportionately affected by policy changes in public financing for end-of-life care.

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