Palliative radiotherapy has been prescribed since shortly after the discovery of the x-ray in the late 1800s, and it provides symptom relief that is successful, time-efficient, and cost-effective. Although palliative radiotherapy is worthwhile in a wide variety of clinical circumstances, there are situations where it is less worthwhile. We contrast the effective use of palliative radiotherapy with its ineffective use because of issues related to the patient, treatment, or health care system.