Why are the vulnerable people less likely to receive end-of-life care consistent with their values ​​and preferences?

First of all, it's important to know that, in the U.S. and Canada, without an explicit note in the medical record, every person is subject to all life-sustaining interventions, including cardiopulmonary resuscitation, mechanical ventilation, and admission to an intensive care unit. So it's crucial to be informed about life-sustaining interventions, to understand their risks and benefits, and to understand how to make our values and preferences known and respected well in advance of an episode of serious illness. This means first of all being aware that this field of decision-making exists, knowing that it is perfectly legal to refuse or discontinue care, but above all, it requires a good level of death literacy.

Death literacy

Death literacy is defined as the knowledge and skills needed to access, understand, and act on end-of-life care preparation. It is the practical knowledge needed to plan effectively for the end of life, for oneself or for those in one's care. Level of health literacy and level of education are some of the determinants of death literacy. Evidence suggests that people increase their death literacy through direct personal experience of caring for someone at the end of life, religious and community activities, and the school environment. I would add that being in contact with people working in the field of palliative and end-of-life care contributes to increasing levels of death literacy.

Lack of access to care leads to lack of access to palliative care

Vulnerable communities often face barriers to accessing healthcare in general, and palliative or end-of-life care is no exception. At the end of life, inequalities persist and are even multiplied! This raises a question:

It has been established that the majority of people in Canada who have recourse to medical assistance in dying (voluntary euthanasia) are well-off people. Does this mean that the original fear that the most vulnerable would resort to this care for lack of access to alternatives has been refuted? Or does it mean that more vulnerable people don't have access to medical aid in dying because they don't have a sufficient level of death literacy?