Background Dignity therapy (DT) has been developed to help reduce distress experienced by people nearing the end of life; however, evaluations of this novel intervention have largely involved non‐distressed samples. Objective The objective of this study was to explore in detail the impact of DT on distressed patients with advanced cancer. Methods We used a case study approach. Three patients with the highest levels of dignity‐related distress who received DT were explored in depth. We collected quantitative and qualitative outcomes from patients in face‐to‐face interviews at baseline and at 1 and 4 weeks after completion of the intervention. We assessed dignity‐related distress using the Patient Dignity Inventory. Patients rated the benefits of DT at completion of the intervention and at both follow‐ups. We conducted qualitative interviews exploring experiences of DT with patients and with two recipients of generativity documents produced by patients. Results These patients were experiencing a wide range of major or overwhelming physical and psychosocial problems when they received the intervention, most of which would not be expected to be helped by DT. All felt that DT had helped them and had helped or would help their families; however, patients' concerns about their current situation made delivering the intervention challenging, and DT‐relevant problems returned when a patients' condition deteriorated. Conclusions The extent to which DT can help these patients and their families, either as a stand‐alone therapy or as an adjunct to other therapies, needs to be determined in studies focussing on distressed patients, particularly those with problems likely to be helped by the therapy.Copyright © 2012 John Wiley & Sons, Ltd.