Determining the medical appropriateness of care during the final months of life, as recorded in billing information, is difficult. Further, billing data do not record patient preferences and expressed wishes. However, assuming that patient preferences are similarly distributed across rural and urban beneficiaries, examining differences in care during this period suggests areas for possible improvement that might both reduce potentially inappropriate care and better comply with patient desires. Overall, rural decedents were more likely to have used outpatient clinic services and less likely to have used inpatient, ambulance, home health, and hospice services. It cannot be ascertained whether these differences result from patient preferences or from differences in facility availability, but they suggest a more conservative use of resources for rural decedents. Lower use of hospice services among rural residents may represent an opportunity to further reduce utilization of acute services. Participation in hospice care was found to reduce the likelihood of inpatient, SNF and ambulance use, while being linked to a greater probability of home-based care. Encouraging use of hospice care among patients for whom this service is appropriate could be beneficial both for overall health services use and for patients. Given that much higher proportions of rural residents visited a physician or outpatient clinic during their last months of life than were hospitalized, discussions of hospice and other forms of palliative care may be best undertaken in those settings. Further research is needed to examine service availability in rural areas, particularly for hospice, and to clarify how availability may affect care at the end of life. Identifying and promoting successful models for hospice care, particularly in remote rural counties, is also needed.