Background Males receive more aggressive care near death. End-of-life (EOL) conversations can protect from aggressive care near death and support more consistent EOL care. Therefore, information about gender effects on engagement in and realization of EOL conversations are needed.

Methods In a cross-sectional study 186 cancer patients from an university and rehab hospital were asked about their preferences for EOL discussions using a semi-structured interview, focusing on a) the importance of six different EOL issues (medical and nursing care, organizational, emotional, social and spiritual/religious aspects), b) the desired time point, c) mode of discussion initiation.

Results The importance of EOL topics differ significantly by issue (p=.002, η2=.02) and gender (p< .001, η2=.11). Females want to speak more about nursing care, emotions, social and religious aspects. Males wish to avoid the engagement in EOL issues and conversations. They prefer to be addressed only about nursing and medical care, whereas females want to be addressed about all EOL topics. Independent of gender, the majority of patients prefer to talk rather late: When the disease is getting worse (58%) or at the end of their palliative therapy or self-sufficiency (27.5%).

Conclusion Because of distinct gender differences for engagement in and realization of EOL conversations a gender sensitive approach is recommended. Independent of gender, the tendency of patients to talk late about EOL issues should be considered to reduce the risk of delayed or neglected EOL conversations. Therefore, a two-step approach of end-of-life conversations is suggested.