The Suddenness of It All
Life turns on a dime. Sometimes towards us, but more often it spins away, flirting and flashing as it goes.
Marcia didn’t know quite what to make of the trip we were about to go on. We had been married for thirty-seven years and had been on many adventures together. But none like this.
It was the last week in June 2019, and we were about to be taken around Israel, Jordan, and the West Bank by a Muslim Palestinian woman Marcia had never met. I had met Rahima, a married PhD and mother of four, only once. It was eighteen months earlier in Briarcliff Manor, New York, during a talk she was giving about issues Muslim women have within Muslim communities in Israel. Having conducted interfaith relations for years and being fascinated by people different than me, I introduced myself to her before her presentation. Although fluent in Hebrew and Arabic, she was unsure of her English and in unfamiliar surroundings—a suburban New York City synagogue—so I hoped to make her comfortable and provide a friendly connection. She was smart, funny, and balanced, rooted in academic rigor, not rancor. Sometimes, you can tell in an instant when you click with someone: eyes light up, facial muscles soften, and a smile emerges. For more than a year after her talk, while we texted via WhatsApp, Rahima repeated warm invitations for Marcia and me to visit her so she could immerse us in Arab culture. Her good-natured persistence eventually won us over, and off we went.
Marcia and I arranged for our flight to arrive in the late afternoon on Friday, June 28 so that we could immediately go to our modest hotel, shower, have an early dinner by ourselves, and recuperate from the long flight. Rahima would have none of that. She was so excited that we had come that she met us at Ben Gurion Airport. Sharing a kindhearted demeanor, Rahima and Marcia bonded as soon as they met in the terminal.
On the walk to her car, Rahima asked us to stop; took a deep, nervous breath; and squared off to face us, clearly looking for the right words for whatever it was she wanted to say. After a few moments of staring at us in silence, she finally let out what she had been holding in for the past few months: how greatly moved and honored she was that we trusted her with this trip even though we really didn’t know her.
And so began a life-changing journey. For the next two inseparable weeks, she took us deep into Arab and Druze cultures, taking care of all the arrangements and, despite my objections, virtually all the meals. It was part of ancient Arab hospitality.
When we returned to New York in mid-July, Marcia and I tried to get our minds around the immensity of the trip. The experience had overwhelmed us and kindled relationships with Palestinian and Jewish change agents that we could build upon in seeking to bridge gaps in the Middle East in our own modest way. Set against this backdrop, the mild stomach pain Marcia experienced upon our return seemed unimportant. When after a few days it didn’t go away, she called a gastroenterologist, probably worried she might come across as a hypochondriac.
That was how it started.
My wife was Marcia Horowitz. She spent her entire professional life as a crisis manager advising high-profile clients and organizations. On September 3, 2019, she found herself in one crisis even she couldn’t navigate. A CT scan revealed that she had stage 4 pancreatic cancer, considered the most lethal cancer. It has the lowest survival rate and one of the shortest life expectancies of all cancers: a median of three to six months after diagnosis, by some accounts. Pancreatic cancer is the third-leading cause of cancer-related deaths in the United States, behind lung and colorectal cancer. In 2020, an estimated 57,600 new cases of pancreatic cancer were diagnosed in the United States, and 47,050 people will die from the disease. Because its symptoms are hard to discern and there are no effective screening tests, a majority of patients with pancreatic cancer (like some other cancers) are first diagnosed in stage 4, after it has spread beyond the pancreas and becomes inoperable. Marcia’s had invaded her liver and abdominal lining.
On February 10, 2020, 160 days after her diagnosis and a month after her sixty-eighth birthday, Marcia passed away in her sleep, at peace with herself, her family, and the world around her.
Through it all, this one patient and her family met short-term terminal illness head-on—with vigor and strength, deploying all they and medicine had to offer. But in contrast with prevailing expectations, we developed a far more expansive view of what strength means in response to life-threatening hardship. We faced the entire experience with composure and clarity by adapting to the new reality, appreciating the miracles of the mundane, and discovering the intense beauty and love that, after reasonable medical measures had failed, the process of dying offered. We called this the Smooth River. This proved to be a way of thinking that was so uplifting and natural that it continues to guide and nourish my family through the voids of grief, and will inspire us for the rest of our lives. Our five-month experience was so distinct and powerful that I’ve been encouraged to share it in an effort to help other individuals and families encountering terminal illness, life-threatening hardship, or serious challenges of any nature, especially where life’s fuse is short.
There are books, articles, and blog posts profiling so-called success stories in managing cancer, even stage 4 metastatic cancer. There are inspiring stories of those who experienced a remission of the disease for long periods of time. These writings provide hope and motivation to those afflicted and are critically important in informing patients and clinicians of possible outcomes and in defying the odds. The problem is that these writings do not speak for huge patient populations battling advanced, aggressive cancer or other diseases likely to end their lives within a compressed time period. They don’t speak to the large number of patients like Marcia who were given a bleak prognosis, where treatment success is unlikely, and the end is in sight. For these patients, the prevailing view is gloomy, and these writings offer little guidance. One can almost feel shunned and on your own because you don’t represent a cancer “victory.” This was unacceptable to Marcia and me. We were determined to chart our own course through the storm, set our own tone, and find our own light.
Marcia was a press communications pioneer, having worked for decades alongside public relations legend Howard Rubenstein (who himself passed away in December 2020 at the age of eighty-eight). She trained scores of employees, headed three practices, and defused hundreds of problems for clients. She was an example of a kind, organized, modest, and highly effective professional rising to the top and becoming respected by virtually everyone she touched. However serious the problem, Marcia always found calm within the storm and provided a clear, forthright, and balanced approach to convey to the press and the public. She had an intuitive knack for reducing very complex matters to a digestible and straightforward narrative that resonated with clients under severe pressure—public figures and celebrities, large companies, law firms, private equity funds, universities, prestigious prep schools, and nonprofits. Her common sense and press-savvy insights made her indispensable to them. Clients knew she had their back, not her own. She had a quiet charisma and authenticity that made people feel safe.
Marcia was on the speed dial of top executives at leading hospitals who sought her magic touch in times of turmoil. She understood the health-care system well and knew the shortest distance between two points, despite layers of convention and complexity that might obscure the picture.
In all other aspects of her life, Marcia was well loved, sincere, and unpretentious. She was so humble that many people outside of work had little idea what she had accomplished professionally or how effectively and quietly she moved behind the headlines they were reading. She was tolerant of imperfections in herself and others and lived in the big picture. And first in the big picture was her family—our two sons, daughter-in-law, toddler grandson, and me. She had her priorities straight and would not be distracted by clutter, spin, or BS.
Soon after the diagnosis, Marcia applied this same clear-headed approach to dealing with her cancer, her treatment, and the possibility of dying. Her mindset, adopted by me and our family, was one of transparency, serenity, and adjusting to a new normal. She wanted to see her life as full, not cut short by tragedy. She took on the cancer aggressively with months of punishing chemo, twice-daily subcutaneous injections of investigational medications, natural remedies prescribed by integrative medicine specialists, and unconventional compounds we identified and used under our oncologist’s supervision (such as the human form of an antiparasitic medication used for dogs). Throughout, Marcia accepted her grim circumstances with grit, grace, and humor. She had the mettle to want to understand what many people avoid: the probability of imminent death.
This supple, expansive Smooth River attitude was an incomparable gift. Marcia loved being around water. The purifying, peaceful properties of flowing water complemented her clear, direct, and unencumbered attitude toward life. The Smooth River way of thinking was so vital that we wouldn’t let anything disrupt it—not the devastating march of pancreatic cancer, not the strongest chemos and their failures to work, not the frequent episodes of severe pain, not how those around us might have expected us to think or act, and not dying itself. She and I spoke about everything—her physical pain, her concerns and anxieties, her wishes. We discussed her broken heart that we would not grow old together; that she would not see her children, daughter-in-law, and grandson ripen; and that, as Marcia’s condition precipitously declined, she wouldn’t experience the upcoming birth of her granddaughter (Mara Sophia, born five months after she passed and who is named in her memory). Marcia needed to clear her mind, to understand the shape of her earthly time, and to leave this world in peace, with no unfinished business or words unspoken. It would be a calm float through white waters.
Although we came up with the term Smooth River as a metaphor for the doctors and nurses to convey that we wanted a well-ordered and tranquil ending, this perspective permeated our entire experience. We had no idea how critical this thinking would be in helping us transition from the shock of her diagnosis, to the ups and downs of her treatment and care, to her final days and passing, and then in carrying our family through the funeral, burial, and life without her. Smooth River thinking—a moving, living, transcendent outlook, soft and strong, liquid and do-able, inspirational and nourishing—has provided us with safe-harbor guidance to make her life and ours a blessing.
As Marcia’s husband, I coordinated her Medical Plan and collaborated with her in setting our Life Plan. Her wishes were for clarity, practicality, directness, and relief from pain so that her remaining time could be filled with peace, dignity, and love unburdened by discomfort. With medical treatment outcomes uncertain and time shrinking, every day was precious.
Our story, then, is far different from the frenetic, fevered atmosphere experienced by many terminally ill patients and their families that leaves them exhausted and unsatisfied.
Born in a slow-motion, five-month cauldron, Smooth River thinking can inspire and guide other terminally ill patients and their families through their journeys too. Hopefully it will give voice to all patients in the throes of disease—those who had treatments they deem successful and those who did not, those whose lives were extended and those whose were not.
The wide expanse of the Smooth River extends well beyond the ill. We will all die one way or another, and we all confront pressures that test our willpower. The lessons are universal.