Purposive sampling allows psychobiographers to select a subject to best meet their objectives (van Niekerk et al., 2019). Marilyn Yalom (1938–2019) was accordingly selected because of her production and publication of a detailed narrative account of her last few months of life. She described her experiences openly, clearly, and with insight into existential themes, rendering her an ideal subject to meet the research aim.

Data collection focused primarily on her reflections published in A Matter of Death and Life: Love, Loss and What Matters in the End (Yalom & Yalom, 2021), as a data source, as it contains her narrative accounts on being terminally ill, in the form of monthly diary entries. Additional publicly available information on Marilyn’s life and work was consulted to contextualise and interpret her reflections.

Data was extracted using Alexander’s (1988, 1990) two proposed methods for psychobiographical data extraction, namely, (a) questioning the data by searching for instances of how the propositions of the theoretical framework present themselves in the narrative; and (b) extracting additional psychologically salient data for further analysis. First, Marilyn’s reflections were extensively reviewed, and excerpts from the text were coded based on the four existential concerns highlighted by Irvin Yalom (1980). This aligns with Alexander’s (1988, 1990) first strategy of “asking the data questions”. These questions are aimed at finding revelatory statements about the subject’s acceptance of, (a) her own mortality, (b) her responsibility and agency in the face of freedom, (c) her existential isolation in the context of meaningful connection, and (d) her role in creating meaning in her life. Second, Alexander’s (1988, 1990) proposed saliency indicators were used to identify additional psychologically relevant information from biographical data. These indicators (frequency, emphasis, uniqueness, primacy, repetition, interruption, isolation, incompletion and distortion) help researchers organise and prioritise information, highlighting elements of unusual prominence and psychological importance (Alexander, 1988, 1990).

The psychobiographical approach entails the application of the propositions of the selected theoretical framework to the biographical data (Ponterotto, 2014, 2025). Data analysis, therefore, examined Marilyn’s reflections through an existential psychology lens to construct a theoretically informed overview of her experiences. Given the subject’s narrative reflection of how she felt prepared to face death as a concept, as opposed to dying as a process, thematic analysis (Braun & Clarke, 2012) was also used to examine the additional psychologically salient data from Marilyn’s narrative accounts, to uncover any additional themes that might fall outside the propositions of the existential concerns. These psychologically salient statements were coded and subsequently clustered into themes. Therefore, deductive and inductive processes of inquiry were utilised to fully explore one individual’s experience of facing death.

The proposal was submitted for ethical review to the General/Human Research Ethics Committee of the University of the Free State (Reference Number: UFS-HSD2025/0548). Ethical principles for psychobiographical research proposed by Ponterotto (2014, 2025) informed the design of this study. Therefore, the sampled subject is deceased, and only publicly available information was included in the collection and analysis of data to protect living relatives from previously unknown information on the subject’s life.

Throughout the text, Marilyn wrote of death with a tone of rational acceptance, as she acknowledged, “I am 87 years old... a ripe time to die” (Yalom & Yalom, 2021, p. 13) and noted that she has already enjoyed “a very satisfying long life” (p. 13), surpassing the average life expectancy. With this pragmatic acknowledgement, she also doubted the value of prolonging her life in the face of “daily misery and despair” (Yalom & Yalom, 2021, p. 13). Early in the text, her acceptance of the timing of her death was tempered by a subtle undercurrent of disappointment in not matching her mother’s longevity, who “died peacefully at the age of 92 ½. I always assumed that I would die at her age...” (Yalom & Yalom, 2021, p. 18). She also reflected on gendered expectations of mortality, noting, “How odd that I should be the one who will probably die first, when statistically it is more frequently the husband who dies first” (Yalom & Yalom, 2021, p. 63). Her linguistic analysis of the term “widower” as a derivative of “widow” underscored this expectation's cultural and grammatical encoding.

Marilyn did not shy away from expressing the emotional complexity of her experience, articulating feelings of sadness and dread in the face of uncertainty, particularly regarding the potentially painful physical experiences of dying. Drawing on a friend’s distinction between la mort (death as a state) and mourir (the act of dying), she revealed a fear not of death itself, but of the suffering that may precede it. She noted:

She proceeded to provide an example of how her “well of hidden anguish” (Yalom & Yalom, 2021, p. 66) in response to her own decline found expression in a vivid dream. Marylin described that in the dream, she was talking to a friend on the phone, who informed her that her adult son had died. She recalled: “I start to scream and awake convulsing with tears. In real life, that friend does not even have a son. So, whose death am I crying about? Probably my own” (p. 66).

She also reflected on moments that provide comfort and promote an acceptance of death, reached mainly through active connection and contemplation. For example, she noted finding solace in the care and concern received from friends and loved ones, including the prayers of friends from diverse religious backgrounds, even though she does not believe in consciousness after death. She noted that religious and literary references now resonated with new significance for her: “familiar poetic phrases take on new meaning in my present situation, as I lie on the sofa and reflect” (Yalom & Yalom, 2021, p. 16). For example, when uncertainties arose about whether she would still be alive for a specific future event, she noted: “I fall back on the words from Ecclesiastes: ‘There is a time for every season... A time to be born and a time to die’” (Yalom & Yalom, 2021, p. 49).

She began to describe death not only as inevitable, but as merciful: “…palliative care and assisted suicide would be a relief if my present treatment is not effective” (Yalom & Yalom, 2021, p. 64). Later in the text, her reflections reveal a more resolute acceptance of death’s imminence as she recounts a dream that signals a definitive shift from philosophical acceptance to readiness. This dream, she noted, “… doesn’t take my psychiatrist husband long to analyze… and see in it my desire to end an agonizing life” (Yalom & Yalom, 2021, p. 75). This shift seems to be supported by the regaining of some autonomy over her final moments once she and her hospice care team had discussed the option of physician-assisted suicide: “In the end, however that comes, I should have some measure of control” (Yalom & Yalom, 2021, p. 123).

However, against the backdrop of increased calm in her acceptance of death, she described how her emotional experience remains coloured by “continued sadness” (Yalom & Yalom, 2021, p. 123), stemming from the anticipation of separating from loved ones: “For all the philosophical treatises and for all the assurances of the medical profession, there is no cure for the simple fact that we must leave each other” (p. 123). This sadness emerged from Marilyn’s reflections as a prominent end-of-life theme related to the existential concern of mortality, namely, the relational considerations in the process of accepting death. This theme highlights how the mourning of one’s own demise is often tied to the anticipated disconnection from loved ones, further complicated by concerns over their grief. This idea echoed throughout her entries, as she noted in a later chapter (wittingly titled Whose death is this anyway?): “It occurs to me… that my death is not mine alone. I shall have to share it with those who love me” (Yalom & Yalom, 2021, p. 64). Marilyn admitted “…it is difficult to accept that I will not be around to watch my three youngest grandchildren grow,” and added “they will not know me, except in flitting memories” (Yalom & Yalom, 2021, p. 43). She later added that she “cannot think ahead to Irv’s widowerhood. It saddens me greatly to imagine him alone” (Yalom & Yalom, 2021, p. 63) and described being “moved and unsettled” (p. 63) by her husband’s anticipatory grief. Death, therefore, is seen as particularly difficult to accept when it implies non-existence in the lives and memories of loved ones, and when it results in their pain.

Marilyn’s reflections throughout the text reveal a lifelong recognition of personal agency and indicate that she valued self-determination. She recounted achievements, milestones and examples of living according to her valued principles (Yalom & Yalom, 2021). She also reflected on how her husband’s writing about the unlived life has been influential in helping her accept death, stating: “I am one of the lucky ones who will die with no regrets” (Yalom & Yalom, 2021, p. 77). Marilyn also set clear intentions for her remaining time, stating her desire to “rise to my best self and express my love… and, with grace, accept my fate” (Yalom & Yalom, 2021, p. 121). She later revisited the idea of how acceptance of one’s degree of satisfaction with the choices throughout one’s life also affects one’s acceptance of death:

Her reflections illuminate the many limitations imposed by ageing, illness, and imminent death as she described the remaining options in her final months of life. For example, she reflected on the choice between assisted living and remaining in her home. While she acknowledged the conveniences and benefits of institutional “round-the-clock care” with “meals prepared and served” (Yalom & Yalom, 2021, p. 29), she also appreciated the impact of her attachment to her home: “It is comforting to move among familiar objects for the last period of our life” (p. 34). She reflected on the privileges that enable her choice, such as the financial means to make modifications to their home for her decreased mobility and to maintain the employment of their long-term housekeeper (Yalom & Yalom, 2021). Her reflections also reveal the difficulty of such decisions: “We sometimes ask ourselves: Are we making a mistake…? But the thought of leaving our home of forty-plus years … deters us. We are simply not willing to give up this house and setting…” (Yalom & Yalom, 2021, p. 29). This also suggests that personal agency may not, in the context of such a lifelong marriage, be easily unravelled from shared decision-making.

In the face of the illness-related limitations towards the end of her life, she noted her commitment to her remaining choices, which revolve around how to continue living according to her lifelong values of kindness. She reflected on the intentional selection of examples worthy of emulation, referring to a friend as “my role model of how I would like to behave in the months to come” as she recalled her grace and loving kindness, adding: “I noticed how respectfully she addressed the nurses as they came in and out of the room” (Yalom & Yalom, 2021, p. 18). She wrote: “I carry within me the memory of parents and teachers and colleagues, who were generous and loving,” and concluded that “now, as my time on earth draws to a close, I am trying to live out my remaining days in accordance with those principles” (Yalom & Yalom, 2021, p. 47). This includes choices about taking leave of friends: “I do not want to disappear from their lives without letting them know how much they have meant to me” (Yalom & Yalom, 2021, p. 103).

Marilyn’s refusal to pursue more aggressive medical interventions, such as stem cell or bone marrow transplants, further illustrates her concern with freedom of choice: “Though I admired the courage of the younger patients… I am not willing to go that route” (Yalom & Yalom, 2021, p. 41). She questioned the medicalisation of ageing and dying with a “one-size fits all” (p. 41) treatment approach, suggesting a critical awareness of how care systems can obscure individual agency. Perhaps most striking is Marilyn’s openness to reflect on her decisions regarding assisted suicide. In existential terms, this would represent the ultimate assertion of freedom: The right to shape not only one’s life but also one’s death. She wrote that she finds herself “grappling” (Yalom & Yalom, 2021, p. 77) with Nietzsche’s proposition that one should ‘die at the right time’, as it presents her with the basic choice about whether to preserve her life in the context of physical decline and suffering. Anticipating that her treatment options were becoming more limited, Marilyn asserted: “It seems to me that the decision to live or die should be primarily mine” (p. 77).

Marilyn’s reflections also reveal another end-of-life offshoot of the lifelong existential concern of freedom. This relates to the decreasing options available for self-description and how the imminence of their death may influence individuals’ view of themselves. In her opening chapter, she hinted at the significance of descriptive labels in this process: “I am trying to resign myself to the life of an invalid, or at least the life of a convalescent, as one referred politely to people like me in the past” (Yalom & Yalom, 2021, p. 20). A visit from friends who attended her literary salons and the outpouring of praise she received from these salonnières triggered careful introspection: “Could I really have been as kind and generous as my friends say I was?” (Yalom & Yalom, 2021, p. 90). She also described instances of emerging dissonance between her sense of self and her environment, such as standing in front of the newly emptied bookshelves in her study, despite her and Irving always having been “book people” (Yalom & Yalom, 2021, p. 127), and the changes imposed by her physical deterioration: “I can’t remember a time when I did not enjoy talking… But today, I am exhausted by lengthy conversation” (Yalom & Yalom, 2021, p. 20). A particularly powerful shift in the experience of the self is seen in her recollection of receiving treatment in the same hospital where one of her sons was born 50 years prior. She sharply contrasted the memory of his birth with her undertaking to, during his upcoming birthday celebrations, “do all I can not to look like a dying old lady…” (Yalom & Yalom, 2021, p. 74).

In exploring Marilyn’s experience of existential isolation, it is important to appreciate the depths of her sense of connection. She often emphasised interconnectedness and her deep appreciation of meaningful relationships (Yalom & Yalom, 2021). As she contrasted her own experience with that of a fellow patient who faced treatment alone, she noted gratitude for not facing her suffering in complete isolation. She wrote: “I have become more aware of the extent to which my life is connected with the lives of others…” (Yalom & Yalom, 2021, p. 13), and added: “Ultimately, I have come to the understanding that one stays alive not only for oneself, but also for others. Though this insight may be self-evident, only now do I realize it fully” (p. 14). This suggests that proximity to death had deepened her sense of a relational ethic even further. Marilyn referred to numerous instances of close relationships being a source of comfort, as her loved ones often became loving caretakers (Yalom & Yalom, 2021). Her mention of gratitude for her continued ability to communicate after suffering a stroke further reveals the relational quality of what has provided comfort to her — visits with friends, shared laughter, the support of her children and her husband’s consistent caregiving. Her relationship with her husband, specifically, emerges as an emotional anchor: “But, most of all, it is Irv who sustains me…” (15). She described his caregiving and presence at all her treatment appointments (Yalom & Yalom, 2021) as not merely functionally supportive, but as an expression of enduring attachment and a testament to their shared life.

However, Marilyn also demonstrated insight into the unbridgeable gap between people that characterises the acceptance of existential isolation. In addition to the lingering sadness associated with this awareness (described under the first existential concern above), she wrote: “I hope I can at least live up to my expectations of dying in such a way as to cause as little pain to others… and to myself” (Yalom & Yalom, 2021, p. 103). Marylin also noted her gradual withdrawal of concerns over the well-being of her loved ones: “I have begun to detach myself from objects and people…I am trying to detach myself a little from the people I love most” (p. 78). As she carefully considered bequeathments of her most cherished possessions, she confronted the fundamental aloneness of experience: “…the stories attached to each one of our possessions will ultimately disappear” (Yalom & Yalom, 2021, p. 32). She also critically reflected on social expectations of generational custodianship over personally significant items: “Who will want all these objects? Just because they appeal to us and hold our memories does not mean that our children will desire them” (Yalom & Yalom, 2021, p. 30). She revisited this idea again, closer to her death:

A theme related to the end-of-life embodiment of this existential concern emerged, based on physical changes and the experience of pain, which seems to renew the focus on existential isolation. Marilyn wrote, “I am exhausted most of the time — as if…a foggy veil exists between me and the rest of the world” (Yalom & Yalom, 2021, p. 12). The differences between her and her husband’s readiness for her death also seem connected to physical changes. On one occasion, she disclosed that the toll of the treatments has become “too great a cost to stay alive” (Yalom & Yalom, 2021, p. 76) and asked: “How much longer must I live before I am allowed to die?” (p. 76). She then refuted his interjecting claim that she still enjoys herself sometimes by stating: “If I could place you inside my body for just a few minutes, you would understand” (p. 76). Confronted with the isolated experience of dying, Marilyn seemed to particularly appreciate the hospice care staff’s capacity to understand and support her physical needs (Yalom & Yalom, 2021).

Marilyn’s reflections on some of her most cherished memories and her proudest achievements highlight her lifelong striving towards a meaningful life. She noted having lived a “very satisfying long life” (Yalom & Yalom, 2021, p. 30), and reminisced often about her marriage, her family and her work. For example, when explaining her emotional ties to their home and its “liveable, lovable space” (Yalom & Yalom, 2021, p. 30), she stated: “How many birthday parties, book parties… and wedding receptions have we celebrated in the living room or outside on the back patio or on the front lawn?” (p. 30). She seemed to find continued meaning in her work. When referring to the manuscript on survivors of World War II, she noted: “I feel a special obligation to communicate these stories” (Yalom & Yalom, 2021, p. 130). Reflecting on the broad impact of her life’s work, she wrote: “It gives me a sense of pride to think that I, too, was part of the feminist movement that advanced women’s rights during the last two generations” (Yalom & Yalom, 2021, p. 101).

Rich with literary, spiritual, and philosophical allusions, she expressed a deeply human desire to have lived a life of value, noting the significance of the idea that one’s memory will endure (Yalom & Yalom, 2021). The theme of kindness that featured so prominently in her concern with personal autonomy also echoed throughout Marilyn’s reflections on her legacy and having lived a ‘good’ life, indicating this was also central to her meaning-making process. She recalled the inscription on a tombstone she encountered when writing about American burial traditions:

Marilyn’s invocation of the dictum ‘The first is to be kind. The second is to be kind. And the third is to be kind’ was followed by her hope “to adhere to this dictum even as I anguish over my personal situation” (Yalom & Yalom, 202, p. 17). This reveals a renewed end-of-life tension between personal suffering and the enduring commitment to meaningful living. Therefore, pain represents a new theme of embodied experience of the existential crisis of meaninglessness. In her earliest reflections in the book, Marilyn asked, “…why should I want to live now with daily misery and despair?” (Yalom & Yalom, 2021, p.13). On the one hand, this suggests that having had the opportunity to create meaning in one’s life positively influences one’s acceptance of the imminence of death. On the other hand, it also suggests that prolonged physical suffering during the process of decline renews the crisis of meaninglessness. Throughout her reflections, the meaninglessness of her suffering underpinned her choices regarding a physician-assisted death. In the month before her death, Marilyn shared a form of meaning she created from her physical suffering by stating: “…In an odd way, I feel that I have ‘paid’ for any sins or wrongdoings I have committed during my lifetime” (Yalom & Yalom, 2021, p. 105).

This single case application of Yalom’s existential psychology propositions demonstrated that all four existential concerns were present in Marilyn Yalom’s experiences of death and dying. Furthermore, the analysis has highlighted specific end-of-life concerns, which were interpreted as variations of the four existential themes specific to the context of imminent death. However, further research can explore whether they could alternatively support Binder’s (2022) proposition of a fifth existential concern, namely, embodiment and emotional being. Drawing from the work of Merleau-Ponty, Gendlin and Winnicott, Binder (2022) asserts that we are grounded by our awareness of our bodies, which allows us to experience feelings both about ourselves and outside events. Embodiment, which has not explicitly been included in Yalom’s framework, motivates the individual to balance feelings of vulnerability and receptivity with a sense of strength and agency (Binder, 2022). Research on the experience of embodiment, especially during the later phases of life, remains underexplored within research (van Rhyn et al., 2022). Marilyn’s specific end-of-life themes related to physical pain and suffering lend support to the need for further research to better understand embodiment as a potential existential concern in the context of failing health and advanced age.

Irvin Yalom’s synthesis of existential philosophy and psychotherapy has influenced contemporary therapeutic interventions and has resulted in these concerns becoming deeply embedded in clinical practice, as patients often grapple with questions of legacy, autonomy, connection, and purpose (Berman, 2019; Binder, 2022; Cunha et al., 2024). As such, the findings of this study readily result in potential practice recommendations to those who provide care for the terminally ill. Firstly, Marilyn’s gradual shift from an abstract acceptance of mortality to a personal confrontation with death’s imminence reveals a complex interplay of factors and demonstrates that the acceptance of death and dying is not a singular event, but a process influenced by emotional complexity, cultural expectations, philosophical and spiritual contemplation, and, significantly, attachment and separation. Clinicians are urged to be mindful of the distinction between acceptance of death and readiness to die. More specifically, support for the terminally ill should include the acknowledgement of continued fears about the physical process of dying, the desire for end-of-life reminiscence, as well as the lingering sadness over death as an impending final separation, even when someone has intellectually accepted the reality of their own decline.

Secondly, Marilyn’s confrontation of existential freedom in her last months involved candid reflections on personal agency, autonomy and responsibility and the drive to empower oneself to shape not only one’s life, but also one’s death. Care providers should be sensitive towards the significant agency that comes from choices about living and care arrangements and the bequeathment and management of cherished personal possessions. Furthermore, clinicians should demonstrate sensitivity to the impact of changing self-descriptors towards the end of life. To help protect the dying person’s sense of self, personal agency to live according to lifelong values should be supported. In this process, Marilyn’s reflections suggest that the identification of role models for “dying well” might be particularly impactful. Ultimately, these findings strongly support individualised medical care and continued advocacy for the autonomy provided by physician-assisted suicide, which remains an inaccessible care option to many.

Thirdly, Marilyn’s reflections also illuminate the importance of the relational core of human existence. Within the security of meaningful connections, the existential crisis of isolation may be reframed in the context of the solitary experiences of suffering and dying. Similarly, Marilyn’s reflections demonstrate how the experience of pain carries the potential to renew a confrontation with meaninglessness, even among those who are satisfied with the meaning they have created throughout their lives. In practice, mindfulness of the dying patient’s growing sense of isolation should also include acknowledgement of a gradual, intentional disconnection from loved ones as the fundamental isolation of the human experience moves to the foreground. Additionally, empathic and knowledgeable medical staff have the potential to provide a useful tether against overwhelming isolation and growing meaninglessness in a manner that loved ones cannot by openly discussing and actively managing the physical concerns and experiences during terminal illness.