Table 2.

Summary of systematic reviews

First author	Ref	Year	Country	Aim	Studies	Summary of outcomes	Recommendations
De Vleminck et al	31	2013	Belgium	To identify the perceived factors hindering or facilitating General Practitioners (GP) in engaging in ACP with their patients.	16	A range of barriers and facilitators were identified and attributed to GP characteristics, perceived patient characteristics and health system characteristics.	Understanding barriers and facilitators, and targeting GP and health system related barriers was considered important for development of interventions aimed at facilitating ACP in general practice.
Durbin et al	35	2010	USA	To systematically analyse evidence about the outcome and percent of newly completed AD, focusing on effectiveness of (1) types of educational interventions versus controls; and (2) one educational intervention over another.	16	After examining various combinations of intervention including single approaches, combined approaches and multiple combinations the authors determined the evidence base for effectiveness of specific interventions was weak, with the exception that combined approaches were more effective than single approaches in increasing the percentage of newly completed advance directives.	More research is needed to address the low number of studies looking at specific interventions.
Jezewski et al	36	2007	USA	To synthesise the state of the science regarding effectiveness of interventions to increase AD completion rates.	25	Interventions with repeated multiple contacts or stimuli were found to be most effective. Not all intervention designs may be effective across the life span and that ‘a single approach’ will likely not be effective because the same approach will probably not work for all people.	A knowledgeable person who can answer questions should be an integral component of any intervention. Creative interventions need to be developed that are matched to the individual’s needs at a particular point in time.
Oczkowski et al	33	2016	USA	To determine the effect of structured communication tools for end-of-life decision making on completion of ACP.	67	Low quality evidence that structured communication tools assist with end-of-life decision making resulting in uncertainty about the magnitude of the effect.	Given the heterogeneity of populations, interventions and effects, more work is needed to guide the selection, adaptation and tailored implementation of tools in local settings and contexts.
Ramsaroop	34	2007	USA	To systematically review studies designed to increase advance directive completion in the primary care setting.	18	There was increased efficacy in achieving advance directive completion with direct patient to health professional contact with this being a consistent finding among studies. The more effective approaches used iterative interactions over multiple visits. Passive education of patients using written materials alone was relatively ineffective Uptake remains low.	Barriers to completion of advance directives warrant attention in future intervention studies.
Sharp et al	32	2013	UK	To investigate attitudes of the public and healthcare professionals to ACP discussions with frail older people.	26	Many frail elderly people would welcome the opportunity to discuss ACP but a significant minority would not. There was no consensus for optimal timing of the conversation. Reluctance of family members to engage is a significant barrier.	Categorised across three levels: health system issues —health providers require support and training to initiate discussions; individual autonomy—raised a number of questions about how to achieve this (inter)personal circumstance—raised a number of questions about how to achieve this
Solis	37	2018	USA	To evaluate strategies used in primary care settings to initiate ACP leading to completion of AD.	12	The use of multipronged approaches was most successful for initiating ACP discussion. Effective interventions included patient education materials, computer generated triggers for providers and multidisciplinary team involvement.	There is a gap in empirical knowledge and this opens an opportunity for more research. Providers should consider increasing ACP discussions with patients and create opportunities to do so more systematically.
Tamayo-Velazquez et al	38	2009	Spain	To identify, appraise and synthesise the results of systematic reviews of the literature that examine effectiveness of interventions to increase advance directive completion rate.	7	Determined that each of the systematic reviews reached very similar conclusions. Passive informative material in isolation does not significantly increase advance directive completion rates. Effectiveness is increased over multiple visits where patients are provided opportunity to interact with an expert in the field and are afforded an individual who will answer any queries.	Further research is required to identify new strategies to increase ACP completion rates.

ACP, advance care planning; AD, Advance Directive; GP, General Practitioner.