Structural caregiving environments and gendered pathways to hospice at the end of life: evidence from Health and Retirement Study.

BACKGROUND AND OBJECTIVES: Hospice is designed to support comfort-focused care at the end of life, yet enrollment often depends on whether supportive caregiving infrastructures are in place. Prior studies rely on single indicators such as living arrangements, offering limited insight into the structural care environments that shape hospice feasibility. This study conceptualizes end-of-life care environments as graded structural positions: care formalization (how care is organized across household and institutional settings) and care scarcity (the availability of hands-on support) and examines their associations with hospice use among older decedents, including gender differences shaped by gendered life-course trajectories.

RESEARCH DESIGN AND METHODS: Using nationally representative data from the Health and Retirement Study Harmonized End-of-Life Interview (1994-2021; N = 12,477), we estimated multivariable logistic regression models of hospice use in the last year of life.

RESULTS: Occupying more formalized structural care positions was associated with greater odds of hospice use (OR = 1.39), whereas greater care scarcity was associated with lower odds (OR = 0.69). Gender moderated both associations: the facilitating effect of formalization was weaker for women (OR = 0.87), while the constraining effect of scarcity was attenuated for women (OR = 1.20), indicating steeper structural gradients among men.

DISCUSSION AND IMPLICATIONS: Hospice use is embedded within structurally patterned caregiving ecologies rather than driven solely by clinical trajectories or preferences. Erosion of support may constrain hospice access, whereas more formalized care settings may enhance referral and coordination. Strengthening caregiving infrastructures and targeting older adults experiencing care scarcity may promote more equitable end-of-life care.