Barriers and facilitators to offering palliative care to patients with heart failure: a mixed-methods systematic review using the COM-B model and theoretical domains framework

Abstract

Objectives

Despite palliative care (PC) potentially improving quality of life, only a tiny proportion of patients with heart failure (HF) are receiving PC. Globally, PC for HF patients faces several challenges; however, a systematic assessment of the barriers and facilitators to PC of patients suffering from HF is lacking. We aimed to identify barriers and facilitators to offering PC to HF patients.

Design

The mixed-methods systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement.

Data sources

PubMed, CINAHL, MEDLINE, PsycINFO, Web of Science were searched from onset of literature database to 24 March 2025.

Eligibility criteria

We included both qualitative studies and quantitative studies addressing barriers and facilitators to offering PC to patients with HF reported by healthcare providers, patients, family members and caregivers.

Data extraction and synthesis

Data extraction was done independently by two reviewers, and quality assessment was completed using the mixed-methods appraisal tool. The Capabilities-Opportunities-Motivations-Behaviour (COM-B) model and the Theoretical Domain Framework (TDF) were used to identify potential barriers and facilitators.

Results

48 studies were included out of 4168. 289 items related to barriers and 88 items related to facilitators were categorised into 72 themes. These themes were found to align with at least one of the 14 TDF domains and the COM-B model. ‘Environmental context and resources’ (eg, lack of time, human, facilities and equipment resources; 77.2% of barriers vs 22.8% of facilitators), ‘knowledge’ (eg, insufficient awareness and knowledge of PC and/or needs; 91.8% of barriers vs 8.2% of facilitators) and “‘social influences’ (eg, limited communication and collaboration between healthcare professionals; 58.7% of barriers vs 41.3% of facilitators) were the three TDF domains that encoded the largest amount of data.

Conclusions

This review identified key barriers to PC for HF patients, primarily involving resource limitations, knowledge gaps and poor interdisciplinary collaboration. Findings highlight the need for targeted interventions addressing systemic and knowledge-related challenges.

PROSPERO registration number

CRD42023484807.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This systematic review comprehensively searched the literature on barriers and facilitators affecting palliative care for heart failure patients and innovatively analysed these factors from a behavioural change perspective.

• The use of the Capabilities-Opportunities-Motivations-Behaviour and Theoretical Domain Framework (TDF) to synthesise the literature provides a framework for selecting the most viable ways to overcome these barriers.

• However, a limitation of the TDF is that all mapped items are given the same weight, which may have the impact of over-representing or under-representing important factors.

Background

Heart failure (HF) is a prevalent cardiovascular condition, which is characterised by notable morbidity and mortality rates, reduced quality of life and substantial financial burdens.¹ Despite stable or slightly declining incidence rates, there has been a rise in prevalence owing to the advancement in HF therapies and increased life expectancy among individuals.^{1 2} It is estimated that there are 64.3 million people with HF in the world,³ with prevalence rates ranging from 1% to 3% of the general adult population in industrialised countries.¹ Notably, due to the increasing demographic burden, global spending on the management of HF patients has increased and will reach approximately US$400 billion by 2030.⁴ Therefore, reducing the social and economic burden of HF patients is a global public health imperative.

WHO regards palliative care (PC) as the prevention and relief of suffering of adult and paediatric patients and family members experiencing challenges connected to life-threatening disease.⁵ These issues include physical, psychological, social and spiritual distress.⁶ PC began with the care of cancer patients and has since expanded to include the care of all individuals impacted by life-limiting diseases, including HF.⁷ Depending on the patient needs and disease stages, PC can be categorised into primary, specialist, generalist and hospice care.^{5 6} Hospice care is a subset of PC for terminal illness, typically with a prognosis of ≤6 months, and it focuses on comfort-focused care, family support and bereavement services.⁸ Previous studies⁹ showed that PC interventions might alleviate symptom burden, depression and improve quality of life (QoL) in HF patients. Despite these data revealing the potential benefits of PC for persons with HF, only a small percentage of them obtain treatment. A study¹⁰ in the UK found that among patients with HF, 7% were entered on the PC register compared with 48% of cancer patients. Even in patients with advanced HF, PC was only provided in the last hours in 48% in Spain.¹¹ What are the reasons for this gap between the recommendations of authoritative organisations and those observed in clinical practice?

Previous studies have identified factors that may impede the provision of PC for HF patients. Such factors include the unpredictable course of HF, patient and family preconception of PC, insufficient knowledge, skills and education of healthcare providers and limited resources.^{12 13} The research on the barriers and facilitators of providing PC to HF patients is expanding, but the data are fragmented and give an ambiguous picture of the variables influencing the systemic provision of PC to HF patients from multiple perspectives.

The lack of theoretical insights is also a gap in the evidence base.¹⁴ Knowing how identified barriers and facilitators connect with theoretical understandings of behaviour change might aid in identifying strategies that lead to intended change in practitioners’ behaviour. The 14 domains of the Theoretical Domain Framework (TDF) align with the Capability-Opportunity-Motivation-Behaviour (COM-B) model (figure 1), which is a broader framework for understanding healthcare professionals’ (cardiologist, PC physicians, nurses, etc) behaviour, such as conducting PC assessment and making PC referral which directly connects to intervention development frameworks. TDF is a validated tool that facilitates the explanation of phenomena related to the implementation of best practice evidence in healthcare organisations.¹⁵ TDF is an extension of the COM-B model, which asserts that for any behaviour to happen, the individual has to possess the physiological and psychological competence, physiological and social opportunity and motivation to complete the behaviour. In our review, we applied the COM-B model and the TDF to map barriers and facilitators to the TDF domains, which can provide a direct link to intervention development frameworks. The domains were adapted to the COM-B model, allowing for theory-based development of intervention features and policy changes for each domain of the model.¹⁶ Therefore, the purpose of this study was to provide a theory-based review of barriers and facilitators that an interdisciplinary HF team experiences in referring patients with HF to specialist PC.

Figure 1. The TDF domains linked to the Capability-Opportunity-Motivation-Behaviour model subcomponents. Reproduced from a study by Atkins et al.⁶⁶ TDF, Theoretical Domain Framework.

Objectives

1. To identify barriers to and facilitators of offering PC to patients with HF.

2. To review how the identified barriers and facilitators align with theoretical understandings of behaviour change as represented by the COM-B model and TDF framework.

Methods

This review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. The protocol was preregistered on PROSPERO (CRD42023484807).

Information sources and searches

The following databases were searched by two experienced researchers (MP and YL), from onset of literature database until 24 March 2025: PubMed, CINAHL, MEDLINE, PsycINFO, Web of Science. The main search terms were ‘palliative care’, ‘heart failure’ and ‘barriers and facilitators’. The search strategy has been peer-reviewed by a medical librarian and can be seen in the online supplemental table 1.

Eligibility criteria and study selection

1. Both qualitative studies, quantitative studies and mixed-methods studies.

2. Address barriers and facilitators to offering PC to patients with HF reported by healthcare providers, patients, family members and caregivers.

3. Participants were restricted to adults (18 years).

4. Published in English.

5. Published in peer-reviewed journals.

The identified articles were uploaded to EndNote X9, where duplicates were detected and excluded. Two reviewers (MP and YL) looked through the remaining articles to find pertinent abstracts and titles. The same two reviewers resumed the blind screening procedure after obtaining full text that met the inclusion criteria and those whose eligibility was not quite obvious. Conflicts were resolved via discussion with the third author (WM).

Data extraction and quality assessment

Data extraction of first author; year of publication; title; country; objectives; study design; study participants, barriers and facilitators was done independently by two reviewers.

Quality assessment was completed independently by two reviewers using the mixed-methods appraisal tool (MMAT). The MMAT was created to assess the quality of various research designs using a single tool comprised of diverse criteria for papers.¹⁶ The tool consists of two screening questions and five questions per research design, with response possibilities of ‘yes’, ‘no’, and ‘can’t tell’. Conflicts were resolved via discussion with the third author (WM).

Data synthesis

The following three-step method was utilised to synthesise data:

1. Two reviewers independently identified, extracted and labelled barriers and facilitators in each article. Framework analysis was conducted to deductively code barriers and facilitators onto TDF domains and COM-B subcomponents. The third author (WM) was involved if there was disagreement between reviewers. This process involved creating tables to assist in the systematic categorisation of barriers and facilitators into relevant TDF domains and COM-B subcomponents.

2. Within each TDF domain, thematic analysis was conducted to group similar barriers and facilitators together and inductively generate summary theme labels. This thorough approach ensured the themes reflected the data’s underlying patterns and enhanced the reliability and depth of the analysis, leading to a more comprehensive understanding of the findings.

3. The most and least often reported domains’ rank order was determined by calculating the cumulative frequency of TDF domains identification. The results of the study are presented in tabular form with a narrative synthesis of the findings.

Results

Flow of studies through the review

4168 references were retrieved, 4119 were excluded, resulting in 48 studies being included in this review (figure 2).

Figure 2. PRISMA flow chart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

Characteristics of included studies

Of the 48 included studies,913 17,61 30 were qualitative; 14 studies were quantitative; the remaining four used a mixed-methods design. The study participants of 28 studies were healthcare providers, 11 were patients, two were caregivers and seven were at least two types of study participants. The studies were globally representative, with 22 from North America, 17 conducted in Europe, four studies carried out in Asia and three in Oceania, and one each from South America and Africa. Online supplemental table 2 lists the characteristics of the included studies.

Methodological quality

Ratings from quality assessment have been given (see online supplemental table 3). Of 30 studies that reported qualitative results, 26 rated ‘yes’ for all seven items of the MMAT.1317 19 22 24,27 32 33 35 36 39 40 42 43 45 47 In contrast, none of the 14 studies that reported quantitative results were rated as ‘yes’ on all seven items. Interestingly, only two studies,^{37 41} out of all the quantitative and mixed methods studies, were able to answer ‘yes’ to the question ‘is the risk of non-response bias low’. No studies were excluded after methodological evaluation. Finally, 26 of the 48 included studies were at a high quality and 22 were at a moderate quality.

Summary of findings

307 items were mapped to the COM-B model and TDF, and the extracted data for each domain are shown in online supplemental table 4. ‘Knowledge’ (37 out of 48 studies) and ‘environmental context and resources’ (37 out of 48 studies) were the TDF domains with the most representations across all studies. Following that was ‘skills’ (23 out of 48 studies). The least often represented domains were: ‘behavioural regulation’ (1 out of 48 studies) and ‘beliefs about consequences’ (2 out of 48 studies). There were no domains unrepresented.

Barriers to providing PC outnumbered facilitators, accounting for 76.7% (n=289) of all items mapped to the TDF domains unique to these constructs. 23.3% (n=88) items mapped to TDF represented facilitating PC (online supplemental table 5).

Numbering for TDF domains follows their original designation.¹⁴ Each of the 72 themes that have been found has been mapped to at least one of the 14 TDF domains and COM-B model components.

Capability (COM-B component 1)

17 themes relate to the capability component of the COM-B, including four TDF domains (knowledge; skills; memory, attention and decision processes; behavioural regulation) (online supplemental table 5).

Knowledge

Theme: did not understand the severity of patients’ illness

11 studies^{13 17 19 23 33 40 45 47 53 60 61} reported on the theme, seven^{13 19 23 47 53 54 61} of which were from healthcare providers. Most HF patients, caregivers and healthcare professionals did not view HF as deadly and were unaware of the disease’s progression because of its unexpected nature. They mostly talked about the next course of therapy; they did not talk much about advance care planning or the mortality of HF, and not many people had advance directives.

Theme: insufficient awareness and knowledge of PC and/or needs

Despite the awareness of PC in HF being growing, the public appears to be confused about the meaning of PC, thereby ignoring the needs of patients. The main areas of PC-related knowledge that HF patients lack include standard definitions, referral criteria, end-of-life discussions and specialty PC services.913 19 20 22 23 29 30 33 35 36 38 43,46 48 49 51 Three studies found that familiarity with end-of-life care pathways^{36 56 60} and two studies^{56 58} found that sufficient knowledge about HF among nurses was a facilitator.

Theme: perceived difficulty when and how to start or referral to PC

15 studies1319 23 24 29 32 34 43 50 54,57 60 61 reported that healthcare providers perceived it difficult to make referrals to PC. One study³⁸ showed that when patients were required to define a point in the disease progression at which to refer to PC, they consistently endorsed a late trigger for PC.

Skills

Theme: difficulty to respond to the fluctuations of a HF illness trajectory

The unpredictable, sometimes worsening, sometimes stabilising trajectory of HF often leaves healthcare providers and caregivers unsure of what the future holds. This sense of disease uncertainty is recognised as a barrier to accessing PC. 14 studies^{13 17 24 27 29 35 36 39 42 43 51 53 55 58} reported that it is difficult for HF specialists and PC specialists to cope with the fluctuations in HF illness trajectory.

Four other less frequently mentioned themes were also related to this TDF domain (online supplemental table 5).

Memory, attention and decision processes

Theme: facing difficult decisions about continuance or withdrawal of treatment and care

Five qualitative studies^{13 27 50 51 61} showed that it is difficult for healthcare workers to decide on the continuance or withdrawal of treatment, which implies making decisions about ‘active’ medicine. In addition, physicians have to make a judgement concerning whether or not to perform cardiopulmonary resuscitation on a HF patient during PC.

Five other less frequently mentioned themes were also related to this TDF domain (online supplemental table 5).

Behavioural regulation

Theme: early timing for referral

Many studies discussed the best time to transfer a patient to PC. Two studies^{23 56} identified that the action of early referral was associated with greater access to specialist PC for HF patients.

Opportunity (COM-B component 2)

There are 28 themes in the opportunity component of the COM-B, which includes two TDF domains (environmental context and resources; social influences) (online supplemental table 5).

Environmental context and resources

Theme: lack of time, human, facilities and equipment resources

This theme outlined the variables that affect HF patients’ ability to access services and resources. Healthcare providers reported a lack of time, human resources, facilities and equipment as a barrier to providing PC in patients with HF due to goal-driven priorities and limited commitment from district staffs.913 24 29 33,35 38 42 50 51 56 Gholami et al³³ suggested that attracting benefactors and charities for financial support for the establishment of PC for HF may address this topic.

Theme: unavailable or underused PC services

In the patients’ misconception, they believe that PC is for patients who are at the end of life and have no hope, therefore, they are rarely referred to PC.³⁰ 13 studies^{9 13 29 31 33 34 36 40 50 54 56 61} reported unavailable or underused PC services in HF patients in hospital and one²⁸ in community. Pragmatic criteria and²⁴ goals-of-care discussions²⁹ were commonly cited facilitators.

Theme: insufficient education or training on PC

Data from seven qualitative studies,^{13 18 19 33 45 47 58} five quantitative studies^{9 31 34 60 61} and two mixed-method studies^{28 56} showed most healthcare providers felt that they received insufficient education and training on PC for HF patients, especially HF physicians and nurses. Three studies on healthcare providers reported that ongoing professional education to expand competency is an important facilitator.^{35 55 56}

Social influences

Theme: limited communication and collaboration between healthcare professionals

Inadequate communication on the management of HF patients within a team and the interdisciplinary network was seen to be an obstacle to the prompt identification of PC need. A lack of communication and teamwork among healthcare workers was found.1921 27 28 33 36 42 43 51 53,56 60 61 Providing effective communication pathways and positive environments for healthcare providers by organisers as a facilitator factor in five studies.^{13 35 55 56 59}

Theme: poor social support

Nine studies^{9 33 37 40 49 51 60 61} reported that patients with HF felt that social support from healthcare providers is diminished due to the nature of the disease. Neglect of social and medical support for older adults with HF occurred with participants.³³ Study reported that healthcare providers lacked support to communicate with the HF patient.⁵¹ Building positive patient-caregiver^{9 17 18 33 58 59} and patient-healthcare provider^{13 22 26 33 38 45 56 59} relationships could act as a facilitator.

Motivation (COM-B component 3)

There are 27 themes in the motivation component of the COM-B, which includes eight TDF domains (intentions; goals; emotion; social/professional role and identity; beliefs about consequences; beliefs about capabilities; reinforcement; optimism) (online supplemental table 5).

Intentions

Theme: patients are not willing for PC involvement

Even many patients reacted positively after exposure to standard PC, only 2 of 27 patients showed previous involvement with the PC in Hadler et al’s study.³⁸ Seven studies^{9 13 33 46 51 60 61} acknowledged that patients with HF had little interest in PC interventions or self-identified as not needing PC services. Three studies reported that integrating PC into traditional HF care can be a facilitator.^{9 43 60}

Theme: initiating end-of-life discussion

Patients do not perceive HF as a life-threatening condition, leading to reluctance on the part of patients and caregivers to transfer to PC and end-of-life discussions.^{9 41} Data from Africa revealed that medical professionals avoided having direct conversations about prognoses because they saw the social stigma associated with talking about death as a barrier.⁴⁷ Clinicians find it difficult to talk about the seriousness of a patient’s illness since it is culturally taboo to discuss death and prognosis.⁴⁷ Healthcare providers from Canada reported that reflecting critically on the PC culture values may facilitate end-of-life discussion.²³

Goals

Theme: prioritisation of PC

Five studies reported that the attention of PC for patients with HF is inadequate because the possible value of PC has not been seen.^{19 22 33 60 61} In Iran’s healthcare system, the mechanism for providing PC to elderly persons with HF has been ignored.³³ Data from patients and family members reported that PC does not work for their QoL; only a few of them were aware of the importance of PC.⁴⁸ Leaders place a high priority on outpatient PC,^{21 58} which was reported as a facilitator.

Theme: inconsistent prognostic understanding and contradictory goals

Six studies reported that only half of the HF patients and caregivers had an understanding of disease prognosis consistent with that given to clinicians, which affected the patient care goals.^{33 49 57 58 60 61} The patient’s perception was that the goals of PC and aggressive symptom control were mutually exclusive options.⁴⁸ Boyd et al saw a proactive shift in care goals as a facilitator.²⁴

Emotion

Theme: negative emotion

11 studies1825,27 33 35 41 50 53 56 58 reported negative emotions of patients, caregivers and healthcare providers. Some negative caregiver outcomes, such as fear, guilt and poor health status, were reported by Alonso et al¹⁸ and Brännström et al.²⁷ When values of palliative culture clash, nurses may easily get into distress and dilemmas, which is revealed as frustrating.²⁵ Feeling uncertain, lonely and fatigued was described by patients with HF.²⁶ However, one study³⁰ reported that depression and lower mental health were facilitating factors.

Social/professional role and identity

Theme: ambiguous role responsibilities

Providing PC for HF patients requires multiple professions working together; seven studies reported ambiguous role responsibilities as a barrier.^{13 27 33 39 51 54} Data from Iran revealed a disparity between different organisations in shouldering the obligation of delivering PC, and them attempting to pass the burden to another, causing them to lose their own duties and responsibilities.³³ In interdisciplinary collaborations, physicians were confused about who should take the primary responsibility for patients’ care.²⁷

Beliefs about capabilities

Theme: concerns about the ability to address PC

Netherlands’ data reported that patients and caregivers worry about the ability to address PC needs.^{41 42 48} According to a qualitative study,²⁶ after reviewing the basic competencies of PC, 13 of the 27 patients indicated a high level of trust in their healthcare providers.

Optimism

Theme: positive attitude to PC

Three studies^{20 30 38} reported that HF patients and healthcare providers showed a positive attitude to PC. Even nurses, despite their low general knowledge and favourable attitude towards PC, felt that delivering PC to the dying is a beneficial learning experience.²⁰

Reinforcement

Theme: lack of performance measures and incentives

Three studies^{18 19 21} reported that a lack of performance measures and incentives for healthcare providers is a potential barrier to implement PC for HF patients. Incentives, such as designing performance measures and providing a supportive workplace, could encourage PC adoption and scale-up,¹⁹ enhancing providers’ and caregivers’ workplace productivity.^{18 19}

Beliefs about consequences

Theme: concerns regarding PC

Healthcare providers raised expectations and worry about the future of providing PC to patients and lack of confidence in combining PC with aggressive disease-modifying therapies.⁵⁵ Patients with severe HF reported that the PC service has boosted their confidence and hope in surviving the downturn.²⁶

Discussion

There is a need to fully understand the aspects that influence providing PC for HF patients from patients’, caregivers’ and healthcare providers’ perspectives. ‘Environmental context and resources’, ‘knowledge’ and ‘social influences’ were the three TDF domains that encoded the largest amount of data in this study. To our knowledge, this review is the first to comprehensively analyse and integrate barriers and facilitators to offer PC to patients with HF using the COM-B and the TDF. The use of the COM-B and TDF to synthesise literature provides a framework for determining intervention. At least one of the barriers or facilitators identified was mapped to all the TDF domains within each component of the COM-B, implying that boosting all aspects of capability, opportunity and motivation might be required for offering PC to patients with HF well.

Several themes were related to both barriers and facilitators, suggesting that multicomponent interventions may be needed. For instance, ‘education’ mapped to the TDF domain of ‘environmental context and resources’ as barriers and facilitator factors. Education is critical to the effectiveness of incorporating PC principles into training programmes for HF clinicians.⁶² However, this review found that insufficient education is a major barrier to PC for HF patients, underscoring the need for better clinician training in this area. Many healthcare providers lack familiarity with when and how to integrate PC into HF management, leading to delayed or missed opportunities to improve patient QoL. This suggests that medical education and continuing professional development should place greater emphasis on PC principles, including symptom management, communication skills and advance care planning specific to HF. By addressing this knowledge gap, clinicians can more confidently initiate timely palliative interventions, ensuring that patients receive holistic care aligned with their needs and preferences throughout the disease trajectory.

This study revealed that the TDF domains of ‘knowledge’ had the maximum amount of data units coded. The domains of ‘knowledge’ reported in the included studies mainly included disease status, PC needs and referral criteria; however, barriers predominated by a large margin. Uncertainty regarding disease prognosis and PC needs and confusion about PC prevented patients’ access to PC services and missed the optimal time for referral. This knowledge gap negatively impacts patient outcomes by prolonging avoidable suffering while diminishing the quality of care through delayed integration of supportive services. Clinically, these results emphasise the urgent need for healthcare providers to improve patient education about disease trajectory, clarify that PC complements (rather than replaces) active treatment and establish systematic protocols for earlier PC assessment in heart failure management—ultimately enabling more proactive, holistic patient care. Additionally, ‘environmental context and resources’ emerged as other most frequently reported factors. This highlights the importance of external conditions such as time constraints, staffing levels, access to specialist services and institutional support. In many cases, healthcare providers may be willing to offer PC but are limited by systemic barriers. The prominence of this domain suggests that improving individual knowledge alone may be insufficient. Healthcare organisations and policymakers need to create supportive infrastructure that allows healthcare providers to act on their intentions and clinical judgement regarding PC.

Behavioural regulation appeared less frequently among the identified factors influencing PC provision for HF patients. One possible reason is that healthcare providers may already rely on established routines or institutional procedures, so they may not view this as a distinct barrier. It is also possible that setting specific goals or planning how to initiate PC is not yet widely integrated into practice, leading to limited mention. This finding suggests that, while not a dominant issue, improving behavioural regulation could still enhance PC delivery. Introducing practical tools⁶³ may help healthcare providers offer PC more consistently, especially when combined with efforts targeting more prominent barriers.

In a previous review, Caleffi et al⁶⁴ discussed that healthcare workers’ perceived communication barriers when attempting to provide PC to HF patients, emphasising insufficient knowledge is a barrier to PC delivery. Our review enriches the study by Caleffi et al. First, we identified factors affecting PC for HF patients from different populations, including patients, caregivers and healthcare providers. Understanding barriers to PC from multiple perspectives may support the development of targeted strategies to overcome them. Second, the barriers and facilitators we identified encompass the entire process of PC in HF patients, such as referral, communication, discussion, assessment, implementation and evaluation. This may help future researchers to understand the barriers and facilitators to PC as a holistic approach to care. Third, this review was influenced by a behavioural change theoretical framework. To develop an effective intervention, it is crucial to consider how identified facilitators and barriers are positioned within the theoretical frameworks of behaviour change.⁶⁵ This may also raise the likelihood that the intervention will be put into practice successfully. Therefore, our review may help future studies in the development and implementation of novel theory-based interventions.

Implications for the provision of PC in patients with HF

Four main recommendations are suggested according to this study’s findings: (1) develop targeted public education campaigns (eg, social media, patient brochures, community workshops) clarifying that PC is not end-of-life care but a supportive service aimed at improving QoL. These efforts should address common misconceptions and raise public awareness of the benefits of PC for HF; (2) integrate mandatory PC education and training into cardiology and primary care curricula, covering symptom management, effective communication and interprofessional collaboration; (3) provide structural and practical support for PC delivery, such as advocating for hospital policies that specifically allocate PC specialist time for HF consults (eg, cardiology 1–2 days per week); (4) engage patients and families through focus groups to explore cultural values and preferences, enabling the adaptation of PC models to better align with diverse cultural needs.

Recommendations for future studies

Numerous studies reported on healthcare providers’ perceptions of providing PC to patients with HF, and few were specific to caregivers. Given that HF is a chronic disease that requires long-term management, there is a growing trend toward shifting PC delivery from hospitals to community and home settings. Therefore, future studies should investigate the barriers and facilitators to PC for HF patients from both caregiver and family member perspectives. Furthermore, this study identified a gap in the literature regarding the use of common PC medications and potential impact on HF-related morbidity and mortality. Future studies are required on the use of medications and minimally invasive therapy in PC, the efficacy of PC in the early stages of HF and standardised needs-assessment tools for patients and caregivers.

Strengths and limitations

Our review’s strength is the inclusion of both quantitative and qualitative studies from the beginning of the literature, which gives readers a thorough grasp of the variables influencing the provision of PC for HF patients. A limitation of the TDF is that all mapped items are given the same weight, which may have the impact of over-representing or under-representing important factors, even if our review was guided by a theoretical framework to help comprehend the barriers and facilitators. Furthermore, the separate completion of data extraction and coding by two reviewers may result in item misclassification. Our review’s inclusion of solely English-language studies means that it might not accurately represent factors encountered in non-English environments. Nonetheless, the fact that the included studies were carried out in a wide range of nations and locales contributes to their representativeness.

Conclusions

This mixed-methods systematic review highlights significant barriers and facilitators affecting PC access for HF patients, primarily involving resource limitations, knowledge gaps and poor interdisciplinary collaboration. These findings emphasise the need for healthcare system improvements, targeted training programmes and cultural shifts to normalise early PC integration in HF management. Future efforts should focus on implementing and evaluating HF-specific PC models to overcome these barriers and improve patient-centred outcomes.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.