The term ‘end of life’ is often used to refer to the final days or weeks preceding death. While this framing is deeply embedded in public discourse and clinical practice, it only partially reflects the lived reality of many people with life-threatening illnesses, including some metastatic cancers and neurodegenerative disorders. For these individuals, the end of life is not a discrete moment but a prolonged trajectory, sometimes spanning several years, marked by uncertainty, ongoing treatment, and repeated confrontation with the perspective of death. This trajectory is frequently accompanied by persistent existential distress, which does not only affect quality of life but also shapes patterns of health care utilization. Anxiety, depression, fear of disease progression, and loss of meaning influence how patients engage with health care systems across the illness trajectory. Existential suffering can thus be considered a determinant of costs which is often not considered in conventional economic analyses of care for people living with life-threatening illnesses (May et al. Reference May, Normand and Morrison2014).

In publicly funded health care systems, expenditures associated with life-threatening illness are not solely attributable to disease-specific treatments but also to the management of psychological issues occurring alongside disease progression. Studies in palliative and end-of-life care have shown that unmanaged distress is associated with higher use of acute hospital services and a greater likelihood of intensive interventions near death, resulting in higher overall costs (Wright et al. Reference Wright, Zhang and Ray2008; Zhang et al. Reference Zhang, Wright and Huskamp2009). These episodes mobilize significant clinical and organizational resources without necessarily altering the overall illness trajectory.

Psychedelic-assisted therapy (PAT), particularly with psilocybin, is an emerging palliative care intervention with an atypical economic profile. Unlike approaches that rely on chronic or repeated treatments, PAT is typically delivered as a time-limited, structured, and intensive intervention, combining preparatory sessions, 1 or 2 dosing sessions, and psychotherapeutic integration within a defined therapeutic framework. Although it requires a concentrated initial investment of clinical and organizational resources, its objective is a durable shift in how patients experience and relate to life-threatening illness. Available clinical evidence indicates that this approach can lead to rapid and sustained reductions in anxiety and depression among patients with advanced disease, with effects persisting for months after treatment (Griffiths et al. Reference Griffiths, Johnson and Carducci2016; Ross et al. Reference Ross, Bossis and Guss2016; Agin-Liebes et al. Reference Agin-Liebes, Malone and Yalch2020).

From a health system standpoint, the potential value of PAT lies less in its immediate cost than in its capacity to influence costly care trajectories. Psychological stabilization may reduce the frequency of emergency department visits. It may also support deprescribing, thereby limiting polypharmacy and associated adverse effects. In addition, greater existential clarity may facilitate earlier and more stable alignment of care with patients’ values, potentially reducing the use of intensive interventions late in the illness trajectory whose benefits are often limited (Boston et al. Reference Boston, Bruce and Schreiber2011; Bélanger et al. Reference Bélanger, Chang and Stephan2025). The potential economic impact of PAT extends beyond patients themselves. Family members and caregivers are often involved over prolonged periods and bear substantial emotional and organizational burdens. Caregiver exhaustion, work absenteeism, and increased use of mental health and social services represent other significant indirect costs.

Economic evaluations of PAT will certainly be challenging. In practice, economic evaluations of health technologies assess the average incremental costs in function of the average incremental effectiveness of patients assigned to 2 different interventions. In the context of existential distress, however, there is no widely accepted or standardized reference intervention against which PAT can be meaningfully compared. Current approaches including pharmacotherapy, psychotherapy, and spiritual support are most often delivered in an individualized manner and have demonstrated modest or inconsistent effects in durably alleviating existential distress among patients with life-threatening illnesses. This absence of a clearly defined effective comparator complicates the application of conventional incremental cost-effectiveness frameworks to interventions specifically targeting existential suffering. Moreover, PAT is currently being administered to small and heterogeneous patient populations raising the risk of highly variable downstream costs (savings) and effectiveness. Furthermore, and as previously mentioned, patients’ existential distress is also likely to impact their caregivers and families which can also lead to added costs. Unfortunately, although systems are in place throughout Canada and abroad to capture health system-specific costs, capturing patient and family-borne costs are quite limited. As financial benefits resulting from PAT will tend to occur outside the health care system, omitting these from the economic evaluation will disadvantage PAT’s economic profile. Such challenges have been documented in economic evaluations of palliative care interventions that act on global trajectories rather than isolated clinical events (Gwyther et al. Reference Gwyther, Bates and Tran2026).

Moreover, experience under Canada’s Special Access Program illustrates how case-by-case authorization for psilocybin requires extensive clinical justification, administrative coordination, and institutional oversight, all of which consume substantial professional and organizational resources (Garel et al. Reference Garel, Plourde and Greenway2025). Without a transition toward a more streamlined regulatory model, the costs associated with access to psilocybin may outweigh potential savings from reduced health care utilization, limiting the sustainability of PAT.

In Québec, which currently reports the highest rates of medical assistance in dying (MAiD) worldwide (Commission sur les soins de fin de vie 2025), these economic considerations are particularly relevant. Requests for MAiD often arise in contexts of profound and multifaceted distress, in which existential dimensions coexist with physical symptoms (Downar et al. Reference Downar, MacDonald and Buchman2023). Such distress may be preceded by high and costly health care utilization, including repeated consultations, complex pharmacotherapy, and sustained involvement of interdisciplinary teams. Without questioning the legitimacy of MAiD or patients’ rights to access it, this observation invites reflection on whether greater attention to interventions that durably alleviate existential distress earlier in the illness trajectory might contribute to more stable decision-making and, potentially, to more efficient use of health care resources.

Recognizing existential suffering as a legitimate economic issue invites a re-examination of how end-of-life interventions are assessed. This does not require opposing humanistic values to economic responsibility. Rather, it acknowledges that how a society responds to suffering directly shapes the organization, efficiency, and sustainability of its health care system. As growing numbers of people live for extended periods with life-threatening illnesses, failing to address existential distress as a determinant of care trajectories may perpetuate structural inefficiencies at considerable human and economic cost.