There is a great variability among advanced cancer patients in the experience of symptoms and their impact on life's activities. A subgroup of difficult patients particularly tax the clinical skills and compassion of practitioners. Although the need for information about these patients is evident, their characteristics have not been explored heretofore. We describe our experience with such patients, a group referred to the Supportive Care Program of the Pain Service at Memorial Sloan-Kettering Cancer Center. Prevalence of pain and other symptoms, patterns of opioid use and routes of drug administration, and the prevalence of suicidal ideation and requests for euthanasia are discussed.