{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T00:40:27Z","timestamp":1782780027827,"version":"3.54.5"},"reference-count":48,"publisher":"MDPI AG","issue":"23","license":[{"start":{"date-parts":[[2022,12,2]],"date-time":"2022-12-02T00:00:00Z","timestamp":1669939200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Cancer Research Foundation in Northern Sweden","award":["AMP 18-928"],"award-info":[{"award-number":["AMP 18-928"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>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).<\/jats:p>","DOI":"10.3390\/ijerph192316134","type":"journal-article","created":{"date-parts":[[2022,12,2]],"date-time":"2022-12-02T03:55:37Z","timestamp":1669953337000},"page":"16134","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Exploring Health Care Professionals\u2019 Perceptions Regarding Shared Clinical Decision-Making in Both Acute and Palliative Cancer Care"],"prefix":"10.3390","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5747-853X","authenticated-orcid":false,"given":"Helena","family":"Ullgren","sequence":"first","affiliation":[{"name":"Department of Nursing, Ume\u00e5 University, 901 87 Ume\u00e5, Sweden"},{"name":"Department of Oncology and Pathology, Karolinska Institute, 171 77 Stockholm, Sweden"},{"name":"ME Head & Neck, Lung & Skin Cancer, Karolinska Comprehensive Cancer Center, 171 76 Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lena","family":"Sharp","sequence":"additional","affiliation":[{"name":"Department of Nursing, Ume\u00e5 University, 901 87 Ume\u00e5, Sweden"},{"name":"Regional Cancer Center, 104 25 Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1248-5581","authenticated-orcid":false,"given":"Per","family":"Fransson","sequence":"additional","affiliation":[{"name":"Department of Nursing, Ume\u00e5 University, 901 87 Ume\u00e5, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6331-8599","authenticated-orcid":false,"given":"Karin","family":"Bergkvist","sequence":"additional","affiliation":[{"name":"Department of Nursing Science, Sophiahemmet University, 114 86 Stockholm, Sweden"},{"name":"Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institute, 171 77 Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,12,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1266","DOI":"10.1080\/0284186X.2020.1822544","article-title":"Trends in cancer survival in the Nordic countries 1990\u20132016: The NORDCAN survival studies","volume":"59","author":"Lundberg","year":"2020","journal-title":"Acta Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"394","DOI":"10.1016\/S1470-2045(18)30060-3","article-title":"Effect of early and systematic integration of palliative care in patients with advanced cancer: A randomised controlled trial","volume":"19","author":"Vanbutsele","year":"2018","journal-title":"Lancet. Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Luta, X., Maessen, M., Egger, M., Stuck, A.E., Goodman, D., and Clough-Gorr, K.M. (2015). Measuring Intensity of End of Life Care: A Systematic Review. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0123764"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Nguyen, M., Kin, S.N.Y., Shum, E., Wann, A., Tamjid, B., Sahu, A., and Torres, J. (2020). Anticancer therapy within the last 30 days of life: Results of an audit and re-audit cycle from an Australian regional cancer centre. BMC Palliat Care, 19.","DOI":"10.1186\/s12904-020-0517-3"},{"key":"ref_5","first-page":"27","article-title":"When to Stop Oncological Treatment in Palliative Patients\u2014An Increasing Challenge in Times of Immunooncology","volume":"55","author":"Knorrenschild","year":"2020","journal-title":"Anasthesiol. Intensivmed. Notf. Schmerzther. AINS"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"399","DOI":"10.1016\/j.profnurs.2014.01.006","article-title":"Enhancing clinical decision making: Development of a contiguous definition and conceptual framework","volume":"30","author":"Tiffen","year":"2014","journal-title":"J. Prof. Nurs."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1089\/jpm.2015.0119","article-title":"The Costs of Waiting: Implications of the Timing of Palliative Care Consultation among a Cohort of Decedents at a Comprehensive Cancer Center","volume":"19","author":"Scibetta","year":"2016","journal-title":"J. Palliat. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1743","DOI":"10.1002\/cncr.28628","article-title":"Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients","volume":"120","author":"Hui","year":"2014","journal-title":"Cancer"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1384","DOI":"10.1089\/jpm.2014.0092","article-title":"Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review","volume":"17","author":"DiMartino","year":"2014","journal-title":"J. Palliat. Med."},{"key":"ref_10","first-page":"CD012780","article-title":"The effectiveness and cost-effectiveness of hospital-based specialist palliative care for adults with advanced illness and their caregivers","volume":"9","author":"Bajwah","year":"2020","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1191\/026921600701536228","article-title":"Minimum dataset activity for hospice and hospital palliative care services in the UK 1997\/98","volume":"14","author":"Eve","year":"2000","journal-title":"Palliat. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1596","DOI":"10.1177\/0269216318801251","article-title":"Quality of care for the dying across different levels of palliative care development: A population-based cohort study","volume":"32","author":"Schelin","year":"2018","journal-title":"Palliat. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e588","DOI":"10.1016\/S1470-2045(18)30415-7","article-title":"Integration of oncology and palliative care: A Lancet Oncology Commission","volume":"19","author":"Kaasa","year":"2018","journal-title":"Lancet Oncol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2069","DOI":"10.1111\/jocn.15216","article-title":"Advance care planning for patients with cancer in palliative care: A scoping review from a professional perspective","volume":"29","author":"Kuusisto","year":"2020","journal-title":"J. Clin. Nurs."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1111\/ajco.12678","article-title":"End-of-life care: Where do cancer patients want to die? A systematic review","volume":"13","author":"Nilsson","year":"2017","journal-title":"Asia-Pac. J. Clin. Oncol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1016\/S0885-3924(01)00334-7","article-title":"Preparing for the end of life: Preferences of patients, families, physicians, and other care providers","volume":"22","author":"Steinhauser","year":"2001","journal-title":"J. Pain Symptom Manag."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1080\/0284186X.2017.1418089","article-title":"Patient-reported experiences on supportive care strategies following the introduction of the first Swedish national cancer strategy and in accordance with the new patient act","volume":"57","author":"Westman","year":"2018","journal-title":"Acta Oncol."},{"key":"ref_18","unstructured":"(2021, October 10). Cancerplan, Stockholm-Gotland 2020\u20132023. Available online: https:\/\/cancercentrum.se\/stockholm-gotland\/om-oss\/strategisk-utvecklingsplan\/cancerplan-2020-2023\/."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1016\/j.ejon.2019.05.009","article-title":"Patient-reported perceptions of care after the introduction of a new advanced cancer nursing role in Sweden","volume":"41","author":"Westman","year":"2019","journal-title":"Eur. J. Oncol. Nurs. Off. J. Eur. Oncol. Nurs. Soc."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"831","DOI":"10.1001\/jama.297.8.831","article-title":"Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care","volume":"297","author":"Kripalani","year":"2007","journal-title":"Jama"},{"key":"ref_21","unstructured":"Ullgren, H. (2017, January 27\u201328). Early palliative care referral, emergency admissions and care transitions- the challenge of integrative care for H&N cancer patients. Proceedings of the National Conference of Swedish Cancer Nursing Society, Stockholm, Sweden."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Morgan, D.L. (1997). Focus Groups as Qualitative Research, SAGE. [2nd ed.].","DOI":"10.4135\/9781412984287"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1609406917750781","DOI":"10.1177\/1609406917750781","article-title":"Two Approaches to Focus Group Data Collection for Qualitative Health Research: Maximizing Resources and Data Quality","volume":"17","author":"Flynn","year":"2018","journal-title":"Int. J. Qual. Methods"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1177\/1468794109356737","article-title":"Putting it in context: The use of vignettes in qualitative interviewing","volume":"10","author":"Jenkins","year":"2010","journal-title":"Qual. Res."},{"key":"ref_25","first-page":"e13361","article-title":"Factors associated with healthcare utilisation during first year after cancer diagnose-a population-based study","volume":"30","author":"Ullgren","year":"2020","journal-title":"Eur. J. Cancer Care"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1016\/j.ejon.2016.12.003","article-title":"Working in silos?\u2014Head & Neck cancer patients during and after treatment with or without early palliative care referral","volume":"26","author":"Ullgren","year":"2017","journal-title":"Eur. J. Oncol. Nurs. Off. J. Eur. Oncol. Nurs. Soc."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Ullgren, H., Fransson, P., Olofsson, A., Segersvard, R., and Sharp, L. (2021). Health care utilization at end of life among patients with lung or pancreatic cancer. Comparison between two Swedish cohorts. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0254673"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1093\/intqhc\/mzm042","article-title":"Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups","volume":"19","author":"Tong","year":"2007","journal-title":"Int. J. Qual. Health Care J. Int. Soc. Qual. Health Care"},{"key":"ref_29","unstructured":"Ritchie, J., and Lewis, J. (2003). Carrying Out Qualitative Analysis. Qualitative Research Practice: A Guide for Social Science Students and Researchers, SAGE."},{"key":"ref_30","unstructured":"Bryman, A., and Burgess, B. (1994). Analyzing Qualitative Data, Taylor & Francis Group."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2423","DOI":"10.1111\/jan.12127","article-title":"Using Framework Analysis in nursing research: A worked example","volume":"69","author":"Ward","year":"2013","journal-title":"J. Adv. Nurs."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Gale, N.K., Heath, G., Cameron, E., Rashid, S., and Redwood, S. (2013). Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med. Res. Methodol., 13.","DOI":"10.1186\/1471-2288-13-117"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1753","DOI":"10.1177\/1049732315617444","article-title":"Sample Size in Qualitative Interview Studies: Guided by Information Power","volume":"26","author":"Malterud","year":"2016","journal-title":"Qual. Health Res."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"e1291","DOI":"10.1200\/OP.20.00013","article-title":"Views from Patients with Cancer in the Setting of Unplanned Acute Care: Informing Approaches to Reduce Health Care Utilization","volume":"16","author":"Kaufmann","year":"2020","journal-title":"JCO Oncol. Pract."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1200\/JCO.2016.70.1474","article-title":"Integration of Palliative Care into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update","volume":"35","author":"Ferrell","year":"2016","journal-title":"J. Clin. Oncol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Colombet, I., Bouleuc, C., Piolot, A., Vilfaillot, A., Jaulmes, H., Voisin-Saltiel, S., Goldwasser, F., Vinant, P., Alexandre, J., and Mons, M. (2019). Multicentre analysis of intensity of care at the end-of-life in patients with advanced cancer, combining health administrative data with hospital records: Variations in practice call for routine quality evaluation. BMC Palliat. Care, 18.","DOI":"10.1186\/s12904-019-0419-4"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1073274819846574","DOI":"10.1177\/1073274819846574","article-title":"The Intensity of Hospital Care Utilization by Dutch Patients with Lung or Colorectal Cancer in their Final Months of Life","volume":"26","author":"Atsma","year":"2019","journal-title":"Cancer Control"},{"key":"ref_38","first-page":"231","article-title":"Experts Foresee a Major Shift from Inpatient to Ambulatory Care","volume":"41","author":"Beans","year":"2016","journal-title":"Pharm. Ther."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1046\/j.1532-5415.2003.51186.x","article-title":"Improving the Quality of Transitional Care for Persons with Complex Care Needs","volume":"51","author":"Coleman","year":"2003","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Ko, W., Deliens, L., Miccinesi, G., Giusti, F., Moreels, S., Donker, G.A., Onwuteaka-Philipsen, B., Zurriaga, O., Lopez-Maside, A., and Van den Block, L. (2014). Care provided and care setting transitions in the last three months of life of cancer patients: A nationwide monitoring study in four European countries. BMC Cancer, 14.","DOI":"10.1186\/1471-2407-14-960"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"i89","DOI":"10.1136\/bmjqs-2012-001171","article-title":"The key actor: A qualitative study of patient participation in the handover process in Europe","volume":"21","author":"Flink","year":"2012","journal-title":"BMJ Qual. Saf."},{"key":"ref_42","first-page":"S284","article-title":"Integrated delivery systems: The cure for fragmentation","volume":"15","author":"Enthoven","year":"2009","journal-title":"Am. J. Manag. Care"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1699","DOI":"10.1080\/0284186X.2019.1659512","article-title":"Assessing the utilization of the decision to implement a palliative goal for the treatment of cancer patients during the last year of life at Helsinki University Hospital: A historic cohort study","volume":"58","author":"Hirvonen","year":"2019","journal-title":"Acta Oncol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1080\/02813432.2019.1608068","article-title":"\u2018We have no crystal ball\u2019\u2014advance care planning at nursing homes from the perspective of nurses and physicians","volume":"37","author":"Kastbom","year":"2019","journal-title":"Scand. J. Prim. Health Care"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1177\/1938965520967769","article-title":"Qualitative Research via Focus Groups: Will Going Online Affect the Diversity of Your Findings?","volume":"62","author":"Richard","year":"2020","journal-title":"Cornell Hosp. Q."},{"key":"ref_46","unstructured":"Kvale, S., and Brinkmann, S. (2015). InterViews: Learning the Craft of Qualitative Research Interviewing, Sage Publications. [3rd ed.]."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1177\/1468794108098029","article-title":"Using focus groups: Lessons from studying daycare centers, 9\/11, and Hurricane Katrina","volume":"9","author":"Peek","year":"2009","journal-title":"Qual. Res."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1188\/16.ONF.253-255","article-title":"The International Society of Nurses in Cancer Care: Position Statements Can Aid Nurses to Think Globally and Act Locally","volume":"43","author":"Beck","year":"2016","journal-title":"Oncol. sNurs. Forum"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/23\/16134\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T01:32:40Z","timestamp":1760146360000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/23\/16134"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,12,2]]},"references-count":48,"journal-issue":{"issue":"23","published-online":{"date-parts":[[2022,12]]}},"alternative-id":["ijerph192316134"],"URL":"https:\/\/doi.org\/10.3390\/ijerph192316134","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,12,2]]}}}