The risk of complications and death from COVID-19 is markedly skewed toward older adults. The US Centers for Disease Control and Prevention (CDC) recently wrote, "Given their congregate nature and residents served (eg, older adults often with underlying chronic medical conditions), nursing home populations are at the highest risk of being affected by COVID-19. If infected with SARS-CoV-2, the virus that causes COVID-19, residents are at increased risk of serious illness." 1 However, in the United States and many other countries, nursing homes are not the only congregate setting that serves older adults with underlying chronic medical conditions. More so, they have been a shrinking component of the residential long-term care system, with some of the largest growth having been in assisted living (AL). AL communities provide supportive care, at least 2 meals a day, and 24hour supervision to individuals who need daily supportive care, but not daily nursing care. 2,3 Recent estimates are that there are 30,200 licensed AL communities across the United States, providing care to more than 835,000 residents 4 dwhich constitutes almost 40% of persons who receive residential long-term care in this country. More than half of the AL residents are "old-old" or "oldest-old": 53% are aged 85 or older, compared with 42% in nursing homes and 47% receiving hospice. 4 More so, many have the chronic underlying conditions implicated in COVID-19: 34% have heart disease, 17% have diabetes, and 15% have lung disease (chronic obstructive pulmonary disease and allied conditions), and more than a quarter have between 4 and 10 chronic health conditions. 5 Thus, the AL population is at high risk for being affected by COVID-19 and suffering serious outcomes.Importantly, AL communities are not the same as nursing homes. In fact, there are several distinct components of AL that make this a unique setting and one not to be ignored in relation to planning and response. This editorial summarizes key differences and their related implications for care.

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This study examined racial, ethnic, and other factors associated with whether older adults discussed their end-of-life (EOL) care wishes with family. A sample of 223 White, 95 African American, and 46 Hispanic adults aged 50 and older from a five-county area of Florida answered questions about sociodemographics, health, and preferences for involving family/friends in health-care decision-making. Analyses describe associations between whether discussions occurred and race/ethnicity and other factors, including preferences for family/friend involvement in health care. In descriptive analyses, one third ( n = 113) had not discussed EOL care. No differences were evident between African Americans and non-Hispanic Whites. In multivariate analyses, EOL care discussions were less likely for Hispanics. Further analysis showed this lower likelihood existed among Hispanics with lesser family/friend involvement. Ethnicity influences EOL care discussion, moderated by family/friend involvement, though results are considered preliminary. Knowing the involvement of patients’ family/friends could help providers initiate EOL care discussions.

It is important to understand the differing experiences and attitudes of those who do or do not engage in EOL discussions. Research is needed on healthcare practitioners' use of decision-making tools to help patients discuss their EOL care preferences with family and others, the goal of which is to provide care consistent with patients' goals.