As our skill in assuaging pain and other symptoms has matured in Western medicine over recent decades, the amelioration of existential suffering, demoralization, and the wish to hasten dying have come into sharper relief. Rational death movements that seek to promote physician-assisted suicide have grown as a threat to palliative care. Yet early referral has highlighted our ability to counter despair, treat depression and promote hope, with the continued maintenance of quality of life until a good death intervenes. The extension of palliative care services into the realm of chronic disease management mirrors this impetus for early referral. Effective communication is a core skill that impacts upon much of this. Family support is another key agenda that optimises care provision and adaptation in bereavement. Thus while pharmacological care proceeds competently, the challenge for the future is sustained psychosocial and spiritual care, achieving continuity with presence and accompaniment, as we strive to ease existential distress and respect natural dying when it comes.