Where do we die? Socioeconomic and cultural drivers of End-of-Life locations using SHARE survey

Abstract Background The place where people die reflects not only individual preferences and clinical needs, but also broader socioeconomic and cultural factors. Dying at home is often associated with greater dignity and alignment with patients’ wishes, yet many die in hospitals or institutions. This study explores whether socioeconomic status (SES) influences the place of death among older adults in Europe, and how this relationship is shaped by familialistic cultural contexts. Methods We use data from the Survey of Health, Ageing and Retirement in Europe (SHARE), using the module the End-of-Life (XT) completed by proxies of deceased respondents. The sample includes over 1,500 cases from 17 European countries. We classify places of death into three categories: hospital, home, and institution (e.g. nursing homes). Using concentration indices (CI), we assess whether socioeconomic position affects the likelihood of dying in each setting. Analyses are stratified by familialistic and non-familialistic countries. Results We find significant socioeconomic inequality in EoL location. Overall, individuals with higher income are more likely to die in institutions (CI = 0.111), while lower-income individuals are more likely to die at home (CI = -0.120). This gradient is stronger in non-familialistic countries (CI = 0.147 for institution; CI= -0.157 for home). In familialistic countries, the gradient is reversed: higher-income individuals are slightly more likely to die at home (CI = 0.148), while institutional deaths are more frequent among those with lower income (CI = -0.132), suggesting a stronger role of informal family care in shaping end-of-life experiences. Conclusions Our study suggests that place of death is not only a clinical or personal matter but also a reflection of social inequality. Policies aimed at improving end-of-life care should consider socioeconomic barriers and cultural expectations, ensuring equitable access to dignified deaths across social groups. Key messages • Place of death is shaped by socioeconomic inequality - those with lower SES are more likely to die in hospitals. • Cultural expectations around family caregiving amplify disparities in end-of-life experiences across Europe.