Unequal goodbyes: disparities in end-of-life care before and after the outbreak of the COVID-19 pandemic across 28 countries.

backgroundThe COVID-19 pandemic significantly disrupted health systems, impacting how individuals received end-of-life (EOL) care and amplifying pre-existing differences in healthcare use across sociodemographic groups. While research has examined the burden placed on healthcare professionals, less attention has been paid to the experience of care recipients in their final year of life, particularly across different socioeconomic groups. This study explores the sociodemographic factors associated with the care that people received in the last year of life, comparing periods before and after the outbreak of the pandemic across Europe.

methodsThe analysis uses data from 5,029 deceased individuals aged over 50, who died between 2018 and 2022. Data include 28 European countries and are drawn from waves 7-9 of the Survey of Health, Ageing and Retirement in Europe. Information was collected via proxy interviews post-mortem and includes details on health, care received in the final year of life, and sociodemographic characteristics. The main outcomes were six binary variables indicating the utilization of care in the hospital, hospice, nursing home, home care, care from a general practitioner, and from a specialist physician. Using six binary probit regression models, we estimated the average marginal effects of dying after the onset of the pandemic (March 2020), with interaction terms for cause of death, education level, and financial difficulty.

resultsEOL care use declined following the pandemic's onset, with particularly steep reductions in home-based care and specialist services. These changes varied across population groups. Dying from cardiovascular or infectious causes was associated with significant declines in hospital, home, and specialist care use. Socioeconomic disparities widened: low education levels were associated with decreases across all care types except nursing homes, while reporting financial hardships was associated with marked reductions particularly in home care and specialist care use. Individuals with higher education or financial security saw smaller or no significant changes in care use.

conclusionsPatterns observed during the pandemic suggest that pre-existing differences in EOL care across Europe might have widened, and lower education and financial resources were associated with lower EOL care use. These results underscore the urgent need for policies that build resilient, equitable EOL care systems capable of protecting disadvantaged populations in times of crisis.