Differences in Quality of Care at the End of Life Among Older Adults: The Intersection of Race/Ethnicity and Veteran Status

Background and Purpose: Racial/ethnic disparities in health and well-being in the United States has been well-documented in the literature, and these disparities have been observed even at the end of life. The theory of intersectionality posits that membership in multiple vulnerable groups may result in greater disadvantages, stressors, and hardships. With documented racial/ethnic differences across multiple domains and research showing post-military hardships among veterans, the purpose of this study was to examine differences in quality of care at the end of life based on the intersection of race/ethnicity and veteran status.

Methods: The sample for this study were derived from the 2012 to 2018 National Health and Aging Trends Study (NHATS) which is a longitudinal panel survey of adults aged 65 and older living in the United States (N=2,539). The NHATS conducts a “last-month-of-life” interview for individuals who die between each year of data collection, using data provided by family members, friends or other individuals familiar with the final months of the person’s life. Chi-square tests were used to identify the association between quality of care and each independent variable, and a multivariate logistic regression model was used to predict quality of care based on the combination of race/ethnicity and veteran status.

Results: After controlling for other variables, results showed that White veterans (OR=.865, CI=.858-.872), Black nonveterans (OR=.733, CI=.728-.739), Black veterans (OR=.704, CI=.693-.714), Hispanic nonveterans (OR=.647, CI=.641-.654) and Hispanic veterans (OR=.486, CI=.474-.498) were all less likely to report excellent or good care at the end of life compared to White nonveterans.

Conclusions and Implications: The results of this study reveal a disparity in the quality of care provided to veterans at the end of life compared to nonveterans. In accordance with the theory of intersectionality, White nonveterans were the most likely to experience excellent or good care at the end of life, while racial/ethnic minority veterans were the least likely to have good care. Considering the subjective nature of care rating, this suggests a disconnect between the preferences/wishes of veteran patients at the end of life and the type of care administered by providers. Interventions should therefore focus on enhancing both military cultural humility and racial/ethnic cultural humility among providers to improve the quality of care provided to veterans in general, and to racial/ethnic minority veterans. Implications for practice, research and policy are discussed.