Barriers and facilitators to advance care planning implementation: a qualitative interprofessional study in the Spanish public health and social care system

Abstract

Advance Care Planning (ACP) is essential for improving the quality of end-of-life care. Despite having a well-established legal framework, the implementation of ACP in Spain is limited and largely bureaucratic. The existing literature has primarily focused on knowledge deficits among professionals, overlooking the emotional, cultural, and organisational dynamics shaping clinical practice. This study aimed to explore the experiences of healthcare and non-healthcare professionals regarding ACP implementation and to identify the multilevel factors that influence its integration into routine practice within the public health and social care system. A qualitative descriptive study was conducted within the Public Health System of Asturias (Spain). A multidisciplinary focus group was carried out with 10 professionals (medicine, nursing, social work, psychology, and auxiliary nursing care technicians [TCAE; equivalent to healthcare assistants]) selected through purposive sampling. Data were analysed using inductive qualitative content analysis. To support credibility, nine participants took part in an immediate participatory review at the end of the focus group, in which they reviewed a preliminary synthesis based on the observers’ field notes and collaboratively reorganised it into a SWOT (Strengths, Weaknesses, Opportunities, Threats) matrix. The study adhered to COREQ guidelines. Two main themes emerged: barriers and facilitators to ACP implementation. Barriers were identified at professional (emotional avoidance, limited communication training), sociocultural (family conspiracy of silence, paternalism), and organisational levels (bureaucratisation, fragmented care, rigidity of the Advance Directive document). Key facilitators included longitudinal care in primary care settings, the strategic role of nursing in initiating and sustaining ACP conversations, and increasing patient empowerment. Participants highlighted the need to move beyond advance directives as isolated documents towards integrating ACP as a dynamic, ongoing process within the electronic health record. ACP implementation is hindered by a perceived dissonance between autonomy-oriented theoretical models and a clinical reality constrained by cultural inertia, emotional avoidance, and organisational fragmentation. Overcoming these barriers may require moving beyond technical training to incorporate emotional and communicative competencies and shifting from a document-centred approach to a relational and dynamic model of care, with primary care and nursing as key drivers. These findings contribute to qualitative ACP research by conceptualising ACP as a “living” process integrated into the electronic health record and by using participatory SWOT analysis to translate findings into implementation-relevant insights.