Barriers to and readiness for advance care planning: a systematic review and meta-analysis of quantitative and qualitative evidence

Abstract

Background

Advance care planning (ACP) allows individuals to express their values and preferences for future medical care, yet participation remains low globally. Understanding readiness for ACP and the barriers and facilitators influencing engagement is essential for effective implementation.

Methods

Following Joanna Briggs Institute (JBI) and PRISMA 2020 guidelines, a comprehensive search was conducted across PubMed, Embase, Scopus, Web of Science, Cochrane Library, and grey literature up to September 2025. Quantitative, qualitative, and mixed-methods studies involving adults (patients, families, or healthcare providers) were included. Quantitative data on ACP readiness or acceptance were pooled using a random-effects meta-analysis, while qualitative data were synthesized thematically. Study quality was appraised using CASP, NOS, and Cochrane RoB tools; certainty of evidence was assessed using GRADE and GRADE-CERQual frameworks.

Results

Twenty-nine studies (n = 15,565 participants) from eight countries met inclusion criteria. Barriers to ACP were identified at the patient (emotional discomfort, limited awareness, cultural taboos), family (overprotection, conflict, poor communication), provider (time constraints, lack of training, role ambiguity), and system (insufficient policies, documentation challenges, and fragmented care) levels. Facilitators included family support, early provider initiation, structured protocols, and culturally sensitive communication. The pooled mean ACP readiness score across four studies (n = 856) was 77.23 (95% CI: 67.86–86.61), indicating moderate readiness with substantial heterogeneity (I² = 99.4%). Readiness was positively associated with family support, prior caregiving experience, and active coping styles.

Conclusions

Global readiness for ACP remains moderate and is constrained by emotional, familial, professional, and systemic barriers. Enhancing communication, training, and supportive institutional frameworks is essential to strengthen ACP engagement and promote person-centered end-of-life care.

Registration

CRD420251172759

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-025-01972-3.

Introduction

Advance care planning (ACP) is a structured process enabling individuals to define goals, values, and preferences for future medical treatment should they lose decision-making capacity [1, 2]. Despite its recognized benefits, such as improved alignment of care with patient wishes, reduced decisional conflict, and enhanced satisfaction among families and clinicians [3, 4] ACP completion rates remain low globally.

Barriers to ACP occur at multiple levels: patient-related (emotional discomfort, limited awareness), provider-related (time constraints, inadequate training), and system-level (lack of institutional support or documentation infrastructure) [5]. Understanding these barriers, together with individuals’ readiness to engage in ACP, is crucial for designing targeted interventions.

ACP readiness reflects an individual’s preparedness to contemplate, discuss, and document their preferences for future medical care. It encompasses awareness, contemplation, decision-making, and action stages, often assessed using validated tools such as the ACP Engagement Survey or similar readiness models [6, 7]. Measuring readiness helps identify gaps between knowledge and behavior, guiding healthcare systems to prioritize supportive interventions. In many contexts particularly in low- and middle-income countries ACP remains poorly integrated into clinical care, reflecting cultural norms, limited policy frameworks, and inadequate provider-patient communication [8, 9].

Globally, as populations age and the burden of chronic and terminal illnesses grows, ACP is increasingly recognized as a public health priority [10]. Quantifying readiness levels provides insight into how well health systems are positioned to implement person-centered end-of-life care. While several narrative reviews have explored obstacles to ACP, few have quantitatively synthesized readiness outcomes using validated scales. This systematic review and meta-analysis therefore integrates both quantitative and qualitative evidence to provide a comprehensive understanding of ACP readiness levels and the barriers influencing its implementation among patients, families, and healthcare professionals.

Methodology

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD420251172759. This systematic review was conducted following the Joanna Briggs Institute (JBI) methodology [11], in line with the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines [12] (Supplementary File 1).

Eligibility criteria

This review included studies involving adults aged 18 years and older, encompassing patients, caregivers, and healthcare professionals engaged in ACP or advance directives. Studies were required to address barriers, facilitators, or readiness and acceptance toward ACP or advance directives. Eligible studies were conducted in any healthcare or community setting, including hospitals, primary care, long-term care, palliative care, and community-based environments.

Quantitative (cross-sectional, cohort, survey, or experimental), qualitative, and mixed-methods designs were all considered for inclusion. Studies were excluded if they focused solely on knowledge or awareness of ACP without examining barriers or readiness, involved pediatric populations, or were conducted in non-healthcare contexts. Reviews, editorials, and conference abstracts were also excluded. Only articles published in English were included unless a translation was available.

Information sources and search strategy

A comprehensive and systematic literature search was conducted across multiple electronic databases, including PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library. To enhance the completeness of the evidence base and minimize publication bias, grey literature sources such as Google Scholar and Theses were also explored. The search strategy was developed using the SPIDER framework (Sample, Phenomenon of Interest, Design, Evaluation, Research type), which is particularly suitable for mixed-methods reviews encompassing both quantitative and qualitative studies.

In this framework, the Sample (S) included adults (patients, caregivers, and healthcare professionals) involved in ACP or advance directives; the Phenomenon of Interest (PI) focused on readiness, acceptance, engagement, and barriers related to ACP; the Design (D) covered quantitative (cross-sectional, cohort, or interventional) and qualitative (interviews, focus groups, or thematic) studies; the Evaluation (E) involved measures or thematic findings related to readiness, attitudes, perceived barriers, and facilitators; and the Research type (R) encompassed quantitative, qualitative, and mixed-methods designs.

Search strings combined Medical Subject Headings (MeSH) and free-text keywords related to “advance care planning,” “advance directive,” “readiness,” “engagement,” “barrier,” “facilitator,” and “attitude.” Boolean operators (AND, OR) and truncation symbols were applied to ensure a comprehensive capture of relevant records. No restrictions were placed on language, publication year, or geographical location. When non-English studies were identified, translations were arranged as needed. The search strategy was adapted for each database to maximize sensitivity and included studies published in English up to September 01, 2025. Additionally, reference lists of relevant articles and reviews were screened to identify any studies not captured in the initial database searches (Supplementary File 2).

Study selection

The study selection process was conducted independently by two reviewers (EGA and SAH). Titles and abstracts of all retrieved records were screened against the predefined eligibility criteria to identify potentially relevant studies. Full-text articles were then obtained for all records that clearly met the inclusion criteria or where eligibility could not be determined based on the abstract alone. Any discrepancies between the two reviewers were resolved through discussion, and if consensus could not be reached, a third reviewer (HSG) was consulted for adjudication. The entire selection process was documented in accordance with the PRISMA guidelines, with a flow diagram illustrating the number of records identified, screened, excluded (with reasons), and included in the final synthesis.

Outcome measurements

The primary outcome of this review was the identification and synthesis of qualitative thematic domains describing barriers and facilitators to ACP or (AD completion). These domains encompassed patient-, provider-, and system-level factors influencing engagement in ACP. Specifically, qualitative outcomes included perceived barriers such as lack of awareness, cultural and religious influences, communication difficulties, emotional discomfort, and institutional or systemic obstacles that hinder ACP discussions and documentation. Findings were organized into overarching themes and subthemes derived through inductive synthesis, capturing patient experiences, healthcare provider perspectives, and organizational dynamics across varied healthcare contexts.

The secondary outcome was the quantitative assessment of readiness or acceptance toward ACP. This was summarized as pooled mean scores (± standard deviation) from studies employing validated or adapted measurement tools. Quantitative synthesis focused on estimating the overall level of ACP readiness, integrating findings from instruments such as the Advance Care Planning Readiness Questionnaire, the ACP Acceptance Questionnaire, and other self-developed readiness scales.

Data extraction

Data relevant to the review objectives were extracted independently by two reviewers (EGA and SAH) using a standardized data extraction form developed in Microsoft Excel. The extraction form captured key study characteristics, including author, year of publication, country, study design, population details, setting, sample size, data collection methods, analytical approach, and principal findings.

For qualitative studies, thematic domains related to barriers, facilitators, and contextual influences on ACP and AD implementation were extracted verbatim where available. For quantitative studies, numerical outcomes such as mean (± standard deviation) scores of ACP readiness or acceptance and the measurement instruments used were recorded.

Discrepancies between reviewers were resolved through discussion and consensus, with arbitration by a third reviewer (HSG) when required. When essential data were missing or unclear, attempts were made to contact the corresponding authors of the original studies for clarification.

Risk of bias and quality assessment

The methodological quality of all included studies was independently appraised by two reviewers (EGA and SAH) using validated tools appropriate to each study design. Qualitative studies were evaluated using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist, which assesses credibility, transferability, dependability, and confirmability. Quantitative observational studies were assessed using the Newcastle–Ottawa Scale (NOS), focusing on selection, comparability, and outcome domains. For randomized controlled trials and cohort studies, the Cochrane Risk of Bias Tool (RoB 2) was applied to evaluate potential sources of bias across key methodological domains.

Each study was rated as having low, moderate, or high methodological quality. Any discrepancies in assessments were resolved through discussion and consensus, with arbitration by a third reviewer (HSG) when necessary. The results of the quality appraisal were summarized both in tabular form and narratively, to inform the interpretation of findings and support sensitivity analyses (Supplementary File 3).

Data synthesis and statistical analysis

A convergent segregated approach was applied to integrate qualitative and quantitative evidence. For the qualitative component, data were analyzed using thematic synthesis, following three iterative steps: (1) line-by-line coding of participant quotations and author interpretations, (2) organization of codes into descriptive themes, and (3) development of analytical themes that explained barriers and facilitators to ACP. Coding and theme development were performed manually in Microsoft Excel, enabling transparent organization and cross-comparison of findings across studies.

The quantitative component consisted of a meta-analysis pooling mean ACP readiness or acceptance scores from eligible studies. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using a random-effects model (DerSimonian and Laird method) to account for between-study heterogeneity. Heterogeneity was assessed using the I² statistic and Cochran’s Q test, with I² values greater than 50% considered substantial. Publication bias was evaluated visually using funnel plots; formal tests for small-study effects (Egger’s and Begg’s tests) were not performed due to the limited number of included studies.

Subgroup analyses were conducted based on the type of ACP scale used to explore potential variations. Finally, findings from both qualitative and quantitative syntheses were integrated narratively to provide a comprehensive understanding of ACP readiness, barriers, and contextual influences. All statistical analyses were performed using R software (version 4.5.0, 2025-04-11 ucrt).

Certainty of evidence

A structured approach was adopted to assess the certainty of evidence. For quantitative outcomes, the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework was applied. Certainty of evidence for mean ACP readiness or acceptance scores was evaluated across the domains of risk of bias, inconsistency, indirectness, imprecision, and publication bias, and classified as high, moderate, low, or very low.

For the qualitative synthesis of barriers and facilitators, the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach was used. This framework assesses confidence in review findings based on methodological limitations, coherence, adequacy of data, and relevance to the review question.

Each synthesized finding, whether quantitative or qualitative, was accompanied by a summary of the certainty or confidence level, providing a transparent evaluation of the robustness of the evidence and supporting informed interpretation of the results.

Results

Out of 1,362 retrieved studies, 29 were eligible and included in the final analysis (Fig. 1).

Fig. 1.

PRISMA flow diagram of search and study selection process

Study characteristics

A total of 29 studies were included in this review, published between 1994 and 2025. These studies were conducted across multiple countries, with the majority from Canada (n = 10), followed by the United States (n = 8), Mainland China, Macau, and Hong Kong (n = 6), and single studies from Japan, Singapore, Norway, the Netherlands, and Australia. The total sample size across all studies was 15,565, ranging from 22 to 4,301 participants. In terms of study design, the dataset comprised 14 cross-sectional studies, including surveys and descriptive studies, nine qualitative studies, three prospective cohort studies, one randomized controlled trial, and one mixed-methods study combining quantitative and thematic analyses (Table 1).

Table 1.

Study characteristics included in the systematic review and meta-analyses

Author	Year	Country	Study Design	Sample Size
You JJ et al. [13]	2015	Canada	Cross-sectional	1256
Cheung et al. [14]	2020	Hong Kong	Qualitative	30
Malhotra et al. [15]	2024	Singapore	Cross-sectional	911
Tanimoto et al. [16]	2025	Japan	Qualitative	22
Zhou Y et al. [17]	2024	China	Qualitative	36
Piggott et al. [18]	2019	Canada	Cross-sectional	68
Ethier JL et al. [19]	2018	Canada	Cross-sectional	30
Westbye et al. [20]	2023	Norway	Qualitative	40
Simon et al. [21]	2015	Canada	Mixed	503
Bernard et al. [22]	2020	Canada	Cross-sectional	396
Wenger et al. [23]	1994	USA	Cross-sectional	4301
Silveira et al. [3]	2010	USA	Prospective cohort	3746
Heyland et al. [24]	2006	Canada	Cross-sectional	600
Schickedanz et al. [25]	2009	USA	Qualitative	143
Sudore et al. [1]	2017	USA	Qualitative	52
Lum et al. [26]	2018	USA	RCT	414
Howard et al. [27]	2018	Canada	Cross-sectional	810
Robinson, C. [28]	2012	Canada	Cross-sectional	386
O’Sullivan et al. [29]	2015	Canada	Cross-sectional	580
Curtis et al. [30]	2000	USA	Prospective cohort	95
Chiarchiaro et al. [31]	2015	USA	Prospective cohort	106
Tung & North [32]	2009	USA	Qualitative	94
Miller et al. [33]	2019	Australia	Qualitative	20
Slort, W. [34]	2011	Netherlands	Qualitative	48
Arnett et al. [35]	2016	Canada	Qualitative	22
Wong et al. [36]	2024	Macau, China	Cross-sectional	306
Zheng et al. [37]	2024	China	Cross-sectional	120
Lyu et al. [38]	2025	China	Cross-sectional	262
Wang & Sheng [39]	2022	China	Cross-sectional	168

USA United States of America, RCT Randomized clinical trial

Barriers to ACP

Patient-related barriers

Patients frequently faced emotional, cognitive, and cultural challenges that limited their engagement in ACP or ADs. Lack of awareness or understanding of ACP/ADs was commonly reported, particularly among older adults, with some perceiving discussions about future care as unnecessary or irrelevant [21, 22, 30, 34]. Emotional resistance, fear of death, or discomfort discussing end-of-life care often prevented participation, while fear of burdening family members or unrealistic expectations about treatment outcomes were also noted [19, 21, 22, 31, 34]. Cognitive impairment or diminished decision-making capacity further limited patient involvement, particularly in acute or long-term care settings [17, 23].

“To be honest, absolutely not… At our ages, death is inevitable. The most important aspect of one’s life is happiness. I have talked with doctors and have said I don’t care… If the doctors say ‘no’… then I will pretend to be fine.” (Patient, Female, Age 60–69) [14].

“Those who smoke can get lung cancer. Those who don’t smoke can also get lung cancer… Just let it go if it cannot be cured.” (Patient, Male, Age 70–79) [14].

Cultural norms and generational attitudes toward death further hindered engagement. Some participants viewed death as a taboo or frightening topic, while others preferred to defer decisions to family members.

“The education we received when we were young was that death is a very scary thing… that’s why it’s difficult for you to talk about death to them.” (H006: Female, Director of Nursing) [17].

“I don’t care about these things… It’s useless if they don’t follow [my wish].” (R006: Female, 95 years old) [17].

Hopelessness and limited awareness of palliative options further constrained planning. Some participants expressed a preference for death over prolonged suffering.

“Actually, I think euthanasia is better and what I fantasise about most is the night I die in my sleep… Because psychological pain is more painful than physical pain.” (R011: Male, 88 years old) [17].

Family-related barriers

Family dynamics consistently influenced engagement in ACP. Across settings, family members frequently experienced emotional discomfort and limited communication skills, which inhibited open discussion of prognosis and future preferences. Generational differences and poor communication often resulted in avoidance or superficial conversations rather than meaningful planning.

“The problem is… Our generation have poor communication skills… He knows he has a serious illness, but he seldom talks about what he wants, or anything else.” (Family, Female, Age 70–79; Patient, Male, Age 70–79) [14].

Similarly, patients in Simon et al. (2015) [21] simply responded “Not yet” when asked about discussing their wishes, demonstrating hesitation and discomfort.

Families also commonly adopted a protective stance, preferring to shield patients from distressing information; this overprotection curtailed initiation of ACP and limited opportunities for patients to express preferences.

“She will be nervous. This (information disclosure) will only pose a burden on her. Her life should end peacefully.” (Family, Female, Age 70–79; Patient, Female, Age ≥ 80) [14].

In many cultural contexts, collective decision-making and filial duty shaped family behavior. Decisions were often framed as a family responsibility rather than an individual choice, which could suppress the expression or documentation of the patient’s own wishes.

“It… should account for a large proportion [in advance care planning], and then consider the nuanced emotions between him and his children… Because in China, at any level, the family is a group, not an individual.” (H003: Female, director of nursing) [17].

Caregiving burden, especially among sole caregivers or only children created additional reluctance to engage in emotionally demanding ACP conversations. The sense of being the sole decision-maker or caregiver increased stress and reduced readiness to initiate planning.

“Unfortunately, I’m the only child in my family, so all the burden is on me. I have to take the responsibility [of providing care] by myself.” (F002: Female, daughter) [17].

Family conflict and the perception that relatives may not follow patients’ wishes also discouraged some participants from formalizing preferences. Where family members disagreed or were perceived as unlikely to respect written wishes, patients sometimes saw ACP as futile.

“I don’t want any arguments arising.” (30–03–094, age 65, female) [22].

“It made me realise that it doesn’t matter what I say really, it would depend on others … if one of my children or someone says, ‘we’re going to resuscitate him’, no matter what I’ve said, it’ll happen.” (Patient 10,103) [33].

Finally, family functioning and communication quality were critical determinants of ACP readiness. Wong et al. (2024) [36] found that low family cohesion reduced participation in ACP, while Lyu et al. (2025) [38] reported that strong family support enhanced readiness and perceived quality of life.

Provider-related barriers

Healthcare professionals reported lack of time, insufficient training or confidence, and discomfort with end-of-life discussions as primary barriers [15, 25, 32, 35]. In some settings, clinicians deferred discussions to other team members or waited for patient/family initiation, which delayed AD completion [13, 21]. Coordination challenges across disciplines and facilities also hindered effective ACP implementation [16].

“The challenge [of advance care planning] is that residents may feel it’s necessary [to join the end-of-life care discussion], but most of the time it is not possible [for the doctors and family members] to talk about this in front of them.” (H004: Female, nurse) [17].

“Doctors have to be honest about the prognosis and the survival time, not perfunctory and say it will be fine. When you (doctors) say it will be fine, of course I want to live, and my children will save me.” (R005: Female, 74 years old) [17].

Time constraints and high clinical workloads further limit provider engagement in ACP discussions. Many reported that limited consultation times, competing clinical priorities, and administrative responsibilities hindered thorough conversations.

“Because we (medical staff) are very busy, and we also lack [communication] training. We are responsible for medical care. Social workers shall take this responsibility [initiate advance care planning].” (H006: Female, director of nursing) [17].

“We are pressured in terms of time and space.” (Senior hospital doctor) [20].

“I don’t have time to document such heavy conversations. I have 15 min per patient.” (GP) [20].

To illustrate how this uncertainty manifests in practice, some clinicians expressed worry that poorly handled discussions might distress patients. Their concern reflects a lack of confidence and preparedness rather than opposition to ACP itself.

“It must not be the case that [we decide on] that ACP is important, we must have it, and then it can actually do more harm than good… It can be very traumatic.” (Experienced GP) [20].

Malhotra et al., 2024 also reported 57% had not facilitated any ACP conversations in the last 1 year [15].

Ambiguity regarding professional roles further complicates ACP implementation. Providers often are unsure who should initiate conversations, whether it be physicians, nurses, or social workers, leading to missed opportunities.

“We think the patient will bring it up. But the patient is ill, and the patient is scared, and they meet someone in a uniform.” (Chief physician) [20].

“If a doctor wanted to talk to me about the end of life, it would not be hard for me to do.” (30–01–053, age 73, female) [22].

System-level barriers

Organizational and structural barriers included unclear policies, limited staffing, documentation burden, and lack of institutional support for ACP [18, 20]. Limited access to technology and health literacy issues were noted in community interventions, while variations in interpretation of ACP definitions and procedures contributed to inconsistent practice [1, 25, 26].

“I experience that I spend an incredible amount of time coordinating cooperation between the various levels in the health service. I am often left with the feeling that this work is meaningless because I do not know how it is documented by the other stakeholder, and I also do not know how what we have agreed upon is followed up.” (GP) [20].

“Consultations are delivered by different doctors. It is not the same person every time.” (Patient, Female, Age 60–69) [14].

Time and resource constraints further limit ACP implementation. Providers reported being under pressure from high patient loads and short consultation times, reducing opportunities for meaningful conversations about patient preferences.

Legal and procedural uncertainties also contribute to systemic barriers. Providers and families may be unclear about the legal status of advance directives or ACP decisions [25], which can create hesitation in initiating discussions.

Finally, providers expressed concern that ACP conversations could negatively affect patient relationships or inadvertently lead to overtreatment.

“It becomes as an opposite to giving hope… and you are placing the stone that burdens.” (Experienced GP) [20].

Together, these organizational, logistical, and legal challenges create a systemic environment that restricts the implementation of ACP, even when providers are willing and patients are receptive.

Facilitators of ACP

Patient-level facilitators

Patients were more likely to engage in ACP when they demonstrated readiness to discuss end-of-life preferences, prior reflection on values, and desire to reduce burden on family members. Clear understanding of treatment options, prior exposure to healthcare education, and positive experiences with healthcare communication enhanced participation [22, 27, 33, 34]. Emotional support from family or caregivers also promoted proactive involvement in AD discussions [14].

“It was a great advantage to be able to speak in a confidential manner to the practice nurse. … They just explain things, leaving me free to express my thoughts too.” (Patient 10,101) [33].

“I found it extremely helpful to have [the GPN] explain several matters … I was able to crystallise what I wanted.” (Patient 10,103) [33].

Making wishes explicit and documented reassured patients and reduced family burden.

“If I had a stroke … I would be happy in the knowledge that my daughter knew exactly what I wanted.” (Patient 20,103) [33].

Family-level facilitators

Family support and involvement helped patients engage in ACP by providing reassurance, guidance, and shared understanding. Open communication with family members allowed patients to clarify preferences while reducing emotional burden. Miller et al. (2019) [33] highlighted these family-level facilitators through patient reports:

“They seemed to be relieved that they’ll know what my wishes are.” (Patient 10,104).

“As far as I’m concerned it’s not them making decisions, it’s me.” (Patient 10,103).

“As we were going along, we were telling my son and daughter-in-law about it … we’ve always been open about things, and they were aware of our preferences.” (Patient 30,207).

Furthermore, involvement of surrogates in ACP was shown to reduce decisional conflict and help ensure care aligned with patients’ preferences. Silveira et al. (2010) [3] reported that surrogates of patients with advance directives experienced less decisional conflict and more often made decisions consistent with patients’ wishes.

Provider-level facilitators

Healthcare professional engagement was critical. Studies consistently reported that proactive initiation of ACP by clinicians, clear communication, and multidisciplinary collaboration facilitated AD completion [13, 16, 35]. Clinician confidence, training in ACP discussions, and continuity of care supported timely conversations. Integration of ACP into routine clinical workflows and early identification of eligible patients were particularly effective strategies [26, 35].

“We … lack [communication] training. Social workers shall take this responsibility … It’s better to have someone appointed to lead this.” (H006: Female, director of nursing) [17].

“Care assistants or social workers … we spend a long time together and we will talk to him like friends on an equal footing.” (H013: Female, social worker) [17].

System-level facilitators

Organizational and system-level support facilitated ACP by providing standardized protocols, clear guidance, and integrated communication channels. Providers highlighted that structured policies, training, and leadership endorsement helped ensure consistent and effective ACP delivery.

“You must be sensitive to the [laughs briefly] feedback that the patient gives. So that we have a guide that we ask from, but you cannot just run through it.” (Experienced GP) [20].

“It is important to see where the patient is at all times. Where is the patient sitting in front of you—and then you have to adapt ACP to that” (Chief physician) [20].

Variation across settings and populations

Hospital and acute care settings

In hospital settings, particularly acute care and oncology wards, barriers included patients’ diminished decision-making capacity at the time of admission, emotional resistance, and family disagreement [18, 19, 23]. Facilitators were early identification of patients for ACP, clinician-initiated discussions, and integration of ACP into routine workflows [13, 35]. Cross-facility coordination was highlighted as a system-level challenge in multi-center or community-based hospital networks [16].

Primary care and community settings

In primary care and community settings, barriers included limited patient awareness, emotional discomfort discussing end-of-life care, and variations in clinician engagement [27–29]. Facilitators involved proactive family physician involvement, structured educational interventions, and use of decision aids or digital tools [1, 26]. Health literacy and access to technology were notable challenges affecting intervention reach and effectiveness [26].

Long-term care and nursing homes

In long-term care facilities, barriers included staffing limitations, unclear policies, and cognitive impairment among residents, compounded by family disagreements regarding care preferences [17, 20]. Facilitators included well-defined ACP protocols, training for staff, and multidisciplinary coordination, which helped overcome systemic and organizational constraints.

Cultural and country-level variation

Cultural factors shaped patient engagement and family involvement. For example, in Hong Kong, discussions of death were culturally sensitive and sometimes considered taboo, limiting patient participation [14]. Across countries, differences in healthcare system structure, availability of ACP resources, and policy frameworks influenced both barriers and facilitators, suggesting that context-specific strategies are essential for successful implementation.

Pooled mean ACP readiness

Four studies [36–39] conducted in mainland China and Macau, including a total of 856 participants comprising older adults and community-dwelling individuals with chronic diseases, were included in the meta-analysis. Using a random-effects model, the overall pooled mean ACP readiness score was 77.23 (95% CI: 67.86–86.61), with substantial heterogeneity observed (I² = 99.4%, p < 0.001). Two studies [36, 37], comprising 426 participants, employed the Chinese version of the Advance Care Planning Acceptance Questionnaire (ACPQ), which contains 19 items rated on a 5-point Likert scale (range 19–95), with higher scores indicating greater readiness. The pooled mean ACP readiness for this subgroup was 69.7 (95% CI: 61.5–78.0; I² = 98.3%, p < 0.001). The other two studies [38, 39], comprising 430 participants, used the Advance Care Planning Readiness Scale (Wang Xinru et al.), consisting of 22 items across three dimensions (attitude, belief, and motivation) also rated on a 5-point Likert scale, with higher total scores reflecting higher ACP readiness. The pooled mean ACP readiness for this subgroup was 84.7 (95% CI: 79.3–90.1; I² = 95.5%, p < 0.001). The difference between the two subgroups was statistically significant (χ²= 8.79, p = 0.003) (Fig. 2).

Fig. 2.

Forest plot of pooled mean advance care planning (ACP) readiness scores across included studies

Across the studies, several factors were reported to influence ACP readiness. These included age, knowledge and prior experience with ACP, personal or family experiences with resuscitation, and family functioning [36]; fear of death, experience caring for a dying relative, duration of chronic illness, presence of complications, natural acceptance, and religious beliefs [37]; and higher levels of family support and quality of life [38]. Additionally, readiness was negatively associated with passive coping styles and positively associated with active coping styles [39].

Sensitivity analysis

The leave-one-out sensitivity plot shows that exclusion of any single study does not substantially change the pooled ACP readiness score, as all CIs overlap with the overall pooled mean (red dashed line). This suggests that no individual study unduly influences the overall estimate, indicating robust results despite the high heterogeneity (Fig. 3).

Fig. 3.

Leave-one-out sensitivity analysis of the pooled mean ACP readiness score

Publication bias

A funnel plot was generated to explore potential publication bias across the four included studies. Visual inspection suggested a roughly symmetrical distribution of studies around the pooled mean ACP readiness score. Therefore, interpretation of publication bias remains exploratory, and asymmetry cannot be reliably assessed (Fig. 4).

Fig. 4.

Funnel plot assessing potential publication bias of the pooled mean ACP readiness

Risk of bias (study quality assessment)

Methodological quality was assessed using design-specific tools. Among 21 observational studies (NOS), scores ranged 5–9/9: 12 studies were good (7–9), and seven were fair (5–6). All seven qualitative studies (CASP) scored 8–9.5/10, rated high quality. The single RCT (RoB 2) was judged low risk of bias. Overall, the included studies were of moderate to high quality (Supplementary File 3).

Certainty of evidence

The certainty of quantitative evidence, assessed using the GRADE framework, was low to moderate. Most cross-sectional studies contributing to the pooled estimate were of moderate methodological quality, employing validated questionnaires and adequate sample sizes but limited by non-probability sampling, self-report bias, and heterogeneity (I² = 99.4%). The evidence was therefore downgraded for inconsistency and imprecision, though indirectness was minimal since study populations aligned with the review objectives. Overall, the quantitative findings provide a cautious but credible estimate of ACP readiness.

For qualitative findings, assessed using the GRADE-CERQual approach, confidence ranged from moderate to high. Themes such as emotional discomfort, family overprotection, and provider time constraints were supported by multiple high-quality studies demonstrating methodological rigor, reflexivity, and adherence to CASP and COREQ standards. Confidence was lower for context-specific factors, such as cultural or religious influences, which were reported in a limited number of settings. Overall, the qualitative evidence was coherent and robust, providing strong explanatory support for the quantitative findings.

Discussion

This systematic review and meta-analysis synthesized evidence from 29 studies conducted across diverse geographic and cultural contexts to provide a comprehensive understanding of barriers, facilitators, and readiness for ACP. The findings reveal that barriers to ACP occur at multiple interrelated levels, patient, family, provider, and health system; while the quantitative synthesis indicated that overall readiness for ACP was moderate (pooled mean = 77.2; 95% CI: 67.9–86.6), with substantial variability likely influenced by cultural and contextual factors. These results emphasize that ACP is not merely an individual behavioral decision but a relational and systemic process shaped by values, communication norms, and institutional capacity.

Patient-related barriers were the most frequently reported and reflected emotional, cognitive, and cultural challenges. Fear of death, discomfort discussing end-of-life topics, and limited understanding of ACP or advance directives often prevented engagement, particularly among older adults and those with limited health literacy [14, 17, 21, 22]. These patterns were consistently observed across several included studies and are in line with previous literature indicating that emotional avoidance and misconceptions about the purpose of ACP remain key obstacles across populations [5, 13, 25]. In many Asian and collectivist societies, discussing death is viewed as taboo or potentially harmful, further constraining patients’ willingness to engage [14, 17]. Additionally, unrealistic expectations about treatment outcomes and a desire to avoid burdening family members contributed to reluctance, consistent with earlier reports by Curtis et al. and Silveira et al. [3, 30].

Family dynamics emerged as both barriers and facilitators of ACP. Protective behaviors, such as withholding information from patients or deferring discussions, were frequently observed, reflecting cultural norms emphasizing filial piety and collective decision-making [14, 17]. While these behaviors may stem from care and respect, they often limit patients’ autonomy and opportunities to express their preferences. Family conflict, low cohesion, and generational communication gaps further hindered readiness [22, 36]. Conversely, open communication and supportive relationships were powerful facilitators, enabling families to engage in joint decision-making and reducing decisional conflict [3, 33, 38]. This dual role of families highlights the importance of interventions that foster transparent and empathetic communication rather than viewing family involvement solely as a barrier.

Healthcare provider barriers were consistent with those reported in prior reviews [5, 15, 20]. Lack of time, inadequate training, and uncertainty about roles frequently limited clinicians’ capacity to initiate ACP discussions. Many clinicians expressed discomfort addressing death-related issues and were unsure whether such conversations should be led by physicians, nurses, or social workers [16, 20, 35]. This role ambiguity, coupled with competing clinical priorities, contributed to missed opportunities for timely ACP initiation. Furthermore, limited institutional support and insufficient documentation systems impeded the translation of discussions into actionable directives [18, 20]. Providers in multiple settings also reported concerns that ACP conversations could undermine patient hope or strain relationships, echoing earlier studies on communication barriers in end-of-life care [25, 32].

System-level barriers encompassed fragmented care structures, lack of clear policies, and inadequate integration of ACP into routine workflows [16, 18, 20]. Uncertainty regarding the legal status of advance directives, insufficient staffing, and lack of standardized documentation were particularly prominent in long-term and community settings. Such systemic challenges indicate that ACP readiness depends not only on individual or provider motivation but also on institutional readiness and policy alignment. In contrast, system-level facilitators, including supportive leadership, formal protocols, multidisciplinary coordination, and training were associated with higher ACP uptake [16, 20, 26, 35]. These findings are consistent with global calls to embed ACP as a routine component of patient-centered care rather than an optional or crisis-driven conversation [1, 2, 9, 10].

The quantitative synthesis revealed that the pooled mean ACP readiness score was moderate (77.2; 95% CI: 67.9–86.6), with substantial heterogeneity (I² = 99.4%). Readiness levels were higher among individuals with stronger family support, prior caregiving experience, and positive coping styles [36–39]. These determinants reflect the psychosocial complexity underlying ACP engagement. While knowledge and awareness are important precursors, emotional preparedness, perceived family support, and health system trust appear to play equally vital roles. The heterogeneity observed across studies likely reflects cultural diversity, differences in measurement tools, and varying health system maturity. This variability underscores the need for culturally validated readiness instruments and locally tailored ACP implementation models. Because all four quantitative studies were conducted in China or Macau, these pooled estimates may reflect cultural norms specific to this region, including family-centered decision making and expectations around medical authority. As a result, the “moderate” readiness estimate should not be interpreted as a global pattern, and caution is needed when generalizing these findings beyond this cultural context.

Overall, the findings from this review are consistent with previous evidence highlighting that ACP engagement is shaped by a combination of personal, relational, and systemic factors. However, this study extends prior work by integrating both quantitative and qualitative data, allowing a richer understanding of how emotional, familial, and organizational influences intersect. It also reveals that readiness is not merely an individual attribute but a shared readiness among patients, families, providers, and institutions. Interventions to improve ACP uptake must therefore address these layers simultaneously through patient education, family engagement, provider training, and supportive policy environments. Context-sensitive approaches that acknowledge cultural beliefs, religious perspectives, and collective decision-making traditions are particularly essential in non-Western settings.

Strengths and limitations

This review’s strengths include its rigorous methodology guided by JBI and PRISMA 2020 standards, preregistration on PROSPERO, and comprehensive inclusion of both qualitative and quantitative studies. The convergent synthesis approach enabled triangulation of thematic and numerical data, offering a nuanced understanding of ACP barriers and readiness. Additionally, inclusion of studies from diverse countries enhanced generalizability and provided insights into cross-cultural variations.

However, several limitations should be acknowledged. The heterogeneity among readiness measurement tools limited comparability across studies, and the small number of quantitative studies reduced the power of subgroup analyses. In particular, all four quantitative readiness studies were conducted in China or Macau, which restricts geographical coverage and limits the global representation of readiness estimates. Most of the remaining studies were also from high- or upper-middle-income countries, with limited inclusion of low-income settings, which may affect broader applicability. Publication bias could not be formally assessed due to the small number of quantitative studies. Finally, variability in ACP definitions and implementation contexts across studies may have introduced conceptual inconsistencies.

Conclusion

This systematic review and meta-analysis demonstrate that readiness for advance care planning remains moderate globally and is constrained by intertwined emotional, familial, professional, and systemic barriers. While awareness of ACP is increasing, genuine engagement requires multi-level interventions that address individual fears, strengthen family communication, enhance provider confidence, and establish supportive institutional frameworks. Culturally sensitive education, early integration of ACP into clinical pathways, and policy mechanisms ensuring legal clarity and documentation are vital to improving uptake. Building readiness across all stakeholders: patients, families, providers, and health systems will be essential for realizing the vision of equitable, person-centered end-of-life care worldwide.

Authors’ contributions

Conceptualization: HSG; Writing – original draft: EGA; Critical appraisal: EGA, SAH, HSG; Data extraction: EGA, SAH, HSG; Statistical analysis: EGA; Writing – review & editing: EGA, SAH, HSG; Validation: EGA, SAH, HSG. All authors agreed to bear responsibility for all parts of the research work and approved the final version of the manuscript.

Funding

The authors received no specific funding for this work.

Data availability

All relevant data are within the manuscript.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.