Table 3.

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

Level identified	Barrier	No of studies	References
Individual level	Lack of (consumer) knowledge about ACP	15	14 39 44–46 49 54 56 57 59 62 66 72 79 82
	Attitudes—perceived irrelevance	7	13 14 39 40 44 50 76
	Trust/questions of efficacy	4	40 41 44 57
	Denial/emotions/reluctance	10	14 32 39 40 44 50 54 56 57 72
Interpersonal level	Role ambiguity—GP expectation patient will initiate discussion about ACP	7	13 46 51 56 58 62 83
	Role ambiguity—patient expectation GP will initiate discussion about ACP	5	41 42 49–51 83
	GP—patient relationship	5	44 49 55 57 62
	Concern with family relationships	6	13 14 32 39 44 74
	Preference for informal discussion with family	1	13
Provider level	Lack of (GP) knowledge/skills/confidence	18	14 31 44 46 49 53–56 58–60 63 69 74 77–79
	Lack of time	12	14 39 46 53–55 58 61 66 74 76 79
	Misc concerns including legal uncertainty, prognosis, best time	9	54 55 60 61 68 70 75 78 83
	Doubts about efficacy of ACP	3	44 58
System level	Lack of linkages and mechanism for sharing ACP	5	31 44 54 58 60 80
	Lack of funding mechanisms	2	56 60
	Lack of standard templates, tools, documents, IT systems	6	44 45 53 57–59
	Accountability	1	46

ACP, advance care planning; IT, Information technology.