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Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis
  1. Markus Schichtel1,
  2. Bee Wee2,
  3. John I MacArtney3 and
  4. Sarah Collins4
  1. 1Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  2. 2Oxford Centre for Education and Research in Palliative Care, Oxford University Hospital Trust, Oxford, UK
  3. 3Academic Primary Care Unit, Medical Sciences Division, University of Warwick, Coventry, UK
  4. 4Oxford Health NHS Foundation Trust, Oxfordshire, UK
  1. Correspondence to Dr Markus Schichtel, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Biomedical Campus, Cambridge CB2 0SR, UK; ms2591{at}


Background Clinicians hesitate to engage with advance care planning (ACP) in heart failure. We aimed to identify the disease-specific barriers and facilitators for clinicians to engage with ACP.

Methods We searched Medline, Embase, CINAHL, PubMed, Scopus, the British Nursing Index, the Cochrane Library, the EPOC register, ERIC, PsycINFO, the Science Citation Index and the Grey Literature from inception to July 2018. We conducted the review according to Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Two reviewers independently assessed original and empirical studies according to Critical Appraisal Skills Programme criteria. The SURE framework and thematic analysis were used to identify barriers and facilitators.

Results Of 2308 articles screened, we reviewed the full text of 42 studies. Seventeen studies were included. The main barriers were lack of disease-specific knowledge about palliative care in heart failure, high emotional impact on clinicians when undertaking ACP and lack of multidisciplinary collaboration between healthcare professionals to reach consensus on when ACP is indicated. The main facilitators were being competent to provide holistic care when using ACP in heart failure, a patient taking the initiative of having an ACP conversation, and having the resources to deliver ACP at a time and place appropriate for the patient.

Conclusions Training healthcare professionals in the delivery of ACP in heart failure might be as important as enabling patients to start an ACP conversation. This twofold approach may mitigate against the high emotional impact of ACP. Complex interventions are needed to support clinicians as well as patients to engage with ACP.

  • heart failure
  • advance care planning
  • barriers
  • facilitators
  • clinicians
  • systematic literature review

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  • Correction notice This article has been updated since it was first published. The article type has been changed to Systematic review.

  • Contributors MS had the idea for the review, wrote the protocol, extracted, evaluated and analysed the data, wrote, critically revised and submitted the entire manuscript. BW critically supervised the conduct of the review and revised the entire manuscript. JIM critically revised the study protocol, the narrative synthesis as well as the SURE analysis of barriers and facilitators. SC independently screened papers, extracted data and evaluated the study quality according to the CASP assessment tool. All coauthors approved the version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.