Choices and challenges in end-of-life care and decision-making: a nationwide cross-sectional study in Bangladesh

End-of-life (EoL) care is the final phase of life (typically the last year when death is imminent), distinct from but related to palliative care, which provides broader support for serious illness. In many low- and middle-income countries, including Bangladesh, end-of-life care remains underdeveloped. Cultural norms, socio-economic disparities, limited palliative care infrastructure, and lack of healthcare provider training further complicate informed decision-making at EoL. This study aimed to evaluate EoL care awareness, preferences, and decision-making factors among critically ill older adult patients in Bangladesh. This cross-sectional study was conducted from September 2024 to February 2025 across eight administrative divisions of Bangladesh, involving 1,270 patients aged ≥ 50 years with chronic or advanced illnesses, including hospitalized patients aged ≥ 18 years with life expectancy < 1 year from private (n = 368), public (n = 439), and community (n = 463) settings. Divisional hospitals provided hospital-based data, while three randomly selected sub-districts per division ensured proportional community representation. Data was collected using structured questionnaires adapted from validated international tools, capturing socio-demographics, and end-of-life (EoL) awareness, preferences, and experiences. Predictors of end-of-life preferences were examined using multiple logistic regression analysis. Only 6.93% had health insurance, with just 1.7% in community settings. Palliative care awareness was highest in private hospitals (70%), followed by public (31%) and community settings (7.1%) (p < 0.01). Advance care planning awareness and documentation were lowest in community patients (p < 0.01). Older adults (≥ 60 years) were more likely to prefer home care (OR = 2.96, p = 0.004), avoid hospitalization (OR = 17.55, p < 0.001), and choose home death (OR = 10.29, p < 0.001). Greater understanding of palliative care (OR = 7.38, p < 0.001) and hospice comfort (OR = 25.26, p < 0.001) strongly predicted documentation of end-of-life preferences. Family openness varied widely (private: 81%, public: 21%, community: 7.1%). Proxy appointment was significantly associated with prior discussions (AOR = 4.11), while trust in healthcare providers reduced the likelihood (AOR = 0.39). Profound disparities in end-of-life awareness and preferences exist across healthcare settings in Bangladesh, driven by socio-economic, cultural, and institutional factors. Efforts must prioritize patient choice through enhanced communication, culturally sensitive advance care planning, and expanding home-based palliative options to honor care preferences at the end of life.