Barriers to and readiness for advance care planning: a systematic review and meta-analysis of quantitative and qualitative evidence.

BACKGROUND: Advance care planning (ACP) allows individuals to express their values and preferences for future medical care, yet participation remains low globally. Understanding readiness for ACP and the barriers and facilitators influencing engagement is essential for effective implementation. METHODS: Following Joanna Briggs Institute (JBI) and PRISMA 2020 guidelines, a comprehensive search was conducted across PubMed, Embase, Scopus, Web of Science, Cochrane Library, and grey literature up to September 2025. Quantitative, qualitative, and mixed-methods studies involving adults (patients, families, or healthcare providers) were included. Quantitative data on ACP readiness or acceptance were pooled using a random-effects meta-analysis, while qualitative data were synthesized thematically. Study quality was appraised using CASP, NOS, and Cochrane RoB tools; certainty of evidence was assessed using GRADE and GRADE-CERQual frameworks. RESULTS: Twenty-nine studies (n = 15,565 participants) from eight countries met inclusion criteria. Barriers to ACP were identified at the patient (emotional discomfort, limited awareness, cultural taboos), family (overprotection, conflict, poor communication), provider (time constraints, lack of training, role ambiguity), and system (insufficient policies, documentation challenges, and fragmented care) levels. Facilitators included family support, early provider initiation, structured protocols, and culturally sensitive communication. The pooled mean ACP readiness score across four studies (n = 856) was 77.23 (95% CI: 67.86-86.61), indicating moderate readiness with substantial heterogeneity (I² = 99.4%). Readiness was positively associated with family support, prior caregiving experience, and active coping styles. CONCLUSIONS: Global readiness for ACP remains moderate and is constrained by emotional, familial, professional, and systemic barriers. Enhancing communication, training, and supportive institutional frameworks is essential to strengthen ACP engagement and promote person-centered end-of-life care. REGISTRATION: CRD420251172759.