Background Advance care planning (ACP) is known to improve the end-of-life care of patients with heart failure (HF) and has been emphasized in international HF guidelines. Despite its known benefits, ACP completion rates remain dismal. We aimed to study the barriers to completion of ACP in HF patients.

Methods We systematically reviewed all the ACP referrals that were made at a tertiary cardiac centre from 2017 – 2021 in Singapore. There were 164 referrals and only 69 were completed. We studied the reasons for incompletion of the remaining 95 referrals. We also conducted a self-administered questionnaire survey to understand the Cardiologists’ perceptions of ACP.

Results Common reasons for ACP incompletion include: 1) Patients/Family declining to complete the ACP discussion. (34%) This is especially so in Singapore as discussion about death is still considered taboo. 2) Patients not returning for ACP discussion (25%) as most of the discussions were conducted in the outpatient setting. 3) Patients/Family changing their minds about completing ACP at the last minute (11%). 4) Patients/Family not being able to make a decision on their preferences (9%). 5) Patients/Family not understanding ACP (5%).

Out of 22 Cardiologists surveyed, 22% felt that ACP was not important for their patients. 68% felt that they were not confident in conducting ACP and only half had ever attempted to do one. The common reasons identified for barriers to ACP include: not having enough time, not knowing how to do ACP and that patients are not ready to talk about ACP. 82% indicated that they would want to learn more about ACP and apply it in their clinical practice.

Conclusion Our study identifies the common reasons for incompletion of ACP and the perception of Cardiologists towards ACP. Future interventions could be developed based on these findings to improve ACP completion rates.