Unmet care needs at the end-of-life among older adults with activity limitations

Despite the growing global demand for end-of-life care resulting from rapid social transformations, significant gaps exist in cross-national research examining unmet end-of-life care needs. Using harmonized end-of-life survey data (2010-2021) from the United States, 28 European countries, South Korea, China, and Mexico, here we show that the United States, Europe, and South Korea exhibit higher overall unmet end-of-life care needs than China and Mexico, where limited formal care provision is compensated with high levels of informal care. Death at institutions is associated with lower overall unmet end-of-life care needs in the United States and South Korea, with Mexico presenting an exception. Similarly, urban areas in Europe and South Korea exhibit lower unmet formal end-of-life care needs compared to rural areas. Among married individuals, only Mexico exhibits significantly lower unmet overall end-of-life care needs compared to unmarried individuals. Having children is consistently linked to lower unmet informal end-of-life care needs across the United States, Europe, and South Korea. Our findings highlight the complex interplay between care systems and family demographic structures in shaping end-of-life care access, and underscore the need for tailored policy approaches that strengthen both formal and informal care systems while addressing sociodemographic disparities in care access. Formal end-of-life care expansion in the US, Europe, and South Korea has not fully compensated for declining informal care, resulting in care gaps. Demographic transitions interact with development contexts to create distinct care landscapes.