Caregiving Relationships, Advance Care Planning, and Hospice Use in Later Life

Little is known about whether primary caregiver relationship is associated with hospice use or advance care planning (ACP) in later life. This study examined variation in hospice use and ACP across primary caregiver relationships.

Gateway Harmonized Health and Retirement Study End-of-Life data were restricted to Wave 12 and later. The sample included 3952 decedents aged 60 years or older. Caregiving category identified the primary caregiver as spouse/partner, child/grandchild, extended family, or non-kin informal, with formal care only and no identified caregiver as additional categories. Multivariable logistic regression estimated hospice use; a joint Wald test assessed overall differences across four informal primary-caregiver categories, and probability-scale decomposition examined indirect associations through ACP.

Among decedents with an identified informal primary caregiver, hospice use did not vary overall by caregiver relationship. Relative to spouse/partner primary caregiving, hospice use was lower among decedents with no identified caregiver (OR, 0.46) and those receiving formal care only (OR, 0.62), while child/grandchild primary caregiving was associated with a 3.87-percentage-point higher probability of ACP. The indirect association through ACP for child/grandchild primary caregiving was small (0.39 percentage points).

Hospice use was not concentrated within a particular informal primary caregiver relationship, whereas differences by caregiver relationship were more apparent in ACP. These findings highlight a distinction between care planning and eventual service use and suggest that caregiver availability and broader caregiving circumstances may be important to consider alongside relationship type.