Background The most common approach to health economic evaluation is based on the principle of maximising total health, with outcomes of value being gains in health and length of life, the ‘Q’ and ‘LY’ elements of quality adjusted life years (QALYs). Health is commonly defined in terms of: pain/discomfort; anxiety/depression; mobility; self care; and usual activities.

Outcomes given intrinsic value in recent reviews of palliative care, such as patient dignity and bereavement support, are not explicitly incorporated within the QALY; they are therefore given zero weight in economic evaluation. It is also feared that interventions in the last few days of life will be deemed not cost-effective because of the value given to time.

Aims To explore: (i) What are the legitimate objectives of a healthcare system spending within a fixed budget? (ii) Should end of life care be considered a “special case” and, if so, what are the practical and theoretical implications?

Methods 20 semi-structured audio-recorded interviews with stakeholders (specialising in health economics, end of life care, ethics) analysed using constant comparative methods.

Results Early analysis suggests stakeholders have a number of issues with the QALY model in this context. These include the inevitability of decline, short remaining life expectancy and the importance to patients and families of broader outcomes. These concerns are not held by all informants, however, with some health economists feeling that health is the legitimate objective for health systems and that end of life care should not be treated differently.

Conclusion As currently operationalised, the QALY is narrow and restrictive, although there was little consensus about how or to what extent QALYs should be modified. The consequences of any refinement will be complex, but we argue this is inadequate justification for sticking with the status quo. We outline an agenda for future research.