Dying in a Homophobic Nation: Addressing Healthcare Disparities, Advance Care Planning and Surrogate Decision-Making Challenges for Sexual and Gender Minority Older Adults at End-of-Life.

Promoting autonomy in medical decision-making is an essential part of palliative care. Therefore, palliative care providers should prioritize supporting the autonomy of sexual and gender minority (SGM) older adults, a community that has historically suffered from healthcare disparities. This support is particularly significant when an illness or injury renders a patient unable to make medical decisions, necessitating the designation of a surrogate decision-maker. Surrogate decision-maker policies vary by state and largely do not represent patients whose support systems are outside of the biological family. This article reviews healthcare disparities experienced by SGM older adults, including higher rates of certain health conditions and barriers to accessing care due to stigma and discrimination. It also highlights the compounded challenges faced by SGM individuals who are part of racial and ethnic minority groups. The lack of inclusive surrogate decision-making policies exacerbates these disparities, as many SGM older adults do not have legally recognized partners or children to act as decision-makers. The absence of inclusive policies for surrogate decision-making results in distress for patients, families, loved ones, and medical providers. This article discusses the importance of advance care planning and completion of advance directives for this population to ensure patient wishes are respected. Palliative providers need to advocate for surrogate decision-maker policies that are more inclusive of families of choice.