Background: There is currently a considerable amount of studies exploring suffering among patients with terminal illnesses. To date, no systematic reviews have been performed exploring which are the factors that trigger suffering at the end of life in patients diagnosed with chronic illnesses.

Aim: We aim to systematically explore, synthesize, and reach a consensus about those factors which trigger end-of-life suffering in patients diagnosed with advanced chronic illnesses. 
Methods: The four major databases in the field (PsycINFO, Pubmed, Web of Science, Scopus) were explored using relevant terms that enabled the access to relevant literature in accordance to the review focus: 'suffering', 'emotional distress', 'end-of-life', 'advanced illness' and 'terminal illness'. PRISMA guidelines were followed, screening the articles by relevance through their title, abstract, and full text.

Results: From the 1,978 results obtained from databases after removing duplicates, 105 articles finally met the inclusion criteria. Preliminary results show that the most relevant factors that generate suffering among patients at the end of life can be grouped in four big dimensions: physical (e.g. pain, fatigue, dyspnoea), psychological (e.g. fear, depression, hopelessness),
social (e.g. family issues, physician-patient communication, isolation) and existential (e.g. unmet spiritual needs, religious fellowships, compromised dignity).

Conclusions: Patients with chronic illnesses at the end of their lives should be attended taking into account the four dimensions that comprise their suffering. Thus, it does not only include the control of their physical symptoms, but also meeting their social, psychological, and existential
needs. Multidisciplinary professional teams, therefore, would provide an optimal attendance to these patients.

Acknowledgment:This study was supported by grant Number PSI2017-85134-R from the Spanish Ministry of Economy, Industry and Competitiveness (MINECO).

Suffering at the End of Life: A Systematic Review