Financial status and pain in the last week of life: Insights from a nationally representative mortality follow-back survey in England and Wales

Pain relief is a priority for patients and families living with advanced illness. There is evidence of socioeconomic inequality in palliative and end-of-life care, yet little is known about how pain might differ according to financial status. We analysed data collected in a mortality follow-back study carried out in England and Wales in 2023, to examine the association between subjective financial status and being affected by pain during the last week of life. Pain was proxy-reported by a family member using the Integrated Palliative Care Outcome Scale (IPOS). We report IPOS pain prevalence, its association with financial status, and whether this was mediated by access to care or moderated by location of care. Of 1194 decedents, 415 (37.9%) were severely or overwhelmingly affected by pain in the last week of life. Compared to decedents financially 'living comfortably', those 'doing alright' (IRR 1.20, 95%CI 1.01-1.43), and 'just about getting by' (IRR 1.31, 95%CI 1.04-1.65) were more affected by pain in the last week of life. Difficulty accessing care did not mediate this association. This association was moderated by location of care (F(14) =107.9, p < 0.001) and was not seen in care homes. Sensitivity analysis suggested high potential for unmeasured confounders (E-values between 1.70-1.95 for the main exposure categories). This study demonstrates that lower financial status is associated with being more severely or overwhelmingly affected by pain in the last week of life.