Table 6 Barriers for the uptake of ACP, as reported in the literature

Despite the fact that there is increasing attention for ACP and a growing body of evidence of its positive effects, research shows that the application of ACP conversations remains still low, and the organization and delivery of healthcare is still predominantly reactive [11,12,13,14,15,16].

Several barriers have been reported that may prevent optimal implementation in clinical practice. First, on the patient-side, participation is at risk in case patients are not ready to talk about themes related to deterioration in their condition or the nearing death [41]. Second, for GPs, insufficient time is among the most important barriers. Third, GPs find it difficult to engage in end-of-life conversations, which is sometimes caused by lack of skills or experience, and that they have a hard time finding the appropriate moment to initiate ACP [27, 31, 33, 42]. Fourth, illness trajectories differ a lot from patient (group) to patient (group). In patients with incurable cancer, the decline is generally progressive and reasonably predictable, usually with a clear terminal phase [18, 19]. Patients dying from a non-malignant cause, however, frequently experience a more gradual decline. In those with organ failure (like respiratory and heart failure), the decline might be punctuated by episodes of acute deterioration and some recovery, with more sudden, seemingly unexpected death. In the elderly with multiple chronic diseases (i.e. multimorbidity) the decline is often prolonged and gradual [18, 19]. Especially in case of uncertainty of prognosis, there are less clear-cut ‘triggers’ that may help GPs to initiate ACP conversations [31].