## 3 Results
### Uncertainties in Clinical Decision-Making
For example, HCPs in one of the acute care hospitals were reported to have access to a specialized cancer ER, meaning that the patients did not have to go to the general ER, where often other acute conditions are prioritized. In addition, heterogeneity in access to SPC inpatient beds also appeared to impact these decisions. In one sub-theme, the reasoning centered on the heterogeneity of competence within/between SPC teams (creating uncertainty about what to expect); _Access to competent care by competent staff._  
_\"I think we all know that the care is very different between SPC teams. Some does all (assessments, antibiotics) and care for them until they are dying, while others always send in the patients.\"_ (FG5, MD2)  
Another finding related to this sub-theme was the resources from either informal caregivers and/or professional care (personal hygiene, feeding), this type of support being separately organized by the municipalities. The SPC teams discussed the difficulties of organizing this important support from the municipalities, especially if urgent, as the process was time-consuming. The HCPs described the challenges involved in coordinating care activities between SPC at home and non-medical support at home. The negative consequences of sending palliative patients to the acute hospital were highlighted by the acute care teams. One organizational factor described was the routine that if a patient were admitted to the acute care hospital for more than 72 h, a new referral to SPC was needed. The new referral, hindering continuity of care and risking unnecessary acute care, is described in, _System and policy_. _\"...This happens all the time- Friday night, because you are perhaps new- it feels stressful when someone cannot breathe properly. You know it may be a pulmonary embolus and there will be a CT (computer tomography). The patient will be admitted and stay over the weekend. Then they lost their place at SPC at home. And then it will be hard to discharge the patient to home.\"_ (FG5, MD1)  
The health care professionals from both settings, described how they felt restrained in clinical decisions due to how the health care system and how economical incitements impacted. This was expressed several times with frustration, i.e., the pressure of fulfilling the policy to occupy all beds in the palliative inpatient ward (leaving no room for an urgent admission from home and/or hindering continuity of care) and fragmented care consequently. _\"It is frustrating to keep the budget, our ward needs to be fully occupied all the time and when that happens, the patient's supposed to \"choose\" another SPC provider. It does matter, it matters a lot. In this case, the patient might end up at a palliative ward somewhere else, making it more difficult for the patients' family to visit.\"_ (FG3, RN3)  
Among participants from both settings and professions, it seemed to be unclear who had the overarching responsibilities for a patients' care. In the sub-theme, _Uncertainty of mandate and goals-of-care_, this was discussed in various ways, for instance when a patient recently had completed cancer treatment and had a follow-up acute cancer care appointment scheduled but also ongoing SPC at home. _\"She is (the patient) still in the care of the oncology clinic even if she doesn 't have active treatment, she still has an appointment there. Here we need to be clear, a clearer decision, SPC is responsible, but the oncology clinic is responsible in one way.\"_ (FG3, RN3)  
All participants agreed on shared responsibility in principle, but different views and uncertainty on what this exactly meant were apparent. Responsibility for cancer treatment and symptom management seems to be the theoretical threshold, but in practice, this seems confusing as treatment and symptom management need to be interlinked in person-centered care. The perceived silos of acute versus palliative care appeared to impact a timely EOL conversation (one team waiting for the other to initiate EOL conversations and planning).