Advance care planning (ACP) related to end of life (EOL) care is an often neglected area in primary care. Nurse care managers (NCM’s) are in a unique position to initiate earlier conversations about illness management and patient preferences regarding end of life so patients have the opportunity to make choices and have their wish known while they are still cognitively independent. The purpose of this quality improvement project was to identify barriers to discussions about end of life care with patients in clinical practice. Six NCM’s participated in two focus groups to identify perceived barriers for end of life care discussions and to identify potential solutions to those barriers. Barriers identified included: patient/family factors, organizational factors, and provider related factors. NCM solutions identified included patient related interventions such as normalizing and routinizing EOL/ACP discussion reviewing choices at all ages annually. Organizational solutions recommended include making EOL care discussions a quality measure and training all office staff to support culture change. Provider related recommendations included providers completing their own advance directive as a way to lead the way for patients. Implications for education, practice, policy, and research are identified.