###### Abstract  
Developments in cancer care have resulted in improved survival and quality of life. Integration of acute and palliative cancer care is desirable, but not always achieved. Fragmented care is associated with sub-optimal communication and collaboration, resulting in unnecessary care transitions. The aim of this study was to explore how health care professionals, from both acute and palliative care, perceive clinical decision-making when caring for patients undergoing active cancer treatment in parallel with specialized palliative care at home. Methods: Qualitative explorative design, using online focus-group interviews, based on patient-cases, among health care professionals (physicians and nurses) and Framework Analysis. Results: Six online focus-group interviews were performed. Few signs of systematic integration were found, risking fragmented care, and putting the patients in a vulnerable situation. Different aspects of uncertainty related to mandates and goals-of-care impacted clinical decision-making. Organizational factors appeared to hinder mutual clinical decision-making as well as the uncertainty related to responsibilities. These uncertainties seemed to be a barrier to timely end-of-life conversations and clinical decisions on optimal care, for example, the appropriateness of transfer to acute care. Conclusions: Lack of integration between acute and palliative care have negative consequences for patients (fragmented care), health care professionals (ethical stress), and the health care system (inadequate use of resources). cancel care; palliative care; clinical decision-making; clinical research home care; focus groups +
Footnote †: journal: Journal of LaTeX Templates  
thorough descriptions of palliative care models [10]. Often palliative care is organized as General palliative care (described as palliative care provided by general practitioners, district nurses or from hospital units), or Specialized palliative care (SPC), provided by a team of health care professionals with training in palliative care, often including inpatient care or SPC at home [11]. Both general and SPC can be provided early in the disease trajectory, as well as at EOL. In Sweden, the provision of palliative care varies between regions [12], both in terms of accessibility and organization. Recent recommendations both in research and by expert panels, focus on the systematic integration of acute and palliative cancer care [13]. [PERSON] et al. (2018) suggests several levels of integration, from less formal working in parallel to being fully integrated. The goal is to provide health care organized from the individual patient's needs, with a seamless provision, formed as one unit from the existing system [13], with clear and integrated goals-of-care. Discussions on goals at EOL, taking into account the patients preferences, is one of several quality indicators for EOL care [12]. [PERSON] et al., 2020, showed that these EOL discussions however, often were conducted too late [14]. In a recent review, the authors concluded that most patients with cancer preferred, if possible, to die at home [15] and wanted to prepare and plan for EOL [16]. In the context of this study, cancer treatment and follow-up are provided by three acute hospitals in the region of Stockholm. The acute cancer care teams offer support and symptom management, with the main point of contact, usually a specialist nurse, working at the hospital out-patient clinics [17]. During the last decade, access to SPC at home has increased in this region, regardless of disease stage [18]. Some of the SPC units provide home care while others have access to SPC in-patient care. Thus, the acute cancer care and SPC at home care teams are organized in separate organizations [18]. Non-medical support at home is provided, if needed, by the municipalities, again separately organized.