Advance Care Planning in structurally vulnerable populations: A scoping review of barriers, facilitators, and interventions

BACKGROUND: Individuals experiencing structural vulnerabilities experience greater rates of serious illness and face barriers to accessing healthcare, including advance care planning. However, evidence to understand relevant barriers, facilitators, and effective interventions for advance care planning engagement among different structurally vulnerable populations remains fragmented. AIM: To inform advance care planning interventions for structurally vulnerable patients by reviewing: barriers and facilitators to advance care planning; and advance care planning interventions. DESIGN: Scoping review. DATA SOURCES: We searched MEDLINE, Embase, CINAHL, and PsycINFO for studies published between January 2003 and October 2024. Eligible studies examined advance care planning for those experiencing housing instability, poverty, racialization of Black or Indigenous race, serious mental illness, or substance use disorders. RESULTS: From 70 included articles, 13 barriers, 13 facilitators, and 6 targets of intervention were identified. Barriers and facilitators were commonly experienced between multiple structurally vulnerable populations. The most common barriers include low advance care planning literacy, discomfort with conversations around mortality, personal, cultural and/or spiritual beliefs, and familial and social isolation. Common facilitators include trusted provider relationships, provider training and empowerment, social support, and tailored advance care planning content and delivery. We identified 27 interventions, most commonly involving advance care planning education and outreach or guided advance care planning. CONCLUSIONS: Structurally vulnerable patients share many barriers and facilitators to advance care planning, which can inform interventions for underserved populations. Interventions targeting advance care planning education and outreach or guided advance care planning show promise if providers can incorporate advance care planning facilitators.