Abstract
Dear Editor:
The drive for cost-effective use of medical interventions has advantages, but it also can be challenging in the context of end-of-life palliative treatments. A quality-adjusted life-year (QALY) provides a common currency to assess the extent of the benefits gained from a variety of interventions in terms of health-related quality of life and survival for the patient. 1 However, because it is in the nature of end-of-life palliative care that the benefits it brings to patients are of short duration, it fares poorly under a policy of QALY maximization. 2 Nevertheless, we argue that the goals of palliative care and QALY are not incompatible, and optimal integration of palliative care into the calculation of QALY may reveal a mechanism to modify considerations of how optimal quality of life can be achieved, even in the face of terminal illness.
The emphasis of palliative care may be counterintuitive to the high-tech American model of health care. Nevertheless, overall costs for patients who have a palliative care consult are significantly lower than for patients who do not. 3 These savings are accrued not only by ensuring that the treatments being provided to the patient are consonant with the patient's needs, preferences, and values, but also by discontinuing nonbeneficial treatments. Morrison estimated that if 50% of U.S. hospitals had palliative care services, and 7.5% of hospitalized Medicare patients received palliative care services (meaning not only more hospitals but also more patients at each hospital), estimated direct cost savings could reach $6 billion per year.4,5 In addition, Temel and colleagues, who studied the effects of providing palliative care from the time of a patient's lung cancer diagnosis, found that patients in the palliative care group lived significantly longer than patients in the traditional care group (11.6 versus 8.9 months). 6
The driving force behind QALY is the optimal utilization of finite resources. Both palliative care and the application of QALY mean choosing the most appropriate treatments in a specific clinical situation. Like QALY and cost-utility calculations, palliative care involves a benefit-burden analysis for optimal treatment recommendations. The level of analysis in palliative care, however, is the individual. The conclusions of QALY and cost-utility analyses can be generalized to a population group, whereas palliative care is customized and involves identifying which treatments can benefit a specific patient.
The use of QALY in resource allocation means that palliative care will always compete with alternative uses of the same money. Decision makers who utilize QALY and cost-utility analysis to allocate resources, however, should not compare like (end-of-life treatments) with unlike (non-end-of-life treatments). Different objectives and outcomes from those distinct services do not justify such comparison. End-of-life care is distinctive enough to necessitate a different calculus. Palliative care for the terminally ill should be compared only with other end-of-life services, including relevant medical inventions. More research should be conducted to evaluate choices between palliative care and more aggressive therapies for the terminally ill. However, current limited data show that when compared with other end-of-life treatments, end-of-life palliative care is enormously cost-effective.