Metastatic bone disease is a major factor contributing to the deterioration in quality of life in patients with cancer. The decision to surgically stabilize an impending or existing pathologic fracture, or to excise a metastatic deposit is difficult because of the paucity of conclusive data regarding the efficacy of surgery in achieving pain relief, improved function, and quality of life. The psychometric properties of quality of life outcomes instruments and the differences between pain, function, and quality of life are explored in an attempt to define surgical goals. The results of different quality of life instruments in existing studies of internal fixation, chemotherapy, radiation therapy, and bisphophonate treatment suggest that although the majority of patients derive benefit from their treatment, the success of such treatment is heavily dependent the quality of life instrument. Existing instruments are deficient and obstacles to the design and implementation of quality of life assessment in patients with skeletal metastasis are reviewed. Recommendations for improving our ability to assess the risk to benefit ratio of surgery include moving away from physician reported results, devising more appropriate quality of life measurement techniques, analyzing the relationship between pain relief, physical function and quality of life, and focusing attention on prospectively evaluating optimal treatments for patients as they near the end of life.