Background: Most cancer patients prefer to die at home, a location associated with better quality of death (QoD) and caregiver outcomes. A number of studies demonstrate disparities in end-of-life (EoL) care among immigrant vs non-immigrant populations in the U.S. This study aims to evaluate how immigrant status affects location and QoD among patients with advanced cancer in the U.S. Methods: Data were derived from Coping with Cancer, a federally funded multi-site prospective study of advanced cancer patients and caregivers. The analytic sample of patients who died during the study observation period was weighted (N_w=308) to reduce statistically significant sociodemographic differences between immigrant (N_w=49) and non-immigrant (N_w=259) groups. Immigrant status was determined by patient self-report. Primary outcomes were location of death (intensive care unit, hospital, nursing home, inpatient hospice, home), death at preferred location (yes/no, as per caregiver report in post-mortem interview), and poor QoD (composite score of post-mortem caregiver ratings for patient psychological distress, physical distress, and quality of life in the last week of life). Results: As compared to non-immigrants, immigrants were more likely to die in a hospital as opposed to home [AOR 3.33; 95% CI (1.65-6.71); p=0.001] and less likely to die where they preferred [AOR 0.42, 95% CI (0.20-0.90); p=0.026]. As shown in Table, values-inconsistent aggressive EoL care mediated the effect of immigrant status on death at the patient s preferred location. Further, immigrants were more likely to have poor QoD [AOR 5.47; 95% CI (2.70-11.08); p<0.001]. In particular, among patients who preferred symptom-directed, comfort EoL care, immigrants as opposed to non-immigrants were more likely to have poor QoD [AOR 9.53, 95%CI (4.05-22.40); p<0.001]. Conclusions: Immigrants, as compared to non-immigrants, are more likely to die in hospital settings, less likely to die at their preferred location, and more likely to have poor QoD. These findings are consistent with previously described inequities in EoL care of immigrants and highlight the importance of determining the potential causes and solutions to ensure immigrants receive values-congruent care.

Notes: All AOR s adjusted for patient sex and level of education AOR s for Death at Preferred Location also adjusted for post-mortem survey respondent (i.e., formal or informal caregiver).