Table 1 Summary of included studies

Wichmann et al. [27]

(2018)

Netherlands

Content analysis; semi-structured interviews; qualitative study

17 GPs

Patients with cancer, heart failure, and COPD

Different clinics across the Netherlands

To identify the experiences of GPs in ACP conversations with palliative patients and the factors affecting these experiences.

Four themes: (1) ACP and society; (2) the role of GPs in ACP; (3) initiating ACP; (4) tailor-made ACP.

Toguri et al. [28]

(2020)

Canada

Thematic analysis; descriptive qualitative study using in-depth, semi-structured, one-time, one-on-one interviews

4 patients; 4 family members; 10 oncologists

Advanced cancer patients

Hospital: department of medical oncology and radiation oncology

To explore the understanding, experiences, reflections, and information needs of patients and their families regarding ACP, as well as physicians’ experiences in initiating ACP and their views on ACP training.

Five themes: (1) initiating ACP; (2) the relationship between patient and family influences and the progression of ACP; (3) limited formal training in ACP; (4) ACP requires teamwork; (5) lack of a coordinated health system.

Sellars et al. [29]

(2017)

Australia

Grounded theory; thematic analysis; semi-structured interviews; qualitative study

20 nephrologists; 7 nurses; 4 social workers

Patients with chronic kidney disease

Clinics in different regions of Australia with experience in ACP for patients with CKD

To describe the experiences and perspectives of multidisciplinary clinicians regarding ACP, and to provide guidance and recommendations for the implementation of ACP for patients with chronic kidney disease.

Five themes: (1) promoting informed decision-making; (2) ethical challenges across moral boundaries; (3) navigating vulnerable conversations; (4) professional helplessness in initiating ACP; (5) clarified responsibilities.

Schichtel et al. [22]

(2021)

United Kingdom

Reflexive thematic analysis; semi-structured interviews; interpretive and descriptive study

17 GPs; 7 nurses

Patients with heart failure

Rural and urban communities: primary health care institutions

To explore the promoting and hindering factors of implementing ACP for patients with heart failure to improve patients’ participation in ACP.

Three main themes: (1) ACP is an integral part of holistic health care in HF; (2) factors that may limit the doctor-patient relationship; (3) approaches to improving patients’ ACP participation.

Robinson et al. [24]

(2013)

United Kingdom

Thematic analysis; focus groups and individual interviews; qualitative study

5 specialist palliative care professionals; 10 GPs; 17 community nurses and AHPs; 10 old-age psychiatrists; 22 mental health nurses and AHPs; 6 social workers; 15 ambulance service workers; 3 solicitors; 7 voluntary sector

Dementia patients

Clinical area of palliative care and dementia

To explore professionals’ experiences in the implementation of ACP for dementia and palliative care patients.

Four main themes: (1) the value of ACP; (2) delivering patient choice and achieving desired outcomes; (3) definition and legal issues of ACP; (4) three uncertain aspects of ACP practice: (a) who’s responsibility; (b) when to start; (c) what documentation is used.

O’Hare et al. [25]

(2016)

United States

Grounded theory; semi-structured, one-on-one interviews by phone or in person

13 physicians; 6 nurses; 3 dialysis technicians; 2 dieticians; 2 social workers

Patients with advanced kidney disease

Multidisciplinary specialties (geriatric medicine, cardiology, intensive care, nephrology, palliative care, nursing, nutrition, physiatry, primary care, social work, and vascular surgery) at Health Care System

To explore multidisciplinary health professionals’ experiences in and perspectives on ACP for patients with advanced renal disease to determine ways to improve the participation rate of this population.

Four themes: (1) ACP is influenced by clinical setting, the role of different healthcare providers, and disease trajectory; (2) lack of a shared understanding and vision of the relationship between ACP and other relevant forgone life resuscitation discussions; (3) unclear responsibilities; (4) lack of active collaboration and communication.

De Vleminck et al. [30]

(2014)

Belgium

Constant comparative analysis; qualitative methodology of focus groups

36 GPs

Patients with cancer, heart failure, and dementia

Palliative home care teams

From GPs’ perspectives, identify the barriers to initiating ACP and gain insight into the barrier differences between ACP trajectories in patients with cancer, heart failure, and dementia.

Two themes: (1) barriers to initiating ACP; (2) differences in ACP initiation barriers in patients with cancer, heart failure, and dementia.

Menon et al. [26]

(2018)

Singapore

Explorative qualitative study; focus groups; individual, semi-structured, in-depth interviews; inductive thematic analysis

15 doctors; 13 nurses; 5 medical social workers; 15 patients; 13 caregivers

Patients with LLI

Multiple health care settings: areas such as geriatrics and family medicine tend to care for patients with life-limiting illnesses

To study the attitudes of patients with LLI, informal caregivers, and healthcare professionals (that care for life-limited patients) toward ACP in a multicultural, family-centered community.

Seven themes: (1) ACP may cause loss of hope and/or depression; (2) ACP may not reflect patients’ preferences; (3) family members play an important role in decision-making, especially for elderly patients and those lacking capacity; (4) ACP may burden families; (5) ACP can bring benefits to all stakeholders; (6) society is not ready for ACP; (7) misunderstandings about laws governing medical care decisions for patients with and without capacity.

Manthorpe et al. [31]

(2019)

United Kingdom

Semi-structured interviews; framework analysis; exploratory study

7 CPNs; 4 doctors; 3 social workers or occupational therapists

Dementia patients

Community mental health services

To explore community-based healthcare professionals’ understanding of the process, experiences, barriers, and contributing factors of ACP for patients with dementia.

Five themes: (1) ACP knowledge and experience; (2) use of ACP; (3) inhibitors of discussion; (4) service influences; (5) recommendations for future ACP implementation.

Kuusisto et al. [17]

(2021)

Finland

Qualitative descriptive study; focus group interviews; individual or couple interviews; inductive content analysis

18 registered nurses; 5 practical nurses; 5 physicians; 5 social workers

Patients with cancer, COPD, and ALS

Palliative care unit in hospital ward or outpatient clinic

To describe medical professionals’ perceptions of ACP in palliative care units in hospital wards or outpatient settings.

Three themes: (1) ACP information content; (2) coordination of ACP care activities; (3) support patients and their families in coping.

Hirakawa et al. [23]

(2021)

Japan

Multicenter qualitative study; in-depth semi-structured interviews; content analysis

7 physicians; 23 nurses; 4 care managers; 4 social workers

Patients with severe COPD

Palliative care services

To explore healthcare providers’ perceptions of ACP implementation in adult patients with severe COPD and challenges in facilitating ACP.

Five main themes based on the stakeholder education model: (1) daily decision-making; (2) sense of ethical decision-making; (3) in-depth interviewing skills; (4) collaborative information sharing among team members; (5) dissemination of knowledge about ACP.