Advanced cancer may trigger significant psychological distress, as patients become more aware of their prognosis and experience greater symptom burden. A significant component of this distress is existential, related to the loss of meaning and purpose in life in the situation of future mortality. Patients with advanced disease must face fears about dying and death: in a large proportion of patients the levels of death-related distress are moderate to high.
Such distress may be related to the fear of burdening others who are close to them, the awareness of the loss of time and opportunity, and the potential for pain and suffering as the disease progresses.

In patients, demoralization has been characterized by feelings of hopelessness, the loss of meaning, and the sense of failure, which may be the clinical manifestation of the inability to cope with impending mortality.
The preservation of morale may be a buffer that protects patients facing death from the terror of dying and death. In advanced cancer patients, demoralization has been associated with higher symptom burden, less perceived social support, and the emergence of anticipatory fears about pain and suffering, and burdening of loved ones.
The sense of connection to others has been linked to less distress in patients with advanced cancer and other life-hostile illnesses. Individuals with a strong sense of connection to others may have more skills to make use of supportive relationships and a greater sense of purpose in life. This experience has been expressed in the concept of social relatedness, deriving from internalized expectations of support (attachment security), and from current perceived social support.

A study in advanced cancer patients demonstrated that higher symptom burden and lower social relatedness were both associated with demoralization, which in turn was strongly associated with death anxiety. These findings suggest that death anxiety may emerge in the context of demoralization, which may develop when patients feel overwhelmed by the cumulative burden of progressive disease and by the experience of social isolation and disconnection.
The joint contribution of psychosocial and disease-related factors stimulate demoralization, which is a key mediating state on the pathway to further distress.
An integrated approach — an interdisciplinary team that provides both early palliative and early psychological care before the rise of emotional disturbance — may be needed to prevent the escalation of existential distress in advanced cancer patients.

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Adapted from An E et al. Demoralization and death anxiety in advanced cancer. Psycho-Oncology 2018; 27: 2566-2572.