ABSTRACT
Background
Racial disparities in end-of-life (EOL) care persist, yet the role of caregiver availability in shaping these inequities remains poorly understood. We examined whether caregiver availability modifies racial differences in perceived EOL care quality and tested the hypothesis that Black older adults without caregivers face compounded disadvantages in EOL care.
Methods
We analyzed data from 2228 non-Hispanic White and Black decedents (weighted N = 10.1 million) from the 2017–2024 National Health and Aging Trends Study. Proxy respondents completed Last Month of Life interviews. Outcomes included overall care quality ratings and receipt of help managing pain, breathing difficulties, and anxiety/sadness. Survey-weighted logistic regression models assessed associations between caregiver availability and outcomes, adjusting for demographic, clinical, and functional characteristics. Interaction terms examined joint effects of race and caregiver availability.
Results
Black decedents were less likely than White decedents to receive excellent/very good care (64.9% vs. 77.8%; p < 0.001) and help with anxiety (28.2% vs. 38.7%; p < 0.001). A significant race-caregiver interaction suggested intersectional disadvantage: compared with White decedents with caregivers, Black decedents without caregivers had the lowest odds of excellent/very good care (OR = 0.36; 95% CI, 0.19–0.67). Black decedents with caregivers also had reduced odds (OR = 0.52; 95% CI, 0.36–0.76) despite receiving more caregiving hours (7.0 vs. 3.4 h/week; p = 0.005).
Conclusions
Black older adults without caregivers had the worst observed EOL care quality. Caregiver presence was associated with narrower but persistent racial differences, suggesting structural factors that may attenuate the benefits of caregiving for Black older adults. Policy interventions designed to provide culturally responsive support to minority caregivers may help reduce racial disparities in EOL care quality.