Introduction
Existential distress is increasingly recognized as an important source of psychological suffering among patients with advanced cancer receiving palliative care (Boston et al. Reference Boston, Bruce and Schreiber2011; Vehling and Mehnert Reference Vehling and Mehnert2014). In addition to physical symptoms, patients approaching the end of life frequently experience hopelessness, fear of death, disrupted identity, spiritual distress, relational disconnection, and loss of meaning, all of which may contribute substantially to emotional suffering and reduced quality of life (Breitbart et al. Reference Breitbart, Rosenfeld and Pessin2000; Kissane et al. Reference Kissane, Clarke and Street2001).
Meaning-centered psychotherapy (MCP), developed by Breitbart and colleagues, is an existentially oriented intervention designed to help patients with advanced cancer sustain or reconstruct a sense of meaning despite progressive illness (Breitbart et al. Reference Breitbart, Rosenfeld and Gibson2010; Breitbart and Poppito Reference Breitbart and Poppito2014). Grounded in Viktor Frankl’s logotherapy, MCP has been associated with reductions in existential distress, hopelessness, depressive symptoms, and desire for hastened death, while improving spiritual well-being and quality of life among patients with advanced cancer (Breitbart et al. Reference Breitbart, Poppito and Rosenfeld2012; Rosenfeld et al. Reference Rosenfeld, Saracino and Tobias2017).
In the context of palliative care, spiritual care is an integral component of whole-person care, addressing patients’ needs for meaning, hope, connection, and spiritual or religious expression through exploration of faith, forgiveness, reconciliation, and preparation for death according to individual preferences (Puchalski et al. Reference Puchalski, Vitillo and Hull2014).
Although MCP has demonstrated promising outcomes in palliative care, reports describing its application among young adults with advanced cancer, particularly within Asian cultural contexts, remain limited. Few case reports have also explored the integration of MCP with trauma-related distress and spiritual care near the end of life. This case report describes the application of adapted MCP in a young Vietnamese woman with advanced cancer experiencing severe depressive symptoms, existential suffering, trauma-related distress, and loss of meaning, highlighting the flexible integration of trauma-informed stabilization, spiritual care, and end-of-life support within multidisciplinary palliative care.
Case report
A 24-year-old Vietnamese woman with advanced-stage cancer receiving palliative care was referred for psychological intervention after multiple courses of chemotherapy with limited clinical response. At referral, she presented with severe depressive symptoms, emotional instability, hopelessness, passive wishes for death, and persistent existential distress. Clinical assessment included behavioral observation, clinical interviews, and standardized psychological measures; although significant depressive symptoms were identified, no formal psychiatric diagnosis was established.
The patient reported adverse childhood experiences, including emotional neglect, family conflict, and exposure to violence, contributing to long-standing difficulties in emotional regulation, self-worth, interpersonal relationships, and coping with illness progression and end-of-life concerns. She also experienced progressive physical decline with fatigue, pain, insomnia, appetite disturbance, and emotional exhaustion. Family members and her romantic partner provided ongoing support and remained actively involved in end-of-life discussions and care planning despite unresolved interpersonal concerns.
Within a multidisciplinary palliative care setting involving palliative care physicians, nurses, and a clinical psychologist, initial assessment showed extremely severe stress (36), anxiety (30), and depression (30) on the Depression Anxiety Stress Scale-21 (DASS-21), with a Beck Depression Inventory-II (BDI-II) score of 29 indicating severe depressive symptoms. At referral, the patient’s most urgent presentation consisted of severe depressive symptoms, marked emotional instability, and passive wishes for death. From both clinical and ethical perspectives, the immediate priority was to assess psychological distress to guide symptom management, safety planning, and risk monitoring. Because patients with advanced cancer often experience fatigue and fluctuating functional capacity, DASS-21 and BDI-II were selected as brief, validated measures that minimized assessment burden while establishing baseline clinical severity, although they do not directly assess MCP-specific outcomes.
Given the patient’s severe emotional dysregulation, passive wishes for death, and unresolved childhood relational trauma, immediate meaning-centered work was considered clinically inappropriate. Therefore, psychotherapy followed a phased approach (Table 1), beginning with psychological stabilization informed by principles of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), including safety planning, psychoeducation, emotion regulation, and supportive coping, to reduce acute distress, establish psychological safety, and strengthen therapeutic engagement, before transitioning to the manualized MCP framework (Breitbart and Poppito Reference Breitbart and Poppito2014). Subsequent sessions focused on meaning, identity, legacy, life review, relational reconciliation, spiritual reflection, and preparation for death. The intervention was culturally adapted by emphasizing family-centered decision-making, relational reconciliation, and spiritual care consistent with the patient’s Christian beliefs and preferences. Session content was flexibly adapted to her physical condition and readiness for end-of-life discussions while maintaining fidelity to MCP.
Structure of the psychotherapy process
Table 1 Long description
Four columns list phase, sessions, primary therapeutic approach, and main focus. Phase 1, Stabilization, covers sessions 1 to 4 and uses TF CBT informed stabilization, focusing on psychological safety, emotion regulation, psychoeducation, supportive coping, and therapeutic engagement to reduce acute distress and prepare for meaning centered work. Phase 2, Meaning centered work, covers sessions 5 to 11 and uses MCP, focusing on meaning, identity, legacy, life review, and relational reconnection. Phase 3, End of life adaptation, covers sessions 12 to 16 and uses MCP adapted for end of life care, focusing on attitudinal meaning, relational reconciliation, spiritual reflection, and preparation for death.
The intervention was implemented in 3 phases (Table 1). The initial 4 sessions focused on trauma-informed psychological stabilization and were not considered part of MCP. The 7 core components of the manualized MCP protocol (Breitbart and Poppito Reference Breitbart and Poppito2014) were subsequently delivered during Sessions 5–11. Sessions 12–16 did not introduce additional MCP components; instead, they reinforced previously explored MCP themes while emphasizing relational reconciliation, spiritual reflection, and preparation for death, with flexibility to accommodate the patient’s progressive physical decline and evolving end-of-life needs.
Throughout the intervention, the patient demonstrated gradual improvements in emotional regulation, interpersonal functioning, sleep quality, and acceptance of illness. She became increasingly able to reconnect with loved ones, discuss unresolved emotional concerns, and engage in meaning-centered and end-of-life conversations. Psychological reassessment showed marked reductions in depression, anxiety, and stress severity (Table 2), accompanied by reduced hopelessness and greater emotional stability despite progressive physical decline.
Psychological outcome measures before and after intervention
Table 2 Long description
Measures are listed with baseline and follow up values for DASS 21 Stress, DASS 21 Anxiety, DASS 21 Depression, and BDI II. DASS 21 Stress is 36 at baseline and 14 at follow up. DASS 21 Anxiety is 30 at baseline and 10 at follow up. DASS 21 Depression is 30 at baseline and 6 at follow up. BDI II is 29 at baseline and 9 at follow up.
DASS-21 = Depression Anxiety Stress Scale-21; BDI-II = Beck Depression Inventory-II.
As her condition deteriorated, psychotherapy increasingly focused on emotional reconciliation, spiritual reflection, and preparation for death. Prior to death, she reaffirmed her Christian faith, received baptism, and fulfilled her wish for a Protestant funeral ceremony. Family members reported that she was emotionally calmer, spiritually at peace, and more connected with loved ones during her final days. She died at home several weeks later from complications of advanced cancer.
Discussion
This case illustrates the complex interplay of existential distress, depressive symptoms, childhood relational trauma, and spiritual suffering in a young woman with advanced cancer receiving palliative care. Her psychological distress extended beyond physical symptoms and was characterized by hopelessness, disrupted identity, emotional disconnection, passive wishes for death, and loss of meaning, consistent with previous descriptions of existential suffering near the end of life (Breitbart et al. Reference Breitbart, Rosenfeld and Pessin2000; Kissane et al. Reference Kissane, Clarke and Street2001).
A key feature of this case was the phased integration of psychological stabilization informed by TF-CBT before introducing MCP. Because the patient initially presented with severe emotional dysregulation, passive wishes for death, and unresolved childhood trauma, early sessions prioritized stabilization and safety before transitioning to meaning reconstruction, identity exploration, and relational reconnection. This approach maintained fidelity to MCP while accommodating her changing psychological and physical condition.
Psychological reassessment demonstrated substantial reductions in depressive symptoms, anxiety, and stress severity. Although DASS-21 and BDI-II do not directly assess the core therapeutic targets of MCP, they may indirectly reflect improvements in emotional distress associated with existential suffering, which often manifests as depression, hopelessness, and desire for hastened death in advanced cancer (Breitbart et al. Reference Breitbart, Rosenfeld and Pessin2000; Frankl Reference Frankl2006). Therapeutic change was therefore reflected not only in symptom reduction but also in greater emotional openness, relational reconnection, acceptance of illness, spiritual reflection, and preparation for death, consistent with previous MCP studies (Breitbart et al. Reference Breitbart, Rosenfeld and Gibson2010, Reference Breitbart, Rosenfeld, Pessin, Applebaum, Kulikowski and Lichtenthal2015).
Another important aspect was the integration of spiritual care during the final stage of life. As her condition deteriorated, psychotherapy increasingly emphasized reconciliation, acceptance of mortality, and spiritual reflection. Before death, she reaffirmed her Christian faith, received baptism, and fulfilled her wish for a Protestant funeral ceremony. Family members reported greater emotional peace and spiritual comfort, consistent with evidence that spiritual care supports dignity, emotional well-being, and psychological adaptation in advanced illness (Chochinov et al. Reference Chochinov, Hack and Hassard2002; Boston et al. Reference Boston, Bruce and Schreiber2011; Puchalski et al. Reference Puchalski, Vitillo and Hull2014).
This case suggests that MCP can be feasibly adapted within multidisciplinary palliative care for patients with advanced cancer, even in the context of progressive physical decline and limited prognosis. A phased approach combining early psychological stabilization informed by TF-CBT principles with subsequent MCP may support emotional stabilization, meaning reconstruction, relational reconnection, spiritual integration, and preparation for death while remaining responsive to patients’ changing psychological and physical needs.
Several limitations should be acknowledged. First, as a single-case report, the findings cannot be generalized to patients with advanced cancer more broadly. Second, because the intervention was delivered within a multidisciplinary palliative care setting involving concurrent medical treatment, family support, and spiritual care, psychological improvements cannot be attributed solely to psychotherapy. Third, although DASS-21 and BDI-II captured changes in psychological symptoms, they do not directly assess key MCP outcomes, such as meaning, spiritual well-being, existential distress, hopelessness, or desire for hastened death. Future studies should incorporate MCP-specific measures, including the Schedule of Attitudes Toward Hastened Death, Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being, Hopelessness Assessment in Illness, Distress Thermometer, and quality-of-life measures.
This case highlights the potential value of culturally adapted MCP for addressing existential distress in young adults with advanced cancer. Further research using larger samples and MCP-specific outcome measures is needed to evaluate its effectiveness across diverse cultural and clinical settings.
Acknowledgments
The authors would like to thank the patient and her family for allowing this case to be shared for educational and scientific purposes.
Funding
This research received no specific grant from any funding agency, commercial entity, or not-for-profit organization.
Competing interests
The authors declare no conflicts of interest.
Ethical approval
All identifying information has been anonymized to protect confidentiality.
Ethics and consents
Written informed consent for publication was obtained from the patient’s family.
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