Who Cares at the End of Life? Unmet Care Needs across 32 Countries

Rapid population aging and shrinking families are reshaping the demand for end-of-life care, yet cross-national evidence on unmet needs remains scarce. Using harmonized end-of-life survey data (2010–2021) on decedents with activity limitations from the United States, 28 European nations, South Korea, Mexico, and China, we document a striking pattern: the United States, Europe, and South Korea exhibited higher overall unmet care than China and Mexico, where sparse formal care was offset by near-universal family care. Death in an institution was associated with lower unmet care in the United States and South Korea, but not in Mexico, and urban residence in Europe and South Korea was associated with less unmet formal care than rural residence. Contrary to expectations, married Europeans faced more unmet care than their unmarried peers, with only Mexico showing the anticipated protective effect of marriage. Having children was consistently associated with lower unmet informal care across the United States, Europe, and South Korea. Results indicate that expanding formal care alone does not fully substitute for declining family care, and that policies must strengthen both systems while addressing sociodemographic disparities in access.