Access to hospice and palliative care remains markedly uneven across racially and culturally diverse and Indigenous populations in the United States — a health equity issue gaining renewed attention as the population ages and care needs increase.

A 2024 review of international studies found that older people from minority ethnic groups consistently face greater obstacles in accessing end-of-life and palliative care compared with majority populations. In the U.S., an integrative review of U.S.-based research identified disparities across five core dimensions of access — from awareness and acceptability to affordability, availability, and appropriateness of care. Evidence suggests in many settings, minorities are less likely than white patients to receive hospice or palliative care when seriously ill.

A detailed analysis by researchers at Johns Hopkins Medicine and collaborating institutions found that among older adults approaching end of life, 46.2 percent of white patients used hospice services over a given period, compared to only 34.9 percent of Black patients. Hopkins Medicine Moreover, Black patients in that study were more likely to receive aggressive treatments in their final months — including intensive care interventions and repeated hospitalizations — rather than comfort-focused hospice care.

Differences in utilization seem tied not only to individual or family preferences but to systemic factors. A 2020 retrospective study across four urban hospitals found that after adjusting for patient characteristics, race and ethnicity did not significantly predict whether patients received an inpatient palliative-care consultation, though discharge to hospice was influenced by hospital-level factors. Still, that same and other studies highlight that many research efforts lack robust representation of racial and ethnic minorities. As one review of hospice and palliative medicine research shows, while nearly all studies include white participants, only about 71 percent include Black people, 43 percent include Hispanics, fewer include Asian participants, and far fewer include Indigenous peoples.

Part of the challenge lies in acceptability, communication, cultural beliefs and awareness. For many communities of color and Indigenous populations, cultural values shape views on illness, suffering, dying, family roles, and decision-making in ways that may diverge from standard Western hospice models. Services that do not reflect culturally or linguistically appropriate practices may feel alien or even threatening. Research and advocacy groups argue that inequities arise from “discrimination and racism, biased health-care responses to culture, religion and race, miscommunication and lack of translation services,” along with structural issues such as uneven distribution of resources and underinsurance in minority communities.

Geographic and socioeconomic inequalities intensify those barriers. Patients living in underserved urban or rural areas — often with high proportions of racial or ethnic minorities or Indigenous people — may have fewer hospice or palliative programs nearby, or services that are underfunded or overburdened. Even when services exist, a dearth of culturally competent clinicians limits their effectiveness; a recent report noted that while the number of hospice and palliative care fellowship programs has grown substantially in recent years, racial and ethnic diversity among trainees remains limited.

For Indigenous communities and other historically marginalized populations, this lack of representation contributes to ongoing mistrust. Historically rooted neglect and systemic inequities in healthcare access foster skepticism toward end-of-life care systems that have not honored cultural traditions, community decision-making, or spiritual practices. In such contexts, standard hospice models may feel out of place or even disrespectful.

Health equity advocates say addressing these disparities requires systemic change. Care providers and institutions must prioritize cultural competence, invest in translation services and community outreach, embed palliative care offerings in under-resourced areas, and recruit more diverse clinicians. Research efforts likewise must commit to inclusion and transparency, standardizing race and ethnicity reporting and analyzing care outcomes with an equity lens.

As the U.S. population grows older and more diverse, demand for high-quality end-of-life care will only increase. Ensuring that hospice and palliative care serve all communities equitably — regardless of race, ethnicity, language, or cultural background — remains a pressing public health and social justice challenge.

In the coming years, closing this gap will require concerted effort from policymakers, health systems, and community leaders alike, with the goal that dignity, comfort, and respect in life’s final chapter are available to everyone.