Table 1.

Table summarizing critical appraisal and descriptive analyses from each of the 15 studies included in review. Table includes article title and year of publication, strength rating, checklist used, context of study (where relevant), reasons for rating, and key findings and themes.

Article Title (Year)	Strength Rating	Reasons for Rating	Findings & Themes
Differences in Symptom Distress Based on Gender and Palliative Care Designation Among Hospitalized Patients (2016)30	Moderate (NICE quant). Inpatients in Sweden.	Pro: Exploratory secondary analysis with reasonable effect sizes & p values/CI. Con: No details of subgroup analysis, no power calculation, not generalizable outside admitted pts & excluded dementia.	Females: More live alone. More pain, fatigue, nausea despite similar documentation by HCPs.
Differences in Terminal Hospitalization Care Between U.S. Men and Women (2016)31	Moderate (NICE quant). Inpatients in US.	Pro: Large sample size. Adjusted for many variables. Precise, narrow CIs. Cons: No validation or justification for outcome measures picked. Small effect size. No detail on subgroup analysis. Info by billing/claims alone (unclear if SDM vs patient vs default decision of code status). Only 20% of all discharges included. Only inpatients in US hospitals.	Females: Older, less likely to be married. More likely under general care versus specialist care, shorter hospitalizations. More likely to have DNR & less likely receive ICU care.
Gender and family caregiving at the end-of-life in the context of old age: A systematic review (2016)3	Weak (AMSTAR).	Pro: Relevant. Thorough & explicit search. Multiple reviewers. Cons: No description of included/excluded articles. Did not include assessment of articles. No risk of biases or heterogeneity discussed. No evaluation of internal/external validity of any included studies. No details on “feminist quality appraisal framework” mentioned in study.	Female: Caregivers more mental & physical strain (societal expectation to provide more care at end of life, home care increase responsibility of women). Less likely to receive informal care, not wanting to be burden. More likely live in poverty.
Until the very end: is there equity in palliative care? (2014)32	Weak (letter format).	Letter to editor. Difficult to appraise as no study conducted.	Perspective on cultural norms affecting gender influences on end of life. Females: Live longer, lower salaries. Husband dies at home with care from wife & uses old age pension. Less $ and need to go to nursing home for wife. Husbands not allowing palliative care or means to access. Social castigation.
Gender differences in prevalence of depression among patients receiving palliative care: the role of dependency (2011)33	Weak (NICE quant). 1 hospice London.	Pros: Thorough dependent variables included. Confounders adjusted. Strong effect size. Cons: Wide CI. No power calculation, sample size 300 arbitrarily chosen. Depression measured via yes/no validated scale instead of spectrum or severity. No rationale for changing categorical variables to binary. Only 1 hospice in London, study funded by this hospice. 40% participation.	Males: Equal or more depression than F compared to outside palliative context. Dose response effect between level of dependency & depression in men.
Gender Differences in Caregiving at End of Life: implications for Hospice Teams (2015)7	Weak (NICE quant). 2 hospices NW USA.	Pros: Adjusted outcomes for demographics. Internally consistent scale for burden across 5 domains. Cons: Secondary analysis off RCT. No info on selection & potential biases. Demographic table had no p values/significance. Small effect sizes, no power calculation. CIs close to 1. Internal validity outcome measure only 0.62-0.83. No info on who did analysis or potential biases. Only applicable to 2 hospices in NW USA, caregiving burden likely greater in home versus hospice.	Females: Caregivers lower self esteem, more negative impact on schedule, health and family support.
Preference for Palliative Care in Cancer Patients: are Men and Women Alike? (2018)14	Weak (NICE quant). 2 cancer centres Buffalo NY and Sacramento CA.	Pros: Logistic & ordinal regression adjusting for confounders. Good effect size. Cons: CI wide, no power calculation. Secondary analysis off cluster RCT but no info about selection (even original VOICE trial no discussion of selection bias or % participation). No calculation of power for clusters. No discussion of how many researchers or inter-rater reliability. No rationale for why excluded hematologic cancers. Outcome measure not validated. Subjective 5 item scale arbitrarily turned into binary variable. Only represents clinic/community sample in 2 US cities.	Females: More likely prefer palliative care, no difference based on education level (could be under powered). Societal beliefs push men to “fight” disease. Focus on helping men understand benefit to family.
Exploring the gender dimension of problems and needs of patients receiving specialist palliative care in a German palliative care unit-the perspectives of patients and healthcare professionals (2019)6	Moderate (NICE qual). 1 inpatient palliative unit Germany.	Pros: Relevant. Defensible design. Aim clear. Purposive stratified sampling for diversity. Cons: No discussion of how they minimized selection bias or cherry-picking patients. Limited description of data collection, what was included in interview, or how they came up with word cards. No description of research explanation to participants. No reflexivity. Only 1 method of data collection. Small sample size. Social desirability bias. Bias depending on participants’ ability to reflect & introspect.	Females: More expressive coping strategies, care more about physical appearance, stronger need for communication & support, activate extended network. Worried about domestic & caring duties, worried more about being a burden. Males: Rely on partners more, greater expectation for care at home & autonomy, more reluctant to take advice from female HCP. Worried about transferring financial/legal duties. Expected partner to take caregiving role.
Sex Differences in Quality of Life and Clinical Outcomes in Patients With Advanced Heart Failure: Insights From the PAL-HF Trial (2020)34	Weak (NICE quant). 1 centre Durham, NC, USA.	Pros: Randomized. Reliable & validated outcome measures. Reasonable FU & loss to FU. Exploratory analysis off RCT. Cons: Underpowered subgroup analysis. No power calculation. Only 1 centre. No justification for only including high risk sample. Selection unclear. No % who agreed to participate. No mention of when ESCAPE score calculated. Excluded those with non cardiac terminal illness (not generalizable). Did not define “terminal illness”. No blinding though likely could have blinded cardiology team. Authors are cardiologists – conflict of interest. Unclear how much crossover. No mention of # lost to FU in each group. Significant baseline differences (HFpEF more in F). No effect sizes. Graph lines not labelled (range, IQR, CI?). Precision unable to assess but lines overlapping and study underpowered.	Females: Greater symptom burden & poorer QOL, more had co-morbid depression. More widowed. No change in QOL with palliative care compared to change in QOL in men with treatment.
Witnessing a body in decline: Men's and women's perceptions of an altered physical appearance (2016)35	Weak (NICE qual). 2 hospices near Lisbon Portugal.	Pros: Relevant. Clear aim. Organized result presentation. Cons: No detail on methods or how interview conducted/structure. No discussion of biases, how participants selected, % agreeing to participate. No reflexivity, one researcher. No ethical discussion/approval. No discussion of how conclusions drawn from data. Small sample size without justification. No inclusion/exclusion criteria. Not generalizable outside Portugal (culture differences).	Females: Appearance is more of social currency & value. More discrimination against F with obvious aged appearance (objectification of women). Similar importance of weight in F versus M. Hair loss more effect on F because linked to femininity – hair dye & painting nails  =  control/agency.
Gender and the language of pain in chronic and terminal illness: A corpus-based discourse analysis of patients’ narratives (2018)36	Strong (NICE qual). Database by University of Oxford.	Pros: Relevant, clear aim. Results presented organized. Good research design with qualitative & quantitative approach. Dataset vigorously & systematically collected. Analysis thorough, systematic & well explained. Conclusions in depth. Good discussion of limitations & practical implications for practice. Mostly generalizable. Cons: Limited to 16 common conditions, may not be generalizable to everyone if they don’t have one of these.	Females: Refer to pain more, wider lexical repertoire to describe, use more cognitive & psychological words. Routinely undertreated for pain (seen as exaggeration, anxiety or emotional distress). Pain more “natural” for females. More sadness & crying. More likely to share pain with HCP & treat as shared goal, more likely to use pluralistic/holistic healthcare methods. Males: Taught to suppress expression of pain because “unmanly”. Use more facts & descriptions. More anger. Discussion surrounds helplessness & vulnerability. Reliance on wife more.
Gendered Processes in Hospice Palliative Home Care for Seniors With Cancer and Their Family Caregivers (2016)24	Strong (NICE qual). Hospice program at Western University.	Pros: Relevant, clear aim. Well thought out research design with validated methods. Ethnographic methods of triangulation used. Multiple data informants, methods, theories/perspectives. Researcher role clearly defined with excellent reflexivity. Analysis systematic and themes related by diagramming. Reviewed by co-authors. Cons: Population not that diverse (all White sample, all nurses were F). Could have used multiple researchers for more perspective.	Regulating gender relation: Assert power. HCP delegate more work to female caregivers. Male caregivers assume nurses do all caring, appeals to physician to help make decisions instead (man's job). Normalizing gender relation: Females expected to do physical care work, males more buying supplies/meds etc Blurring of “caring for” with “caring about” for F. Equalizing gender relation: Deflect gender as a contributing factor. HCPs claim to treat M/F same. Though F caregivers assume most care they are not thought to (renders work invisible).
Critically examining diversity in end-of-life family caregiving: implications for equitable caregiver support and Canada's Compassionate Care Benefit (2012)37	Moderate (NICE qual). PCP from BC, MB, ON, QC, NL from admin, clinical, home care settings.	Pros: Relevant, clear aim. Diversity of provider roles & settings. Data analysis rigorous, reviewed by multiple investigators. Cons: Evaluating CCB use with “utilization focused evaluative approach” but did not study in intended users (caregivers) so does not fit with outlined approach. Sample limited to 5 provinces. Unclear what patient diversity is & no context for patients. No method triangulation. One researcher conducted interviews, no reflexivity.	Many not aware of CCB, access affected by intersectionality. Females: Less likely to qualify because stay home or part time work. Get less with it due to lower income. Males: Less likely to receive benefit, underutilization for their often female patient. Need to be taught caring roles & managing home.
'Because it's the wife who has to look after the man': A descriptive qualitative study of older women and the intersection of gender and the provision of family caregiving at the end of life (2017)4	Moderate (NICE qual). Focus groups in New Zealand.	Pros: Relevant, clear aim. Two researchers conducted focus groups. Findings convincing and results reported in organized manner under 3 main themes. Vignettes were previously deemed useful in research. Cons: Study population lacks diversity (white, heterosexual, older women) even though men present in group. Selection bias through recruiting in community organizations that lobby for older people. Only one method data collection. Vignettes to stimulate discussion very gender normative. No role descriptions or reflexivity. Insufficient detail on thematic analysis.	3 themes: Expectation that women care (despite burden), women's duty to care (internalized gender normative beliefs), women's construction of men. Females: Community care really means unpaid care by families which usually burdens women more. Depression & caregiving strain higher. Norms of expectation to act compassionately & sympathetically, being sensitive to others, willing to put others before self even if ill health. Duty as “good daughter or wife”. Often assumed as carer & supports provided instead of assumption challenged. Males: Need to be seen as strong, independent, self-sufficient.
Gender and palliative care: a call to arms (2020)5	Weak type of study as only critical essay but strongly presented.	Critical essay, literature review. Difficult to critically appraise as no study done. Pros: thorough discussion, offers insight into complexity of issue (also have to consider intersectionality, gender as no longer a binary construct). Good practical steps at end for research & for practice.	Females: Experiences less visible. “Unfeminine” if put career before being wife/mother. Less likely to seek & accept formal support, usually invisible & economically undervalued work. Expectation to provide care so husband can have good death. Guilt/feeling of failure when cannot. HCP assume F need less help caring. More fatigue & greater severity. Continue to do housework & care post diagnoses. More accepting of palliative care but do not benefit from early integration as much as men. Accept dying outside home due to fear of being burden after living longer & being caregiver. More likely poverty (unequal pay/working conditions). Males: Less likely report emotional concerns. More likely to die at home.

Thematic Analysis Legend: Living situation Care context Symptom experience Care preferences Caregiving Coping strategies.