Table 6.

Main pros and cons of using the QALY in palliative care and suggested alternatives/approaches from theoretical literature mapped thematically.

	Cons	Pros	Alternatives
Theme 1	Objective palliative care is to improve QoL, not (necessarily) life expectancy.5,18	Fact that “we are all dead in the long run” (Keynes), does not make the QALY inapplicable across the board.6
	QALYs implicit assumption that interventions must increase life expectancy flawed.5	Our QoL matters to us while we are alive, and this is what the QALY seeks to capture, too.6
	Because of low life expectancy, in palliative care effects enjoyed over short time, life-saving therapy will result in higher QALY gains.5,18	QALY enables comparisons between competing demands by combining both quality and quantity of life in a single metric.7
	Even when costs are modest, palliative interventions cannot prove themselves cost-effective as no enough time for them to generate QALYs.18	Increases in QALYs are possible; even if one of the weighing factors does not change significantly (i.e. if life cannot be lengthened), improvements can be made in the other.7
	Developing more accurate QoL instruments (link theme 2, red.) would not solve QALY problem; limiting factor short life expectancy.6	Other non-life prolonging interventions, only increasing QoL (or limiting its potential loss, red.) can be measured in QALYs (e.g. hip operations).6,8
Theme 2	Analysis of outcomes needs to embrace complex and multidimensional objectives of palliative care, as broad as notion of QoL itself.12,29	Palliative care and QALY are not incompatible. Like QALY and cost-utility calculations, palliative care involves a benefit-burden analysis.30	Narrative theory
	Limitations and standard outcome measures (like the EQ-5D) make comparisons inappropriate.12	Palliative care can be optimally integrated into the calculation of the QALY.8,30
	Even if refinement analytical tools lead to increased assessment QoL, limiting factor still shortens life expectancy.6	QALYs’ ability to rate changes in morbidity and mortality in a single measure and to enable comparison between competing demands for resources are as applicable in this population as in any other.7
	Resources tend to be biased away from services received at the EoL because they are hard to evaluate.12,18	Scoring badly on measure of outcome is not a good reason to reject that measure.6
	Therapeutic nihilism undermines ability to see value beyond cure-oriented disease modification.29	If aspects are missed or if there is a lack of precision in QALY analysis, this is a shortcoming of ways of measuring rather than failing of QALY approach.6,7
	Interventions could be assessed based on their impact on what a person is able to do or be (capabilities) and not solely on functioning.14	In the capability approach, in which capabilities are taken into account instead of functioning, QoL is measured in a richer evaluative space.14	Capability approach
	Dimensions of palliative care that are not considered when calculating QALYs can be added when using the PalY.12	Instruments could be developed that take account of the domains of relevance to a certain population.7
	Assumption that there is a mathematical continuum between death and excellent health is a fundamental problem.5	Non-HR domains can be considered in the QALY, but to date, they are not. Fact that researchers have not taken advantage of the flexibility (as offered in extra welfarism) is not a criticism of the framework itself.7
	Bad death can destroy much of value of total life,6 allowing a value to be put on components of good death.6,12,29,41	Terminal care can be justified in QALY terms when refinement of definition of “quality” and “life.”42
	Assumption that there is a mathematical continuum between death and excellent health is a fundamental problem.5	Living with heterogeneity in evidence used for policy choices is less serious than fitting all evaluation activity into systematically flawed frameworks.18
		If EoL patients are treated inequitably, an equity weight could be derived and applied as required.7
Theme 3	Valuation of time not fixed; it increases as time itself is running out.29,30	Relative simplicity: time for any individual at any point in time has a constant value, which has useful properties (such as being additive).12	Peak End Rule
	A value can be put on components of a “good death,” which is separate from the days that led up to it (PalY).12	Value of time changes throughout life, but not clear in which direction variable preference acts.43	PalY
	Since valuation of time is not fixed, QALYs’ feature of additivity is problematic.5,12	Valuing time spent in terminal phase is more high than time during other stages without empirical support.7,43	VIP
	Periods of time cannot be added up at different points in time for individuals.12,18	Assumption valuation of time should be determined by patients, while accepted practice that values placed on health states are determined by general population.43
	A QALY gained at the EoL is not equivalent to a QALY gained earlier in life.41	It is not clear that palliative patients have greater needs than others.6
	Way in which life ends impacts overall value of that life.42	Objection valuation of time ignores option of weighing health gains differently for different populations.7
	Benefit EoLC is an addition of value to life as whole, independent of any particular time-slice, which is not captured by QALY.6	The need-principle cannot be the sole criterion for distribution of resources. It should be combined with some measure of benefit.6
	As time itself is running out, willingness to pay for it appears to increase.29	Equity issues arise when resource allocation decisions are made based on situations no more unique to patients at the EoL than they are at any other life stage.7
		Economic principles suggest that value of time to individuals does not increase, but that value of alternative uses of individual resources decreases.43

QoL: quality of life; EoL: end of life; QALY: quality-adjusted life year; VIP: Valuation Index Palliative Care; PalY: Palliative Care Yardstick.