Table 3

Key barriers to ACP sorted by socioecological levels of influence and ranked by frequency

Level identifiedBarrierNo of studiesReferences
Individual levelLack of (consumer) knowledge about ACP15 14 39 44–46 49 54 56 57 59 62 66 72 79 82
Attitudes—perceived irrelevance7 13 14 39 40 44 50 76
Trust/questions of efficacy4 40 41 44 57
Denial/emotions/reluctance10 14 32 39 40 44 50 54 56 57 72
Interpersonal levelRole ambiguity—GP expectation patient will initiate discussion about ACP7 13 46 51 56 58 62 83
Role ambiguity—patient expectation GP will initiate discussion about ACP5 41 42 49–51 83
GP—patient relationship5 44 49 55 57 62
Concern with family relationships6 13 14 32 39 44 74
Preference for informal discussion with family1 13
Provider levelLack of (GP) knowledge/skills/confidence18 14 31 44 46 49 53–56 58–60 63 69 74 77–79
Lack of time12 14 39 46 53–55 58 61 66 74 76 79
Misc concerns including legal uncertainty, prognosis, best time9 54 55 60 61 68 70 75 78 83
Doubts about efficacy of ACP3 44 58
System levelLack of linkages and mechanism for sharing ACP5 31 44 54 58 60 80
Lack of funding mechanisms2 56 60
Lack of standard templates, tools, documents, IT systems6 44 45 53 57–59
Accountability1 46
  • ACP, advance care planning; IT, Information technology.