Multilevel determinants of palliative care access in 27 European countries

Background

Europe is experiencing population ageing with increasing “slow dying” and serious health-related suffering becoming a major public health challenge. Despite being a recognised right, palliative care (PC) remains unevenly implemented. This study examines factors influencing PC access across micro-, meso-, and macro-levels, assessing whether inequalities persist beyond clinical need.

Methods

Data from SHARE (Waves 7–9) were analysed, including decedents with a completed end-of-life proxy interview and a cause of death consistent with PC needs. The outcome was self-reported PC access in the last month of life. Given the hierarchical structure (individuals nested within 27 EU countries), multilevel logistic regression models were estimated. We fitted a null model, a micro/meso-level model assessing compositional effects (including age, sex, education, income, household size, cause of death, symptom burden, and area of residence), and a full model adding a macro-level predictor (welfare regime).

Results

A total of 5,320 individuals were included. The null model attributed 9.4% of the variance to country-level differences, which did not decrease after adjustment for individual determinants (ICC = 0.11), but declined to 0.06 after including welfare regimes. Compared with Nordic systems, Eastern regimes showed lower access (OR 0.39, 95% CI 0.21–0.74).Symptom burden was the strongest predictor (OR 3.52, 2.74–4.52), and diagnosis-based disparities persisted, (organ failure vs cancer: OR 0.27, 0.23–0.31). Socioeconomic factors were not significant, whereas rural residence was associated with lower access (OR 0.78, 0.61–0.99).

Conclusions

Inequalities in European end-of-life care appear to be driven less by socioeconomic status than by geopolitical context, geography, and diagnostic labelling. Addressing these gaps requires shifting to needs-based eligibility and strengthening community-based services to support non-cancer trajectories and mitigate geographic barriers

Key messages

• Palliative care access in Europe is shaped more by welfare systems, geography and diagnosis than by socioeconomic status, highlighting structural inequalities in end-of-life care.

• Non-cancer and rural patients face lower access to palliative care, supporting a shift toward needs-based eligibility and stronger community services.