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Whether prognostic awareness benefits terminally ill cancer patients' psychological–existential well-being and quality of life (QOL) is unclear because of lack of well-controlled longitudinal studies. This study longitudinally evaluated the associations of accurate prognostic awareness and prognostic acceptance with psychological distress, existential suffering, and QOL while comprehensively controlling for confounders in Taiwanese terminally ill cancer patients' last year of life.A convenience sample of 325 cancer patients was followed until death. Psychological distress and existential suffering were assessed by severe anxiety and depressive symptoms and high self-perceived sense of burden to others, respectively. Dichotomized and continuous (QOL) outcome variables were evaluated by multivariate logistic and linear regression modeling with the generalized estimating equation, respectively.Accurate prognostic awareness was not associated with the likelihood of severe anxiety or depressive symptoms but significantly increased the likelihood of high self-perceived sense of burden to others and was associated with poorer QOL in participants' last year of life. Participants who knew and highly accepted their prognosis were significantly less likely to experience severe anxiety symptoms than those who were unaware of or knew their prognosis but had difficulty accepting it.Knowing one's poor prognosis and confronting one's impending death without full acceptance and adequate professional psycho-spiritual support may harm more than benefit terminally ill cancer patients' psychological state, existential well-being, and QOL. These findings highlight the importance of tailoring psycho-spiritual support to cancer patients' psychological and existential needs when prognostic information is disclosed. Copyright © 2015 John Wiley & Sons, Ltd.