SUMMARY
Suffering in the dying patient derives from immediate sources of physical distress, perceived threats to the integrity of the self, and the psychological make up (memory, beliefs, expectations) of the individual at the end of life. The most common causes of somatic distress in dying patients with cancer are: (1) pain, (2) shortness of breath, and (3) nausea and/or vomiting. Other noteworthy problems include confusion, restlessness, itch, disturbed bladder and bowel function, sleep disruption, low energy, sedation and cachexia. Specific physiological mechanisms foster suffering in dying persons. These include tissue trauma, visceral distention and cardiovascular events. Neurological signals generated by tissue trauma or sensitization during inflammation lead to sensations of pain and also produce emotional arousal in noradrenergically innervated limbic brain structures. In addition, such signals stimulate the hypothalamo-pituitary-adrenocortical axis. This creates a stress response which, if prolonged, disturbs circadian and ultracadian biological rhythms. One can direct preventative and palliative interventions toward such mechanisms. Patients also suffer because of unmet psychological needs or psychosocial problems. Identifying such needs or problems and addressing them can often contribute substantially to patient comfort. Since we have the resources to prevent or largely alleviate pain and other distressing conditions in the majority of cases, and care providers can meet most patients' psychological needs once they identify them, unaddressed suffering need not accompany death from cancer or other prolonged disease.