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Background. The U.S. population is aging and increasingly culturally diverse. The challenges of an aging population desiring a good end to their lives combined with soaring costs for medical care serve as a mandate for providers to be aware of both patient preferences and other factors influencing decision-making at the end of life. Methods. Systematic review of published research studies examining African American preferences related to end-of-life care and decision-making. Findings. There are well documented differences in preferences for end-of-life care and utilization of services between non-Hispanic Whites and African Americans. African Americans do not use advance care planning (ACP) documents or hospice to the same extent as non-Hispanic Whites, and, even after controlling for income and access, the difference is significant. Many African Americans choose aggressive life-sustaining treatment at the end of life, even if that treatment seems likely to confer great burden with little chance of benefit. The reasons for this are multi-faceted and include knowledge of and access to services, historical mistrust of the health care system, and spiritual beliefs. Conclusions. African American end-of-life choices are influenced by knowledge of and access to services as well as by shared cultural beliefs in the role of family and others in decision-making, mistrust toward the health care system, and the importance of spirituality.