Background <p>Spiritual well-being is a key protective factor against psychological distress in individuals receiving terminal cancer care, and several approaches have been proposed to enhance this aspect of care. In this study, we developed and evaluated the effectiveness of a novel intervention combining life review (a method known to improve spiritual well-being) with songwriting, a form of music therapy.</p> Methods <p>Eighteen adults with terminal cancer received the intervention in four sessions. During each session, participants discussed their life experiences guided by a brief life review questionnaire and collaboratively composed song lyrics with the researchers based on these narratives. Participants then selected their preferred melodies and chord progressions from five options provided by the researcher. Upon completion, they listened to their personalized songs and received a CD recording. The primary outcome was spiritual well-being, assessed using the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale. Secondary outcomes included anxiety and depression, measured by the Hospital Anxiety and Depression Scale. Assessments were conducted at baseline, immediately post-intervention, and at 2 and 4 weeks post-intervention. Qualitative content analysis of participants’ feedback was conducted to assess the acceptability and overall impressions of the therapy.</p> Results <p>Immediately following the intervention, participants demonstrated significant improvements in spiritual well-being (<i>p</i> = 0.011), depression (<i>p</i> = 0.001), and anxiety (<i>p</i> = 0.022). However, no sustained effect was observed for spiritual well-being. Depression scores remained significantly improved at the 4-week follow-up (<i>p</i> = 0.022). Anxiety levels stayed below the clinical cutoff at all assessment points, indicating a consistent absence of clinically significant anxiety. Qualitative analysis of participants’ feedback yielded 77 codes, which were integrated into four major categories: (1) Positive feelings toward researchers or the music, (2) Recalling the past and realizing it was a good life, (3) Hope for the future, and (4) Sharing with others.</p> Conclusion <p>The intervention significantly improved spiritual well-being, depression, and anxiety in individuals with terminal cancer. These findings help address prior concerns regarding the applicability of life review and songwriting and suggest that this integrative approach may offer a beneficial therapeutic option for alleviating psychological distress in terminal cancer care.</p> Trial registration <p>Japan Registry of Clinical Trials (jRCT1032230494; November 30, 2023).</p>