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Background: Suffering threatens the integrity of the person, never more so in palliative care than when existential distress is left unaddressed., Objective: To describe a framework for considering existential distress, for use by the clinician, which includes issues of death anxiety, meaning of life, grief resulting from loss, isolation, loss of control and loss of dignity., Discussion: Each existential challenge operates across a spectrum of response from successful adaptation to morbid complication. Clinical responses to such predicaments and their complications described herein, are exemplified by the demoralisation syndrome and its treatment. Boundary violations that arise from a 'burnt out' clinician can be avoided. Our goal is to ameliorate suffering and help our patients accomplish a more peaceful journey during their dying.

Anger is a commonly encountered emotion in the cancer setting. Understanding its origin is vital but the practitioner needs to facilitate more than the ventilation of feelings; some change in attitude, the provision of social support and the promotion of adaptive coping need to be generated. The perceived unfairness of illness and death commonly underpins anger in the patient with cancer. Management strategies are discussed.

As more patients come to survive cancer, controlling their fear of its recurrence and minimising anxiety are important in re-establishing their quality of life. Combinations of therapies that acknowledge existential realities, encourage expression of feelings, identify irrational thoughts and promote self-helping behaviours are needed.

The family constitutes the key social group involved with mourning. A model of family response patterns to bereavement is presented that contrasts the adaptive family's response with maladaptive patterns that are avoidant, distorted, inflexible or that amplify grief. Guidelines in working with these families are discussed.