I read with interest Dr. Coulehan's article, "The Man with Stars Inside" [1]. I, too, am troubled by calls for euthanasia and physician-assisted suicide because of accusations that we do not adequately alleviate the pain and suffering experienced by our dying patients.

As Dr. Coulehan pointed out, communication with our dying patients is a major issue. Communication can be thwarted by fear and distrust on the part of patients and by lack of time, interest, or sensitivity on the part of the physician. I wish to offer an additional perspective. We fail to adequately alleviate pain in dying patients because we fail to realize that pain is, by nature, multidimensional [2] and dynamic. We tend to focus primarily on the physiologic aspect of pain. Pain, however, has not only physiologic but also psychological, spiritual or religious, and social dimensions. These different dimensions are operative to varying degrees throughout the patient's dying process.

We do know that pain seems to be more tolerable if some good is expected to come of it, if the pain is anticipated, and if its meaning is understood. Although we may not be able to understand or explain all of the aspects of pain, it is imperative that we have close, constant communication with our dying patients to allow us the best opportunity to recognize which pain dimension is primarily active at any given time. Focus can then be shifted to address concerns in that particular dimension to alleviate suffering.

I believe that our effectiveness in alleviating pain and suffering is limited not only by communication difficulties with our dying patients but also by our own lack of insight into the multidimensional and dynamic nature of pain and our ability or willingness to react to its changing nature. It is only through continuing dialogue with our colleagues in medicine, ethics, law, and religion and with our patients that we may eventually achieve the literal meaning of euthanasia: good death.